Management of Alzheimer's disease

Abstract

AD is one of the principal causes of disability and decreased quality of life among the elderly and is a leading obstacle to successful aging. AD is a treatable condition. Today's treatment options are greatly improved over those available a few years ago. The complexity and heterogeneity of AD requires comprehensive assessment and possibly multiple layers of intervention for the patient as well as the caregiver. Current management focuses on establishing an early accurate clinical diagnosis, early institution of ChEIs, treating medical comorbidities and dementia-related complications, ensuring appropriate services are provided, supporting caregivers, and treating cognitive and behavioral problems and functional deficits with appropriate non-pharmacological and pharmacologic interventions. A therapeutic alliance between physician and caregiver is critical to the success of AD management. AD is a terminal illness, and the patients and caregivers should be given an early opportunity to decide about intensity of care before the disease inevitably progresses. Physician involvement in ethical issues raised in the management of AD and a multidisciplinary team approach is strongly recommended. ChEIs should be considered in all patients with mild to moderate AD. ChEIs have been shown to temporarily stabilize cognition and ADL and may delay nursing home placement and reduce demands on caregiver time. Preliminary evidence also indicates that these benefits may extend to patients with more advanced AD and rapidly progressive AD as well as to patients with VaD and LBD. Patients not responding to one agent in the class may respond to another. Discontinuation should be monitored; deterioration during withdrawal indicates therapeutic benefit and the medication should be reinstated. Other drugs such as memantine look promising in their effect in slowing functional decline in patients with moderate to severe AD. Estrogen should not be prescribed to treat AD. Psychotropics play a critical role in the management ofmoderate to severe behavioral disturbances in patients with AD. Short-term programs directed toward educating family caregivers about AD should be offered to improve caregiver satisfaction. Intensive long-term education and support services (when available) should be offered to caregivers of patients with AD to delay time to nursing home placement. Professional caregivers need higher expectations and better training and support. Staff of long-term care facilities should receive education about AD to reduce the use of unnecessary psychotropics. This article is by no means exhaustive. Readers are encouraged to read other articles for treatment of problems/issues that we may not have adequately addressed in the management of AD (Table 9). Patients with AD are at risk of becoming medical orphans in a health system geared toward cure and in a culture where it is "normal" for the elderly to suffer. AD patients and their families have a right to receive competent, compassionate, and consistent care. With appropriate treatment, we can substantially reduce the number of AD patients receiving inappropriate medication, futile procedures, and hospitalization and surgeries. With active research in AD, some of the current recommendations may become outdated by the time of publication of this article. Also, physicians must decide to adopt any particular recommendation in the light of available resources and the circumstances of individual patients. Patients and their families have reason to be optimistic. The intense ongoing research in the area of etiology and treatment of AD offers hope and confidence that treatments to delay onset of AD; to treat, inhibit, and reverse symptoms; and, ultimately, to prevent AD, will indeed be discovered. Until then, patients and families can benefit from the variety of pharmacologic and nonpharmacologic interventions described here.