Several prescription drugs are approved by the U.S. Food and Drug Administration (FDA) to help manage symptoms of Alzheimer’s or slow its progression. Most work best in the early- to mid-stage, which is why the Alzheimer’s Foundation of America recommends regular memory screenings to identify problems early. While treatments can help, there is currently no cure. When considering treatment, it’s important to talk with a healthcare professional about what may be most appropriate.
Slowing progression
Lecanemab (Leqembi®) and donanemab (Kisunla®) are anti-amyloid intravenous (IV) infusion therapies for early Alzheimer’s. These drugs can change the course of the disease in its early stage, giving people more time to remain independent. They reduce beta-amyloid plaques in the brain (one of the two key pathological features of Alzheimer’s).
While they do not reverse or stop the underlying disease process, clinical trials have shown that they are associated with a modest slowing of decline in cognitive and functional outcomes in some individuals. Each works differently and targets amyloid at different stages. Individuals receiving these medications require ongoing monitoring for potential side effects, including brain swelling or bleeding.
Reducing cognitive symptoms
For mild to moderate Alzheimer’s
Cholinesterase inhibitors (donepezil/Aricept®, galantamine/Razadyne®, benzgalantamine/Zunveyl®, and rivastigmine/Exelon®) prevent the breakdown of acetylcholine, a chemical messenger important for memory and thinking. As Alzheimer’s progresses, the brain produces less of this. These inhibitors may help stabilize or modestly improve cognitive and behavioral symptoms for a period of time.
For moderate to severe Alzheimer’s
A glutamate regulator (memantine/Namenda®) is used to treat moderate to severe Alzheimer’s by blocking the toxic effects associated with excess glutamate, a chemical messenger. It may help people maintain daily functions for a longer period (e.g., use the bathroom independently).
Memantine may be prescribed alone or in combination with donepezil.
Other approved treatments for later stages include donepezil, the rivastigmine patch, and the combination memantine/donepezil (Namzaric®).
Managing behavioral symptoms
Behavioral symptoms such as agitation, anxiety, sleep problems and wandering are common. Experts recommend trying non-drug strategies first (routine, environmental adjustments, reassurance) and using medications only when symptoms are severe or distressing.
For insomnia
Suvorexant (Belsomra®) has been approved to address insomnia, tested in people with dementia, and shown in clinical trials to be effective for people living with mild to moderate Alzheimer’s. Possible side effects include impaired alertness, worsening of depression and sleep-walking.
For agitation
Dextromethorphan-bupropion (Auvelity®) has been approved for the treatment of agitation associated with dementia due to Alzheimer’s. It is a new first-in-class treatment for agitation, and a significant milestone since it is not classified as an antipsychotic treatment (these have been shown to have more serious side effects).
Brexpiprazole (Rexulti®) has been approved for the treatment of agitation associated with dementia due to Alzheimer’s. In addition to common side effects such as weight gain, sleepiness and restlessness, it is important to recognize the risk of extrapyramidal symptoms and other motor side effects, including parkinsonism, stiffness, tremor and akathisia.
As with all antipsychotic medications, there is also an increased risk of death in older adults with dementia-related psychosis. Many atypical antipsychotic medications are used “off label” to treat dementia-related behaviors, but Rexulti® is the only one currently FDA approved for agitation in Alzheimer’s.
Note: Rexulti® is not approved for the treatment of people with dementia-related psychosis without agitation.
Side effects and safety
All medications can cause side effects. Doctors typically start with a low dose and increase gradually. Patients should be monitored closely, and any unusual symptoms should be reported promptly. Seek out the manufacturer’s websites for more detailed information.