Pills for Memory: The Medications That Define Dementia Care Today

By: Noah W Chung | PharmD

This article is for educational purposes only. Always consult your healthcare provider before starting or changing any medication.

Quick Hits

• Cholinesterase inhibitors

  donepezil (Aricept), rivastigmine (Exelon), galantamine (Razadyne). Modest improvement in memory, function, and behavior in Alzheimer’s and some other dementias.

• Memantine (Namenda)

  regulates glutamate; used for moderate-to-severe Alzheimer’s, often combined with a cholinesterase inhibitor.

• New monoclonal antibodies

  aducanumab (Aduhelm), lecanemab (Leqembi). Target amyloid plaques; controversial but signal a shift toward disease-modifying approaches.

• Supportive medications

  antidepressants, antipsychotics, and sleep aids, used carefully for behavioral and psychological symptoms.

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Dementia Medications: Hope, Limits, and the Long Wait

For decades, dementia, especially Alzheimer’s disease, was treated as untouchable. Families watched loved ones fade, doctors could offer only reassurance and coping strategies, and research seemed to stall.

That began to shift in the 1990s, when scientists identified the chemical imbalances in Alzheimer’s brains: lower levels of acetylcholine, a neurotransmitter tied to memory, and glutamate dysregulation, linked to cell death. The first wave of drugs — cholinesterase inhibitors, arrived, offering modest but real benefits. Later came memantine, another symptom-targeting medication.

In the 2020s, the landscape began shifting again. With the controversial approval of aducanumab in 2021 and the subsequent launch of lecanemab in 2023, medicine took its first steps toward treatments aimed at the disease process itself , not just symptoms.

Today, dementia care is a patchwork of old standbys, new experiments, and deep frustration. None of the available drugs are cures. Yet for many patients and families, they offer precious time, an extra year of conversation, a little more independence, a few more memories held onto.

Cholinestrase Inhibitors: The First Breakthrough

The first real pharmacological hope for dementia came in 1996 with the FDA approval of donepezil (Aricept). By blocking the enzyme that breaks down acetylcholine, donepezil boosted levels of this key neurotransmitter, temporarily improving signaling between neurons.

How they work: Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) don’t stop Alzheimer’s. But they can slow symptom progression, improve memory recall, help with daily activities, and sometimes reduce agitation.

Everyday impact: Families often notice subtle but meaningful changes. A grandmother who could no longer remember her grandchildren’s names might recall them again. A man who once wandered the house confused might now be calmer and better able to dress himself.

Key players:

• Donepezil (Aricept): Once-daily pill, widely prescribed. Approved for mild, moderate, and severe Alzheimer’s.

• Rivastigmine (Exelon): Available in pill and skin patch forms, useful if side effects limit pill use.

• Galantamine (Razadyne): May have additional effects on nicotinic receptors, potentially boosting its impact on cognition.

Drawbacks: Side effects often include nausea, diarrhea, weight loss, and sleep disturbances. Not all patients benefit, and gains may fade after a year or two.

Still, for many, these medications mark the first step in treatment.

Memantine: Balancing the Brain’s Signals

In 2003, the FDA approved memantine (Namenda), the first drug for moderate-to-severe Alzheimer’s disease. Unlike cholinesterase inhibitors, memantine targets glutamate, another neurotransmitter.

Mechanism: In Alzheimer’s, excess glutamate overstimulates brain cells, contributing to their death. Memantine acts on NMDA receptors to regulate this activity, protecting neurons.

Impact: Memantine doesn’t reverse disease, but it can help patients remain more independent for longer. It may improve language, reduce agitation, and delay nursing home placement.

Everyday example: A 78-year-old man with advanced Alzheimer’s who could no longer manage basic tasks experiences small but meaningful improvements, less aggression, slightly clearer speech, after memantine is added to his regimen.

Often combined: Many patients take memantine with a cholinesterase inhibitor, targeting multiple pathways at once.

Disease-Modifying Therapies: A Controversial New Era

For decades, drug development for dementia was littered with failures. Hundreds of trials targeting amyloid plaques, sticky protein clumps found in Alzheimer’s brains, fizzled. Then, in 2021, the FDA approved aducanumab (Aduhelm), the first monoclonal antibody against amyloid.

The controversy: Aducanumab reduced amyloid on brain scans, but evidence for slowing cognitive decline was shaky. Its approval was met with both excitement and outrage, leading to limited uptake and insurance hurdles.

Next in line: Lecanemab (Leqembi), approved in 2023, showed clearer evidence of slowing disease progression in early Alzheimer’s. It still requires IV infusions and monitoring for brain swelling or bleeding, but it’s seen as a landmark step.

Other candidates: Donanemab and similar drugs are in late-stage trials, suggesting more options may arrive soon.

What it means: For the first time, patients with early Alzheimer’s can be offered therapies that may slow the underlying disease, not just treat symptoms. Yet the treatments are expensive, logistically demanding, and not without risks.

Supportive Medications: Managing the Unseen Symptoms

Dementia is not only about memory. Many patients experience depression, anxiety, insomnia, or psychosis. These symptoms often cause more distress to families than memory loss itself.

Doctors sometimes prescribe:

• SSRIs like sertraline for depression or anxiety.

• Antipsychotics like risperidone for severe agitation or hallucinations — though used cautiously due to increased stroke risk.

• Sleep aids for disrupted sleep-wake cycles, though behavioral strategies are preferred.

These drugs don’t treat dementia directly but can significantly improve quality of life.

Safety: Balancing Fragility and Function

Dementia patients are often older, frailer, and on multiple medications. That means side effects carry extra risk:

• Cholinesterase inhibitors: nausea, weight loss, fainting from slowed heart rate.

• Memantine: dizziness, confusion.

• Monoclonal antibodies: brain swelling or bleeding (ARIA, amyloid-related imaging abnormalities).

Doctors weigh the modest benefits of these drugs against the potential harms, tailoring decisions to each patient’s stage of disease and family priorities.

The Future: Toward Prevention and Precision

The future of dementia treatment may lie in early intervention. By the time symptoms appear, much brain damage has already occurred. Trials are shifting toward treating patients in the preclinical phase, when amyloid is present but cognition is still intact.

Other directions include:

• Tau-targeting drugs, aiming at another hallmark protein in Alzheimer’s.

• Lifestyle interventions, which already show promise in reducing risk (exercise, diet, cognitive engagement).

• Blood tests and biomarkers,hich may soon make Alzheimer’s diagnosis faster, cheaper, and more accurate.

The dream: one day preventing dementia before it starts, or halting it at its earliest stage.

Dementia Medications at a Glance

Dementia Medications: Small Steps, Hard Truths, Glimmers of Hope

Dementia medications are not cures. They don’t restore lost memories or stop the disease in its tracks. But they do matter. They buy time, time for families to connect, for patients to remain independent, for conversations that might otherwise be lost.

The arrival of monoclonal antibodies marks a turning point. For the first time, drugs are moving from symptom relief toward modifying the disease itself. Yet questions of access, cost, and safety loom large.

In the meantime, the familiar pills, donepezil, memantine, and their cousins, remain the daily companions for millions living with dementia. They are imperfect, but they are also a testament to medicine’s persistence: even against a relentless disease, science keeps chipping away, offering light where once there was only darkness.

Sources

Alzheimer’s Association. 2023 Alzheimer’s Disease Facts and Figures. Alzheimer’s Association, 2023.

Cummings, Jeffrey, et al. “Alzheimer’s Disease Drug Development Pipeline: 2022.” Alzheimer’s & Dementia: Translational Research & Clinical Interventions, vol. 8, no. 1, 2022, e12295.

National Institute on Aging. Medicines to Treat Alzheimer’s Disease. NIH, 2022, www.nia.nih.gov/health/alzheimers-treatment.

Selkoe, Dennis J., and John Hardy. “The Amyloid Hypothesis of Alzheimer’s Disease at 25 Years.” EMBO Molecular Medicine, vol. 8, no. 6, 2016, pp. 595–608.

Salloway, Stephen, et al. “Lecanemab in Early Alzheimer’s Disease.” New England Journal of Medicine, vol. 388, 2023, pp. 9–21.

Winblad, Bengt, et al. “Donepezil in Patients with Severe Alzheimer’s Disease: Double-Blind, Parallel-Group, Placebo-Controlled Study.” The Lancet, vol. 367, no. 9516, 2006, pp. 1057–1065.