Cognitive Decline of Dementia

5 Steps to Help Slow Cognitive Decline
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Although it's unfortunately true that there's no cure for Alzheimer's disease or other forms of progressive dementia, there are concrete steps that you can take to try to slow the rate of cognitive decline in a loved one who's been diagnosed. My patients' families are often surprised to learn that they can play an active, productive role that might make a noticeable difference.

Here are five things you can do that yield the most benefit in slowing mental decline in someone with dementia.

1. Help your loved one avoid problematic medications.

"Psychoactives" are medications that affect thinking skills -- usually for the worse -- in anyone who takes them. Since your loved one already has an illness featuring cognitive impairment, these medications can compound the problem.

Yet I often find that older people with dementia are taking medications that make their thinking worse. Many doctors continue to prescribe psychoactive medications for patients with dementia. And some such drugs are available over the counter, so you may buy them not realizing there's a risk.

Long-term use of psychoactive medications can permanently worsen cognition. Most psychoactives also impair balance, putting your loved one with dementia at risk for a potentially disastrous fall. Fortunately, when these medications are discontinued we often see a noticeable improvement in thinking ability, even in someone who's been diagnosed with dementia.

Action steps:

  • Learn to recognize commonly used medications that make thinking worse. Rule of thumb: If it comes with a warning about sedation or sedative effects, it should probably be avoided by someone with dementia.

    Specifically, avoid these three types of drugs: Anticholinergic medications, which potentially counter the effect of choline-boosting drugs such as Aricept. Commonly used anticholinergics include:

    • Sedating antihistamines, which are commonly included in the PM versions of over-the-counter painkillers and cold/cough medications
    • Tricyclic antidepressants, often used for nerve pain, such as amitriptyline (Elavil)
    • Medications for overactive bladder, like oxybutynin (Ditropan)
    • Medications for vertigo and/or nausea, such as promethazine (Phenergan) and meclizine
    • Medications for muscle spasms, such as cyclobenzaprine (Flexeril)
    • Sleep medications, such as zolpidem (Ambien)
    • Sedatives/tranquilizers, such as alprazolam (Xanax), lorazepam (Ativan), and diazepam (Valium)
  • Whenever a new medication is prescribed, ask, "Could this medication cause increased confusion or sedation in my loved one?" If the answer is yes, make sure the doctor explains why the medication is still absolutely necessary, and ask for the lowest possible dosage.

2. Learn how to spot delirium -- and how to prevent it in the first place.

Delirium is a state of acute mental confusion, meaning a person's state of mind becomes worse than usual, usually over a period of hours to days.

Delirium is usually brought on by some kind of stress on the body or mind, and it can be the only outward sign of a potentially life-threatening illness. It's especially common in older adults who are hospitalized, although hospital staff often overlook this complication.

You don't have to have Alzheimer's or another dementia to develop delirium. But in someone with Alzheimer's, experiencing delirium has been linked to a faster decline, especially if the delirium is prolonged or severe. Although many people return to their baseline abilities after having delirium, a significant number experience a permanent decline in cognitive function.

Action steps:

3. Encourage daily exercise.

Exciting new research suggests that daily exercise may slow down the cognitive decline seen in Alzheimer's and other dementias. Activity is also a great way to boost mood and emotional well-being.

Action steps:

  • Incorporate active time into your loved one's daily routine. Try to think about it the same way you do meals and hygiene "“ it's something that happens every day.

  • Encourage activities that suit your loved one's physical capabilities -- but realize that basic movements like household chores or walking around the house can constitute beneficial exercise. The main point is to keep moving.

  • Get exercise yourself, along with your loved one. It's a pleasant way to spend time together, and you need to fit in your own daily dose of exercise. You'll feel better -- and offload some of the stress that often accompanies dementia caregiving or simply worrying about a loved one.

4. Consider a cognition-enhancing medication.

Cholinesterase inhibitors and memantine have been FDA-approved for the treatment of dementia. The effect tends to be small, equivalent to delaying the progression of dementia by about two months per year. That being said, some patients and families notice a definite improvement within weeks of starting a cognitive enhancer.

Know that many families don't notice any change at all after a loved one begins Alzheimer's medications. If no improvement is noted after two to three months of treatment, it's reasonable to consider stopping medication, especially if the medication is a financial burden.

5. Avoid very high blood pressure and blood sugar.

Many older people with Alzheimer's also have some degree of vascular dementia, which is cognitive impairment due to stroke damage (usually multiple ministrokes).

Avoiding very high blood pressure and poorly controlled diabetes can help reduce the chance of future small strokes, which could spur even more mental decline.

Action steps:

  • Try to be careful but not obsessive. Note I refer to "very" high blood pressure. For many elderly adults with Alzheimer's, moderate control of blood pressure and blood sugar is often safer than very tight control of blood pressure, especially if falls have been an issue. That's because the elderly are more prone to experience a blood pressure medication's side effects, such as dizziness when standing or episodes of low blood sugar.

For these reasons, in most patients I aim for a blood pressure of less than 150/80, and a hemoglobin A1C of 8 percent or less. In some cases, I aim for a lower blood pressure, but I'm always careful to monitor for falls.

Dr. Leslie Kernisan

Leslie Kernisan is a clinical instructor in the University of California, San Francisco, Division of Geriatrics, and maintains a popular blog and podcast at BetterHealthWhileAging. See full bio

over 5 years, said...

Wel written and explained. Easy for the layman to understand as well.

over 5 years, said...

Action steps particularly helpful Thanks.

over 5 years, said...

Great list! If your loved one is like my mother was, sometimes, many times, it was difficult to keep her happy and content. We were always looking for an activity she would enjoy doing and at that time there were none. It is very important to choose the activities carefully, don't just give them anything to keep them occupied. They may have dementia... they still have feelings. Choosing age appropriate activities and one they can complete will help build confidence and they will enjoy doing. Fun brain and memory exercises.

over 5 years, said...

After looking over this list I'm mad all over again. My husband (now 80) who clearly had some cognitive decline was prescribed Elavil for frequent night-time urination a few yrs ago. He himself discontinued it because he said "I am not myself"; then after a couple trips to the ER with UTI and a cellulitis (presumed and treated for MRSA) his new primary suggested he take Lunesta to sleep because he was awake most of the night--he took 1/2 a pill exactly once and was up all night incoherent and paranoid. After another UTI and a subsequent bout of dehydration he was hospitalized, given Ativan and lost it completely, allegedly hit a nurse who was trying to make him stay in bed and pee in diapers which he couldn't understand at all (he was a fall risk) he was then strapped down & shot full of Haldol & subsequently diagnosed with frontotemporal dementia by a hospital neurologist who only saw him once; then he was in an assisted living dementia unit with an open prescription for Ativan (and Haldol, but I put my foot down when they told me they were about to give him a dose of Haldol AFTER the doctor had discontinued the order which they didn't seem to know!) "as needed", which he was given several times (the Ativan) to get him to sleep; his fancy new neurologist diagnosed him with small vessel disease/vascular dementia & prescribed Seroquel at 6 p.m. for agitation, which sedated him terribly and didn't help with agitation--I hired private caregivers who kept him from being given Ativan and figured out how to get him to sleep and after two weeks he was well enough to return home; when I finally had time to read up on Seroquel I found that there is a black box warning on Seroquel not to give it to elderly dementia patients (!) I stopped it myself after consulting with the pharmacist--the very first night off it he was neither agitated nor sedated and we stayed awake for a couple of hours just joking and giggling, like old times. He takes Aricept now; we've tried going without it a couple of times and he seems to do better when he's on it so we are staying on it for now. Although he was definitely cognitively impaired before all this happened, and steadily declining, and although he's recovered dramatically in the past two years from all this, he didn't return to his pre-infection, pre-overmedication cognitive level and is now sufficiently demented to require "24-hour supervision" for his safety. I often wonder if he would have declined so far so fast if he'd either not been hospitalized (he wasn't "sick" but was only there because he was weak & disoriented and they wanted to do an MRI but couldn't do it until the next day for some reason) or had had continuous support while IN the hospital, or had never taken Ativan or Lunesta or for god's sake Haldol (even his Seroquel neurologist said that giving him Haldol was practically malpractice). I'm also angry with myself because I always read about drugs before we take them and question the doctors but I was too overwhelmed by the repeated ER trips and illness and insomnia & paranoia & incontinence & wandering and what I now see clearly was delirium so I trusted the doctors, and he was overmedicated so fast that I didn't or couldn't do anything to prevent it.