Medications and Alzheimer's: what families should know

These are often the first medicines a doctor suggests after an Alzheimer's diagnosis. They include:

• Donepezil (brand name Aricept)
• Rivastigmine (brand name Exelon), which also comes as a skin patch
• Galantamine (brand name Razadyne)

How they work: The brain uses a chemical messenger called acetylcholine for memory and thinking. Alzheimer's lowers the amount the brain makes. These drugs slow the breakdown of acetylcholine so more of it stays available.

What they may do: They may keep symptoms from getting worse for a limited time and can help with some behavior symptoms. Because the brain keeps making less acetylcholine as the disease progresses, the effect may fade over time.

Which one is best? No study has directly compared them, and they work in similar ways. Still, some people do better on one than another, so the doctor may suggest switching if the first one doesn't suit.

In the last few years, the FDA has approved a newer kind of Alzheimer's drug that targets amyloid, a sticky protein that builds up in the brain in Alzheimer's. Examples include lecanemab (brand name Leqembi) and donanemab (brand name Kisunla).

Here's what families should know:

• They're for the early stage only. They're meant for people with mild cognitive impairment or mild dementia due to Alzheimer's, with tests confirming amyloid in the brain.
• They may slow decline, not reverse it. In studies, people on these drugs declined more slowly than people on a placebo. They don't restore lost memory.
• They're given by infusion. That means regular visits to a clinic for an IV, at least to start.
• They need close monitoring. They can cause swelling or small bleeds in the brain, so people need regular MRI scans. Some people, including those on blood thinners or with certain genes, may face higher risks.

Ask a specialist whether your person might be a candidate, what the visits involve, and what your insurance covers.

Doctors usually start with a low dose and raise it slowly to lower the chance of side effects. Higher doses can bring more side effects.

Cholinesterase inhibitors may cause nausea, vomiting, diarrhea, loss of appetite, weight loss, muscle cramps or tiredness. Taking them with food may help, but ask the pharmacist.

Memantine may cause dizziness, headache, constipation, diarrhea or confusion.

Anti-amyloid drugs can cause infusion reactions and, more seriously, brain swelling or bleeding. Report headache, confusion, vision changes or dizziness right away.

Watch your person closely when a medicine is started or changed, and report anything unusual to the doctor. Don't stop a medicine on your own. Always tell the doctor before adding any new prescription, over-the-counter medicine, vitamin or herbal supplement.

Bring this list to the next appointment:

• What is this medicine supposed to do, and how will we know if it's working?
• What side effects should we watch for, and which ones mean we should call you?
• Should it be taken with food or at a certain time of day?
• Could it interact with anything else my person takes, including vitamins?
• How long should we try it before deciding whether it helps?
• Is my person a candidate for a newer drug or a clinical trial?
• What will it cost, and is there a generic?
• When would it make sense to stop?

Taking a family member or friend to appointments helps. One of you can listen and ask questions while the other takes notes.