I. Drugs to improve cognition in patients with dementia
(i) Cholinesterase inhibitors
Used in the treatment of patients with mild to moderate dementia. The representative drugs are Aleshin, Esnon and Haberin.
Clinical trials have found that 5-10 mg/d of Enrichen is an effective dose. The recommended dose is 5mg/d for the first 4-6 weeks and then increased to 10mg/d. The therapeutic effect is observed with Asperger’s at 1-4mg daily, but is best at 6-12mg/d (divided into 2 doses). Haberin is usually taken in doses of 100-200 micrograms twice daily, but not more than 450 micrograms daily.
(ii) Monoamine oxidase B inhibitors
It can reduce the progression of disease in AD patients, and siliquelan can delay the onset of functional impairment in dementia patients. The recommended dose for dementia treatment is 5-10 mg/d. Selegiline (10 mg/d) or Vit E (2000 iu/d) alone in moderate AD disease can slow down the progression of dementia.
(iii) Ginkgo biloba preparation
It has improved the cognitive function in vascular dementia and Alzheimer’s disease, but not in non-cognitive function and activity function. Some patients with non-specific dementia may benefit from the use of ginkgo biloba preparations, but clinically robust evidence is lacking.
(iv) Glutamate receptor antagonists
such as memantine are effective in patients with moderate to severe dementia including dementia caused by VaD and HIV. The initial dose is 5 mg/d, and the dose is increased to 10 mg/d after one week, 15 mg/d at the third week, and 20 mg/d at the fourth week for a maintenance dose for 4 months.
(v) Calcium antagonists
There is much evidence that excessive calcium inward flow is a possible mechanism of cortical cell death, and there is also evidence of altered calcium self-stability in AD patients. nimodipine is the representative drug with selective cerebrovascular dilation. It increases cerebral blood flow and reduces cerebral ischemic damage at doses that do not affect peripheral blood flow or blood pressure. It is taken orally 20-60mg each time, 3 times a day.
(VI) Pro-intellectual drugs
Nicergoline 10-20mg/dose, 3 times a day; others are aniracetam, oracetam and cytarabine
II. Treatment of psychiatric and behavioral symptoms
There are several principles that must be followed in the pharmacological treatment of psychiatric behavioral disorders (BPSD).
1, first of all, to determine the patient’s “target symptoms”, that is, the patient’s core symptoms, such as the patient’s sleep rhythm disorders will inevitably lead to night wandering, the elimination of sleep disorders as a core symptom can solve the patient behavior abnormalities.
2.Start treatment with the smallest effective dose.
3.Adjust the drug dose appropriately according to the change of condition.
4.The starting dose should be small, the magnitude of dose adjustment should be small, and the time between dose adjustment should be long.
5.To pay attention to the adverse drug reactions and drug interactions.
(I) Drugs for cognitive dysfunction
Cholinesterase inhibitors can treat a variety of behavioral symptoms, such as emotional indifference, mood symptoms or psychotic symptoms have a role, and meperidine hydrochloride has a certain effect on symptoms such as agitation and irritability.
(ii) Antipsychotic drugs
Classical antipsychotic drugs can effectively control most psychotic behavioral symptoms with similar efficacy. The effective doses and the doses leading to adverse reactions are much lower than those used to treat schizophrenic patients of the same age, and commonly used drugs include haloperidol, methiodiazide, fenadine, chlorpromazine, etc.
Non-classical antipsychotics are equally effective in BPSD, with mild adverse effects such as extrapyramidal symptoms and postural hypotension.
Antipsychotic drugs commonly used in BPSD
Drug Starting dose Dose adjustment time Dose increase Maximum dose
(mg/d) (d) (mg/d) (mg/d)
Haloperidol 0.5 4-6 0.5-1 2-5
Fenazaquin 2-4 4-6 2-4 16-24
Gathiopyridazine 25-50 4-6 25-75 150
Risperdal 0.5 4-6 0.5 2-3
Clozapine 6.25-12.5 4-6 12.5 75-100
Olanzapine 2.5 5-8 2.5-5 10
Quetiapine 50-100 4-6 50-100 300-400
(iii) Application of anti-anxiety drugs
It is advocated that antipsychotic drugs and antidepressants should be the main treatment. If the effect on patients’ anxiety and sleep disorders is not obvious, anxiolytic drugs such as buspirone and benzodiazepines can be considered for treatment. This class of drugs is prone to fall, excessive sedation, ataxia, dyskinesia, etc. As far as possible, drugs with milder sedative adverse effects, weaker central muscarinic effects and shorter half-life should be selected, and the dose should be as small as possible and the duration of use should be as short as possible. commonly used drugs are midazolam, diazepam, norethindrone (lorazepam) alprazolam, clonidine, etc.
Mood stabilizers: For patients with obvious agitation, the addition of mood stabilizers can reduce or mitigate aggressive behavior, commonly used drugs are lithium carbonate, valproate, carbamazepine, lamotrigine, etc.. Among them, lithium carbonate to pay attention to lithium toxicity, other drugs to pay attention to liver function damage, leukopenia, individual patients can occur rash or even exfoliative dermatitis (carbamazepine).
(D) the application of antidepressant drugs
Antidepressants are mainly used for depressive symptoms in patients with dementia, tricyclic drugs have strong anticholinergic adverse reactions, and are likely to induce consciousness disorders, especially delirium, habitual constipation, induce glaucoma, aggravate cognitive impairment, cause tachycardia, conduction block or postural hypotension, urinary retention, etc. 5-hydroxytryptamine reuptake inhibitors (SSRI) also have the above adverse reactions, but The incidence and severity are much lower than those of tricyclics, so they have now become the drugs of choice for the treatment of depression in the elderly. The most common adverse effects include gastrointestinal symptoms, insomnia, agitation, inability to sit still and other psychiatric symptoms, and these drugs include fluoxetine, fluvoxamine, paroxetine, sertraline, and cetropinopram.
Commonly used antidepressants
Drug Starting dose Dose adjustment time Dose increase Maximum dose
(mg/d) (d) (mg/d) (mg/d)
Doxepin 25 3-4 12.5-25 100-150
Amitriptyline 25 4-6 12.5-25 100-150
Promethazine 25 3-4 12.5-25 100-150
Chlorpromazine 25 3-4 12.5-25 100-150
Fluoxetine 10-20 4-6 10-20 20-40
Paroxetine 10-20 4-6 10-20 20-40
Fluvoxamine 50 3-5 50 50-150
Sertraline 50 3-5 50 50-150
Cetaprotilam 10-20 4-6 10-20 20-40
Venlafaxine 25 5-7 25 50-100
III. Non-pharmacological treatment of dementia in old age
Non-pharmacological treatment, i.e. psychological and social-behavioral treatment, aims to preserve the patient’s level of functioning to the greatest extent possible and to ensure the safety of the patient and his/her family in coping with the difficult problem of dementia and to reduce the burden on caregivers.
(i) Cognitive function training
Through cognitive rehabilitation patients make great progress in learning new things, memory, executive function, daily living skills, general cognition, and depression improvement. The types of cognitive impairment should be classified before cognitive rehabilitation exercises, and the general classification is as follows: language, memory, visuospatial, attention, and problem-solving skills. Memory therapy, word association, motor therapy, categorization training and functional training for daily living can slow down the progression of dementia patients and can also significantly improve daily living skills.
(ii) Exercise therapy
Movement therapy can be applied to all stages of dementia to maintain and improve motor function. For patients with mild to moderate dementia, the treatment goals make balance, mobility and strength. The combined application of movement therapy and music therapy in patients with dementia is much more beneficial than music therapy alone.
(iii) Music therapy.
Music therapy allows patients to listen to familiar music and songs that evoke a pleasant experience, or they can be coached to hum songs they liked in their youth in the form of karaoke. Playing soothing background music in the patient’s living environment can stabilize the patient’s mood. It can significantly improve the control of positive and negative symptoms such as agitation and agitation.
(iv) Functional exercise for daily living
Functional exercises for daily living can significantly improve the ability of daily living, executive ability and cognitive function of elderly patients.
(V) Behavioral therapy
It refers to the application of psychotherapeutic knowledge to the whole range of experimental psychology, is through spontaneous responses and classical conditioned reflex methods, exemplary learning can basically establish good operant behavior, cognition and emotion, through daily behavioral training, restore skills that have been lost, reduce interference behavior, activity level can be significantly improved, compared with the control group depressive symptoms are significantly reduced, the accompanying psychiatric symptoms will also have The level of activity can be significantly improved, depressive symptoms are significantly reduced compared to the control group, and the accompanying psychiatric symptoms are greatly improved. Behavioral therapy for patients with dementia focuses on adjusting the relationship between stimuli and behavior, commonly done by changing the stimuli that stimulate the patient’s abnormal behavior and the consequences of that abnormal behavior. For example, the interrelationship between the stimulus and the behavior and the related factors in the whole process should be carefully analyzed, and every effort should be made to reduce the frequency of such stimuli and the negative consequences of the behavioral response.
(VI) Psychotherapy
Commonly used psychotherapies include supportive psychotherapy, reminiscence therapy (inducing patients to recall events that elicit and maintain positive emotional responses), confirmation therapy, which enables patients to experience self-worth and reduce negative stimuli by identifying links with emotional responses experienced in the past), role-playing therapy (reducing patients’ social isolation by making them play a role in a family or event), and skill training (simulating learning in a classroom environment and reducing the negative consequences). classroom environment to maintain the patient’s residual cognitive function as much as possible).
(vii) Environmental therapy
Environmental therapy includes: clear signals, sensory stimulation, stimulating environment, avoiding distraction, and verbal communication skills. As an example of sensory stimulation aromatherapy can improve the patient’s nighttime sleep and reduce daytime disruptive behaviors.
(viii) Reality orientation therapy
It can improve time, place, and person orientation disorders in patients with dementia. Comparison between the reality orientation group and the randomized control group showed significant improvements in memory, orientation, and orientation-related behaviors.
(ix) Imitation reenactment methods
For example, watching a video of a family member.
(x) Other methods
Such as massage, soothing therapy, bright and quiet living environment, etc.
IV. Treatment of several specific types of dementia
(I) Treatment of vascular dementia
Treatment is mainly directed at three aspects: first, control of cerebrovascular disease risk factors such as hypertension, hyperlipidemia, diabetes, etc.); second, prevention of stroke; third, improvement of cognitive function (e.g. cholinesterase inhibitors). If needed, symptomatic treatment with antipsychotic drugs is available.
(B) Treatment of frontotemporal dementia
There is no special treatment method yet, mainly symptomatic treatment and supportive treatment, and functional training should be given early to improve social life ability.
(C) Treatment of Lewy body dementia
Anti-psychotic drugs should be avoided, such as fenadine, haloperidol, hydropromazine and other drugs with high extrapyramidal adverse effects. For patients with hallucinations and other psychotic symptoms, olanzapine, quetiapine and other drugs with low extrapyramidal adverse effects can be used.
(iv) Treatment of dementia in Parkinson’s disease
Add cognitive improvement drugs to anti-Parkinsonian drugs such as amantadine, compound dopa, dopamine receptor agonists, and monoamine oxidase B inhibitors: cholinesterase inhibitors can be used. Antipsychotic drugs such as quetiapine, olanzapine and other drugs with low extrapyramidal adverse effects are appropriate.
(E) Treatment of Creutzfeldt-Jakob
There are no effective treatment measures, mainly supportive and symptomatic treatment. Early diagnosis can reduce the medical transmission of the disease.