Management of Alzheimer dementia

Alzheimer’s disease (AD) is the most common cause of dementia in the elderly. Currently, 4.5 million individuals in the United States are estimated to have AD, and that number is projected to increase to at least 14 million by the year 2050. AD is a major cause of disability and mortality, and its impact on health care costs, including direct and indirect medical and social service costs, is estimated to be greater than $100 billion per year.

Medications
No current treatments can either cure or permanently arrest AD; however, AD-specific therapies are available. The current AD therapies can be divided into two types: (1) symptomatic approaches based on enhancement of neurotransmitter systems and (2) neuroprotective strategies using antioxidants. The most successful AD medications to date are the acetylcholinesterase inhibitors, which enhance the brain’s cholinergic system. Acetylcholine is believed to play a major role in the expression of cognitive, functional, and possibly behavioral symptoms in AD. Cholinergic treatment probably does not alter the progression of neurodegeneration, however. The acetylcholinesterase inhibitors reduce the metabolism of acetylcholine, which is deficient in the AD brain, thereby prolonging its action at cholinergic synapses. Three cholinesterase inhibitors are currently marketed for the treatment of mild to moderate AD: donepezil (Aricept®), galantamine (Reminyl®, Raza-dyne®), and rivastigmine (Exelon®) ( Table 5 ). As a class, these agents have demonstrated measurable, albeit modest, effects on cognition, behavior, activities of daily living, and global measures of functioning versus placebo in clinical trials The main adverse effects are gastrointestinal (nausea, vomiting, diarrhea, anorexia, weight loss), and, not surprisingly, the drugs are better tolerated on a full stomach. Insomnia and vivid dreams have also been reported. In the absence of head-to-head comparisons of the cholinesterase inhibitors, the main differences appear to be their side effect profiles, titration schedules, and dosing regimens. Although studies have found modest benefits, cholinesterase inhibitors should be considered in patients with mild to moderate AD.[1] Further studies are needed to assess possible long-term benefits such as delayed institutionalization, decreased mortality, and economic savings in the cost of patient care.

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