Treatment

All types of dementia are treatable at least to some degree by environmental or psychosocial interventions. Treatments for Alzheimer's disease are an intense area of research. Recently, tacrine, a cholinesterase inhibitor, was shown to improve cognitive function in patients with Alzheimer's disease. Tacrine has been approved by the FDA for AD treatment. It does not slow progression of the disease. This therapy is best initiated and monitored by caregivers that will follow the patient through the course of the disease. Other treatments are under active investigation with goals of reducing oxidative stress and inflammation, modifying protein processing, and prolonging neuronal life.14

The behavioral symptoms of patients with Alzheimer's may be disruptive to the home environment and distressing to the patient and caregivers. Hallucinations, delusions, repetitive behaviors, and depression are all common. Patients may misidentify other people and family members may be regarded as strangers, sometimes with apparent great fear. Antipsychotic drugs have been used for management of the psychotic and nonpsychotic behaviors, but treatment remains problematic because of adverse drug effects. Use of these drugs should be selective and reserved for patients with persistent psychotic features or those with extreme disruptive or dangerous behaviors.15 Again, treatment is best coordinated with caregivers that are in a position to monitor the patient's behavior patterns over time.

Treatment of vascular dementia is limited to treatment of risk factors including hypertension.

If a treatable form of dementia is suspected or discovered during evaluation, efforts should be directed toward that underlying cause. Even so, treatments must be individualized. For example, the discovery of chronic subdural hematomas and subsequent evacuation may lead to improvement of a dementia for one patient, but at times an underlying dementia will remain unchanged for another.

The diagnosis of normal pressure hydrocephalus (NPH) is problematic. Excessively large ventricles discovered on CT may prompt consideration of a trial of ventricular shunting. The clinical suspicion of NPH should be increased with the presence of urinary incontinence and gait disturbance at a relatively early point in the disease.16 Improvement in some individuals may be striking, but controversies remain on patient selection and the duration of improvement.1 1Z

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