Dementia Treatment Options: Medicines, Side Effects and Review — A Geriatrician’s Guide
There is currently no cure for the common degenerative dementias. Treatment can, however, ease symptoms, help some people keep their function and independence for longer, and make daily life safer for the person and the family. What is appropriate depends on the type and stage of dementia, other medical conditions, pulse rate, the other medicines being taken and the person’s own wishes.
This page explains the medicines I use, who they suit, what to expect in the first weeks, why private prescriptions are needed at the start, and how treatment is reviewed. It assumes the diagnosis has been made. If you are still trying to find out what is wrong, see my dementia guide for families for the early signs and how dementia is diagnosed for the tests.
As a consultant geriatrician I treat dementia as part of a whole-person comprehensive geriatric assessment, reviewing memory alongside mood, function, medication and general health. Depression, hearing loss, thyroid disease and anticholinergic medicines can all worsen cognition and are dealt with first.
At a glance
- No GP referral required
- Usually seen within 24–48 hours
- Whole-person comprehensive geriatric assessment
- Clinic, home visit or video consultation
Treatment starts with the right diagnosis
Medicine choice follows the type of dementia, so the diagnosis comes first: a clinical history, an account from someone who knows the person well, a cognitive assessment, blood tests and usually brain imaging, in line with NICE NG97. I set out each step in how dementia is diagnosed. Treatable contributors (depression, thyroid disease, B12 deficiency, anticholinergic and other sedating medicines, hearing loss) are corrected at the same time, because they can make memory worse whatever the underlying dementia.
What happens after a dementia diagnosis?
Following assessment, I explain:
- The most likely type of dementia
- The evidence supporting the diagnosis
- Whether any additional investigation is required
- Available medication and non-drug treatments
- Driving and safety implications
- Recommended follow-up
- Support available for the patient and family
I provide a detailed report to the patient and their GP, with consent.
For families adjusting to a diagnosis, my dementia guide for families covers stages, changes in behaviour, care and practical support.
Treatment
Can dementia be treated?
There is currently no cure for the common degenerative dementias, but treatment can reduce symptoms and may help some people maintain function and independence for longer.
Treatment must be selected according to the type and severity of dementia, other medical conditions, pulse rate, medication burden and the person’s preferences.
| Dementia type | Typical first-line medication |
|---|---|
| Alzheimer’s disease (mild–moderate) | Donepezil, then rivastigmine if not tolerated |
| Alzheimer’s disease (moderate–severe) | Memantine, alone or added to donepezil |
| Parkinson’s disease dementia | Rivastigmine (usually patch) first-line |
| Dementia with Lewy bodies | Rivastigmine; memantine in selected cases |
| Vascular or frontotemporal (pure) | Not routinely indicated unless mixed dementia |
Donepezil and rivastigmine
Donepezil and rivastigmine are acetylcholinesterase inhibitors. They are commonly used for mild-to-moderate Alzheimer’s disease and may also be used in some other dementias.
For Alzheimer’s disease, I most commonly start with:
Donepezil 5 mg once daily
If it is tolerated, I usually review the patient after approximately four weeks and consider increasing the dose to:
Donepezil 10 mg once daily
Possible adverse effects include nausea, diarrhoea, disturbed sleep, vivid dreams, dizziness, loss of appetite and a slow pulse. Treatment must therefore be individualised.
If donepezil is not tolerated, a rivastigmine patch may be considered. The patch can be useful when gastrointestinal adverse effects, swallowing difficulties or problems with tablets are concerns.
For Parkinson’s disease dementia, rivastigmine — usually as a patch — is often my preferred first treatment (see my Parkinson’s disease assessment page).
When is memantine used?
Memantine works differently from donepezil and rivastigmine.
It may be considered:
- For moderate Alzheimer’s disease when acetylcholinesterase inhibitors are contraindicated or not tolerated
- For severe Alzheimer’s disease
- In addition to an acetylcholinesterase inhibitor when Alzheimer’s disease has progressed to the moderate or severe stage
- In selected patients with dementia with Lewy bodies or Parkinson’s disease dementia when acetylcholinesterase inhibitors cannot be used
For example, memantine may be more appropriate when there is significant intolerance or a contraindication such as clinically important bradycardia.
Medication decisions should follow the diagnosed dementia subtype. These drugs are not routinely appropriate for pure vascular dementia or frontotemporal dementia unless there is another relevant coexisting dementia.
NICE recommends acetylcholinesterase inhibitors and memantine only for defined clinical indications.
Side effects, switching and stopping treatment
Cholinesterase inhibitors are usually well tolerated, but side effects are the commonest reason for a change. They tend to appear when treatment is started or the dose is raised, which is why the early review matters.
- Nausea, diarrhoea and loss of appetite are the commonest. They often settle; taking the tablet with food can help.
- Vivid dreams or disturbed sleep may improve if the dose is taken in the morning.
- A slow pulse, dizziness, fainting or falls need prompt review. Donepezil and rivastigmine can slow the heart, so pulse and any history of heart block or fainting are checked before and during treatment.
- Weight loss is monitored, particularly in frail people.
If one cholinesterase inhibitor is not tolerated, switching to another, or to the rivastigmine patch, is often successful. Memantine is an alternative when cholinesterase inhibitors are contraindicated or cannot be tolerated.
Stopping is a clinical decision, not an automatic one. NICE advises against stopping a cholinesterase inhibitor solely because the dementia has become more severe or because a cognitive test score has fallen. Reasons to consider stopping include side effects that outweigh any benefit, no worthwhile benefit after a fair trial, or a change in the person’s wishes or circumstances. When treatment is stopped I prefer to reduce the dose gradually and review a few weeks later, because some people decline noticeably after stopping; if that happens, restarting is considered.
Please do not stop dementia medicines yourself without speaking to the prescriber.
Shared care
Why are private prescriptions initially required?
Donepezil, rivastigmine and other dementia medicines are locally managed as specialist-initiated or shared-care medicines within South Yorkshire.
When treatment is initiated privately, I issue the initial private prescription and retain responsibility while the medicine is started and adjusted.
The usual pathway is:
- I initiate treatment using a private prescription.
- I review the patient after approximately four weeks.
- If appropriate, I increase or adjust the dose.
- A further review is arranged after another four weeks when clinically required.
- Once the treatment is stable, optimised and tolerated, I ask the GP to consider taking over NHS prescribing under the applicable shared-care arrangement.
Transfer to the GP is not automatic. The GP must receive the relevant clinical information and agree to accept prescribing responsibility. Until shared care has been formally accepted, private prescriptions remain necessary.
This process ensures that adverse effects, pulse rate, tolerability and early response are assessed while treatment is being established.
Ongoing care
Why is a six-month review important?
Dementia is progressive, and a medication that was initially suitable may need to be reconsidered as the condition changes.
A six-month review can assess:
- Cognitive and functional change
- Medication benefit and adverse effects
- Ability to manage everyday activities
- Behavioural or psychological symptoms
- Falls, weight loss and physical health
- Driving and home safety
- Carer concerns and support needs
- Whether the diagnosis or treatment plan remains appropriate
If Alzheimer’s disease has progressed into the moderate or severe stage despite donepezil treatment, adding memantine may be considered. A fall in a cognitive-test score alone does not determine treatment; the decision should also consider function, behaviour, carer observations and the overall clinical picture.
Regular review also helps identify unrelated problems — such as infection, depression, medication side effects or delirium — which can cause an apparent sudden deterioration.
What non-medication treatment can help?
Medication is only one part of dementia care. Other important measures include:
- Regular physical activity
- Treatment of hearing or visual impairment
- Good sleep and adequate nutrition
- Management of blood pressure, diabetes and vascular risk
- Social engagement and meaningful activity
- A predictable daily routine
- Medication supervision where necessary
- Occupational therapy and falls prevention
- Advance care planning and lasting power of attorney
- Practical and emotional support for carers
The best plan is individualised to the person’s diagnosis, health, abilities, priorities and family circumstances.
FAQ
Frequently asked questions
Can donepezil stop dementia progressing?
Donepezil does not cure dementia or permanently stop progression. It may improve or stabilise symptoms for a period in some patients.
What happens if donepezil is not tolerated?
The dose may need adjustment, or rivastigmine may be considered. Memantine may be appropriate when acetylcholinesterase inhibitors are contraindicated or not tolerated, depending on the diagnosis and dementia severity.
Why does the GP not prescribe the medicine immediately?
Locally, these medicines require specialist initiation and monitoring. A GP may take over prescribing only after the patient is stable and shared care has been agreed.
How often should dementia medication be reviewed?
An early review is required after starting or increasing treatment. Thereafter, six-monthly review is clinically useful, although some patients need more frequent assessment.
Can dementia medicines be stopped?
Yes, but the decision is made case by case. Side effects that outweigh benefit, or no worthwhile benefit after a fair trial, are the usual reasons. A fall in a test score or a more advanced stage is not by itself a reason to stop. Do not stop without speaking to the prescriber.
Do dementia medicines work for vascular dementia?
Not routinely. Treatment of pure vascular dementia centres on controlling blood pressure, cholesterol, diabetes and other vascular risk factors. Medicines such as donepezil are considered when vascular disease is mixed with Alzheimer’s disease or another dementia.
Do I need a GP referral to start treatment privately?
No. You can self-refer. I keep your GP informed with a full written report, and GP involvement becomes essential later, when stable treatment is ready to transfer to NHS shared-care prescribing.
Dementia treatment in Sheffield: when to ask for advice
If you or a relative has a diagnosis of dementia and want a specialist view on medication, side effects, a change of treatment or a six-monthly review, I can help in clinic, at home or by video. Please bring a current medication list and any previous scan or memory clinic letters.
I offer private dementia assessment and treatment review in Sheffield, usually within 24–48 hours, with no GP referral required.