Introduction
In the pharmacological treatment of dementia, it is essential to recognise that the therapeutic approach is not limited to cognitive decline. During the course of the disease, most patients develop behavioural and psychological symptoms, such as depression, apathy, agitation, psychosis and sleep disturbances, often with greater functional impact and caregiver burden than memory loss itself. Therefore, interpretation of these tables is based on an essential distinction between therapy directed at cognition and strategies aimed at neuropsychiatric symptoms.
Cognitive treatment
Currently available drugs have mainly a symptomatic effect of modest magnitude. Cholinesterase inhibitors are the main option in mild to moderate Alzheimer’s disease and may provide temporary stabilisation or slight cognitive improvement. However, response varies between individuals, making periodic reassessment of clinical benefit and tolerability essential. Memantine has a more defined role in moderate to severe stages, especially when there is intolerance to cholinesterase inhibitors or an additional need for behavioural control.
Monitoring and safety
A central aspect in the interpretation of these therapies is the need for continuous monitoring. Adverse effects — particularly gastrointestinal, cardiovascular and those related to weight loss — are frequent and may limit adherence. Therefore, the decision to maintain, adjust or discontinue treatment should always be based on the balance between meaningful functional benefit and iatrogenic risk, rather than on disease progression alone.
Behavioural and psychological symptoms
When behavioural symptoms predominate, the clinical priority changes. The first step is not pharmacological, but aetiological and environmental. Many episodes of agitation, anxiety or confusion are triggered by reversible causes, such as pain, infections, constipation, urinary retention, sleep deprivation or adverse drug effects. Identifying and correcting these factors may resolve symptoms without the need for psychotropic medication.
Non-pharmacological interventions
Non-pharmacological strategies are the foundation of treatment. Environmental organisation, predictable routines, appropriate stimulation and caregiver support are interventions with significant impact on reducing agitation and improving quality of life. Pharmacological therapy should therefore be reserved for persistent symptoms associated with relevant distress or safety risk.
Pharmacological treatment of behavioural symptoms
Antidepressants have a well-established role in clinically significant depression. In contrast, antipsychotics require particular caution because of the increased risk of cerebrovascular events, sedation, falls and mortality. They should be used only when strictly necessary, at the lowest effective dose and with frequent reassessment.
Specific clinical situations
In certain conditions, such as dementia with Lewy bodies and dementia associated with Parkinson’s disease, there is marked hypersensitivity to antipsychotics, which may lead to severe motor worsening or neuroleptic malignant syndrome. In these cases, the approach should prioritise review of dopaminergic therapy and the selection of drugs with lower dopamine-blocking activity.
Sleep disturbances
Sleep disturbances are common and often poorly managed. Prescription of hypnotics should be avoided whenever possible because of the risk of delirium, falls and cognitive deterioration. The approach should prioritise sleep hygiene, stabilisation of the circadian rhythm and treatment of precipitating factors.
Conclusion
The interpretation of these tables reflects a clear clinical logic: distinguish cognitive from behavioural treatment, prioritise non-pharmacological interventions, use psychotropic drugs cautiously and continuously reassess clinical benefit. This structured approach helps reduce iatrogenesis, optimise quality of life and support consistent clinical decisions throughout the course of dementia.
