Treatment of dementia and cognitive impairment

Treatment of dementia and other disorders of cognitive functions

Optimal management of patients with cognitive impairment includes the following measures:

• early detection of cognitive impairment;
• determination of their nature and severity of violations, establishment of a nosological diagnosis;
• dynamic observation of the patient;
• early treatment with the use (if possible) of pathogenetic therapy;
• duration and continuity of therapy;
• treatment of concomitant neurological, psychiatric and somatic disorders;
• medical, social and professional rehabilitation of patients;
• psychological support and (if necessary) correction of the behavior of the immediate family of the patient.

The choice of therapeutic tactics depends on the cause (nosological diagnosis) and the severity of cognitive impairment. In the stage of mild and moderate dementia associated with Alzheimer's disease, vascular and mixed (vascular degenerative) dementia, dementia with Lewy bodies and Parkinson's disease with dementia, acetylcholinergic and glutamatergic drugs have proved themselves.

Currently, 4 drugs from the group of acetylcholinesterase inhibitors are used in the therapy of dementia: donepezil, rivastigmine, galantamine and ipidacrin. The use of these drugs helps to reduce the severity of cognitive impairment, normalize behavior, increase adaptation in everyday life, which ultimately leads to an improvement in the quality of life of patients and their immediate environment.

Another approach to the pathogenetic therapy of dementia is the use of memantine, a reversible non-competitive blocker of N-methyl-O-aspartate receptors for glutamate. It is used for the same diseases as acetylcholinesterase inhibitors. In severe dementia memantine is the first choice drug, as the effectiveness of acetylcholinergic drugs in this stage is not well understood. Contraindications to the appointment of memantine - epilepsy and renal failure. Side effects are extremely rare.

If the effectiveness of monotherapy is inadequate and appropriate, combined use of an inhibitor of acetylcholinesterase and memantine.

To control behavioral and psychotic disorders in patients with dementia with insufficient effectiveness of pathogenetic therapy, neuroleptics are used. Most preferred are those that do not have extrapyramidal side effects (atypical antipsychotics), for example quetiapine and olanzapine. Especially great is the propensity to complications of neuroleptic therapy in patients with motor disorders (eg, disease

Indications, contraindications and side effects of acetylcholinergic therapy (donepezil, rivastigmine, galantamine, ipidakrin) Alzheimer's with extrapyramidal symptoms, dementia with Levy bodies, Parkinson's disease with dementia).

Indications	Absolute contraindications	Relative contraindications	Side effects
Alzheimer's disease Vascular dementia Mixed Dementia Dementia with Levy bodies Dementia in Parkinson's Disease	Diseases of the liver	Syndrome of weakness of the sinus node Bradycardia (<55 in min) Severe bronchial asthma Exacerbation of peptic ulcer of the stomach or duodenum Uncontrolled epilepsy Renal insufficiency	Dizziness Nausea Vomiting Diarrhea Anorexia Weight loss

In the stage of non-categorical (mild and moderate) cognitive impairment, drugs with neuroprotective action are preferred, since they are potentially able to prevent or delay the development of dementia. However, in practice, it is very difficult to assess the preventive effect of a given drug. Therefore, there is no single approach to management of patients with mild or moderate cognitive impairment. In everyday clinical practice, drugs with a vasoactive and metabolic action (phosphodiesterase inhibitors, calcium channel blockers, pyrrolidone derivatives, peptidergic and amino acid preparations, ginkgo biloba leaf extract) are widely used. Against the background of the use of vascular and metabolic drugs, there is a decrease in the severity of cognitive and emotional disorders, and improvement in the well-being of patients. It remains an open question about the duration of application of these drugs. Empirically accepted intermittent (course) treatment of non-cognitive cognitive impairment does not have sufficient justification.

As with dementia, with mild and moderate cognitive impairment, the effect on neurotransmitter systems is very promising in order to optimize the processes of synaptic transmission, which plays a key role in the formation of cognitive functions. Regression of cognitive impairment in patients without dementia is noted on the background of the use of pyribedil (a D ₂ / D ₃ -receptor agonist for dopamine and an antagonist of presynaptic alpha-adrenergic receptors, stimulating dopaminergic and noradrenergic transmission). At the same time, the use of acetylcholinergic drugs, apparently, should be limited to the initial stages of dementia, but it is not justified in patients with mild and moderate cognitive impairment.