Treatment
Treatment :
1. Drug Treatment
- Four medications have received marketing authorization in France. Three are central acetylcholinesterase inhibitors (which increase the bioavailability of acetylcholine in the brain): donepezil, rivastigmine, and galantamine. The fourth, memantine, is an NMDA glutamate receptor antagonist. All are available in generic form.
- These treatments are administered orally. Rivastigmine is also available as a transdermal patch.
- Current indications are limited to the dementia stages of the disease (mild to moderately severe).
- Clinical trials show that cognitive decline is slightly less pronounced in treated patients. These treatments may also improve certain behavioral symptoms (apathy, agitation, hallucinations).
- The main side effects of acetylcholinesterase inhibitors are gastrointestinal disorders (nausea, vomiting, diarrhea, weight loss) and muscle cramps.
- Due to their pharmacological action, cholinesterase inhibitors may have vagotonic effects on heart rate (e.g., bradycardia), especially in patients with supraventricular conduction disorders (sick sinus syndrome, sinoatrial or atrioventricular block), increasing the risk of syncope and falls. Contraindications and precautions must be strictly respected. A systematic ECG, and cardiology consultation if necessary, are required before prescription, along with careful monitoring, particularly of heart rate.
- Initiation of treatment must be performed by a neurologist, psychiatrist, or geriatrician.
- Due to their modest symptomatic efficacy, the French National Authority for Health (HAS) considered their benefit insufficient relative to their risks and recommended full withdrawal of reimbursement, effective since August 1, 2018. These treatments may still be prescribed under the conditions outlined above but are at the patient’s expense.
- Other medications aim to limit behavioral disorders and mainly include psychotropic drugs, which must be used with great caution.
- Medications that may worsen cognitive impairment should be reduced or discontinued whenever possible.
Non-Drug Treatment
Cognitive Stabilization or Compensation
- Cognitive rehabilitation or remediation sessions with a speech therapist (by prescription).
- Cognitive rehabilitation programs aimed at maintaining or restoring autonomy in daily tasks, provided by specialized Alzheimer teams (ESA) composed of psychomotor therapists, occupational therapists, and gerontology care assistants (by prescription), for mild to moderate stages.
- Cognitive stimulation in medicalized day-care centers, upon registration.
Human Support and Third-Party Assistance
- Support for caregivers, including home care services (home care aides, nursing assistants).
- In cases of significant loss of autonomy or complex situations (e.g., individuals living alone and refusing care), recourse may be made to integrated care coordination systems (such as MAIA) to organize assistance and healthcare services.
- Institutionalization when home care is no longer possible: medicalized nursing homes (EHPAD) or long-term care facilities.
Financial and Medico-Legal Support
- Recognition as a long-term illness (ALD-15) with 100% coverage (dementia stage).
- Financial support:
- Personalized Autonomy Allowance (APA), subject to income and level of dependency, for individuals aged 60 and over;
- Disability Compensation Benefit (PCH) for individuals under 60.
- Legal protection measures such as safeguard of justice, guardianship, or family authorization, if necessary (not systematic).
Lifestyle Measures and Other Interventions
- Daily physical activity (e.g., walking).
- Daily outings.
- Treatment of sensory impairments (hearing loss, visual disorders), which can worsen cognitive difficulties and social interaction.
- Treatment of reversible aggravating factors (anemia, heart failure, pituitary insufficiency, sensory deficits, subdural hematoma, etc.).
- Prevention of iatrogenesis, including discontinuation of non-essential psychotropic drugs.
- In advanced stages of dementia, close monitoring of nutritional status is necessary due to frequent forgetting of meals.
Support for Caregivers
- Caregiver support and respite platforms (psychological support, training).
- Family and caregiver associations.
Objectives of These Measures
Most of these interventions aim to:
- Prevent social withdrawal and lack of physical and cognitive stimulation;
- Support families, who are often exhausted by the long-term management of the disease.
