Dementia: your complete guide to the new treatments

From the new antibody drugs to jigsaw puzzles, here are the best medical and non-drug therapies for dementia, as recommended by experts

Dementia is the biggest health challenge facing the UK’s ageing population with 900,000 currently living with the disease and predicted to increase to 1.6 million by 2050. Now, for the first time, a new group of drugs called monoclonal antibodies have been shown to slow down the decline in thinking and memory in Alzheimer’s patients, the most common form of dementia.
Lecanemab has been approved by the US Federal Drug Administration and is available in the United States.
It is expected to get the greenlight from the UK’s Medicines and Healthcare products Regulatory Agency (MHRA) on Thursday. This will mean it can be prescribed privately in the UK for the first time. Lecanemab could then become available on the NHS subject to approval by the National Institute for Health and Care Excellence (Nice).
Approval for donanemab, another antibody treatment, has been delayed after the FDA asked for more information on safety and efficacy.
“These new antibody treatments [lecanemab and donanemab] represent a defining moment in the history of treating Alzheimer’s disease and give much needed hope,” says Katherine Gray, the head of research at the UK’s leading dementia charity the Alzheimer’s Society.
“They target amyloid protein buildup in the brain, which are thought to be toxic to brain cells. Amyloid causes brain cells to get sick, and eventually die, which leads to the symptoms of Alzheimer’s disease. These new immunotherapy drugs trigger the body’s immune system to break down amyloid plaques.”
Gray stressed the effects are quite modest and only really effective at the really early stages of Alzheimer’s disease (and don’t work for vascular dementia, a type of dementia caused by reduced blood flow to the brain). “But they are the first drugs that have ever been proven to have an impact on disease progression.”
 Trial data has found the new drugs can slow down disease progression.
“Lecanemab researchers estimated that over the 18 months of the trial, it may slow progression in memory and thinking skills by 27 per cent and slow decline in quality of life by 56 per cent,” says Gray.
Research on the long term effects of lecanemab, published in Neurology and Therapy, found it resulted in a delay of two to three years in the average progression to severe stage of Alzheimer’s, if given in the early stages. But this is yet to be proven in patients and was using a simulation model only.
“Trial results for donanemab showed it could delay progression of Alzheimer’s by between 4.5 and 7.5 months, over the 18 month trial period, and reduce decline in the ability to carry out daily activities, such as managing finances or driving, by 40 per cent,” says Gray. “But we do need to see what the effects are in the longer term outside of clinical trials.”
The new drugs can have side effects for some, says Dr Bal Athwal, a consultant neurologist at The Wellington Hospital and the Royal Free London NHS Foundation Trust. These include swelling and /or bleeding on the brain called amyloid related imaging abnormalities (ARIA). 
“Switching on the immune system within the brain may clear amyloid, but there may also be some collateral damage – and sometimes that can be quite severe – and you can get these inflammatory reactions called ARIA. Some of these reactions can be quite severe and include seizures and bleeding,” says Dr Athwal.
ARIA side effects were visible on a scan in 36 per cent of patients in the donanemab trial, but only 16.5 per cent had symptoms. In the lecanemab trial, 29.7 per cent of participants had ARIA detected, but only 10.4 per cent  had symptoms.
The effectiveness of the new drugs also depends on early diagnosis and there are concerns the NHS isn’t prepared for providing the PET scans and lumbar punctures that will be needed to confirm diagnoses, as it lacks both the workforce and facilities to cope with such large numbers. 
A briefing paper from NHS England has estimated between 50,000 and 280,000 patients could be eligible for the treatments at a cost of £500 million to £1 billion a year. There are hopes that a blood test for biomarkers for Alzheimer’s may be developed soon as an easier method to diagnose the disease.
Treatments currently available in the UK for Alzheimer’s disease focus mainly on controlling symptoms for people with mild to moderate disease, says Dr Athwal, adding there are currently no treatments for vascular dementia. 
“These symptomatic treatments try to compensate for the deterioration of the brain by boosting certain chemical functions in the brain,” Dr Athwal explains. “They all work by boosting the brain’s supply of a neurotransmitter called acetylcholine and they seem to give people a boost in their brain function for a limited period of time. They don’t work forever though.”
Dr Athwal says these drugs can only be prescribed to patients with mild to moderate disease and won’t stop progression.
“Sooner or later the brain is going to deteriorate beyond the point that these drugs can have much impact.
“The drugs can give you a modest boost for three to five years, although this varies. They won’t return the person to normal, but the difference they make can be quite meaningful to some people and allow them to remain independent and do more things. In some people, though, they make no difference and cause side effects such as confusion and agitation.”
Medication not specifically for Alzheimer’s may also be prescribed to help with individual symptoms, such as antidepressants for depression and antipsychotic drugs for delusions. A new study, however by the universities of Manchester, Nottingham, Edinburgh and Dundee, published in the BMJ, has found that antipsychotic drugs prescribed to dementia patients cause more side effects than previously thought.
They are believed to increase the risk of heart attack and stroke, as well as pneumonia, fractures, heart failure and acute kidney injury, after as little as three months. The most commonly prescribed antipsychotic drugs were risperidone, olanzapine, quetiapine, and haloperidol.
The Alzheimer’s Society says a range of non-drug therapies can support people living with the disease. These include reminiscence therapy about a person’s life story to bring back happy memories, using a scrapbook, or photo album. 
Other strategies include activities to keep the brain active and engaged, such as puzzles, talking about the news, or creative activities such as singing, (the Alzheimer’s Society runs Singing for the Brain groups) or painting.
Complementary therapies such as aromatherapy, massage, and bright light therapy can also be used, although evidence on their effectiveness is limited.
“We think that the mechanism of vascular dementia is increasing inefficiency and deterioration of the blood vessels, and we know that there are risk factors for that include Type 2 diabetes, high cholesterol and smoking,” says Dr Athwal.
“Controlling those is going to help vascular dementia, although we don’t have direct evidence on this.”
“There are other factors which are less quantifiable, which we think are conducive to good brain health, such as exercise, having a good social network and trying to keep your brain active by learning new things, as well as a stable home life where you are well looked after,” says Dr Athwal.
“There’s no evidence herbal remedies or food supplements can stop progression of dementia,” says Dr Athwal. ”But I don’t take a dogmatic view on this: if there is something that makes you feel good then by all means go and do it. I just try to steer people away from things that might be harmful to their health or finances.”
Signing up for a clinical trial can give hope and trial participants will usually have regular medical appointments and check-ups which many people like as it makes them feel looked after. 
“Recruiting and supporting people with dementia to take part in clinical trials has been a real challenge (in 2021 only 61 people with Alzheimer’s took part in trials) and that has held up research development,” says Gray.
“People who take part say they feel like they’re doing something for future generations.”
Your GP can direct you to social support.The Alzheimer’s Society has a helpline (0333 150 3456) to give carers and family advice on the extensive national network of support groups.”
The charity Dementia UK offers advice and support to families living with dementia through its specialist dementia registered nurse Admiral Nurses service.
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