Q+A - Dr. David Hogan

Dr. David Hogan answers our questions about dementia medications

Photo by Riley Brandt/University of Calgary–image is for editorial use only and not to be re-distributed without permission from the University of Calgary

Photo by Riley Brandt/University of Calgary–image is for editorial use only and not to be re-distributed without permission from the University of Calgary

David B. Hogan is the academic lead of the Brenda Strafford Centre on Aging at the University of Calgary. Geriatric medicine has been a longstanding area of interest of his.

Hogan worked closely with the late Dr. Irma Parhad who established one of the first dementia clinics in Canada. As well, his own mother developed dementia, which Hogan says “made it very real and personal to me.” 

Hogan has been actively involved in developing clinical practice guidelines for dementia and therapeutic strategies around Alzheimer’s disease. He shares his insights into the condition and treatment options.

Q  |  What are some commonly prescribed medications for treating dementia?

A  |  “The most commonly used of these medications are called cholinesterase inhibitors. There are three of them available in Canada covered by the public drug benefit program in our country: donepezil, galantamine and rivastigmine. There’s a fourth medication called memantine, which is not generally covered by public-funded drug benefit programs, so I will not be discussing it here.” 

Q  |  How do these medications work to improve symptoms of dementia?

A  |  “The thinking is that people with Alzheimer’s disease — these drugs were developed for Alzheimer’s — have a deficiency in a neurotransmitter called acetylcholine and that’s called a cholinergic deficit. Acetylcholine is released by brain cells and they stimulate other brain cells. We have mechanisms in our bodies to break acetylcholine down because you wouldn’t want to be in a permanently excited state. What these drugs do is they inhibit and slow down the breakdown of acetylcholine and because you have more of it around, the cholinergic deficit is partially corrected.”

Q  |  What are some potential side effects?

A  |  “It depends on the individual. Some people don’t have any trouble with these medications. In general, rivastigmine tends to have more stomach upset and the other two might be more likely to lead to problems with sleep and dreams. The difference is there, but it’s not overly marked. Any of them is a reasonable first choice.”

Q  |  When is a pharmacological approach the best option for treating dementia? 

A  |  “Drug therapy should not be viewed as instead of non-pharmacological approaches. The care of a person suffering from a dementia is complicated and includes considering both drug therapy and other interventions. The available medications for Alzheimer’s disease would be a consideration at all stages of this condition, but deciding on a trial of one of them is a shared decision based on weighing the relative benefits and risks of their use for that person. Treatment with one of these drugs always requires a commitment to monitoring the effects of therapy and continuously re-visiting whether therapy should be considered.”

Q  |  What are some non-pharmacological approaches to treatment? 

A  |  “Management is a better word than treatment. It isn’t simple. Management includes identifying a family caregiver who is providing support — or potentially could — and finding out what support this person can provide and addressing their needs. It includes deciding on whether any referrals should be made to help assess or manage the problems being faced, assessing for safety concerns, ensuring to the best of your ability that advance planning (e.g., updated will) is done, assessing the person’s capacity to make reasonable decisions for themselves and referring them and their family to the local branch of the Alzheimer Society. It includes providing information and advice about non-pharmacological interventions and pharmacological ones and developing a comprehensive treatment plan with defined goals, monitoring response to any intervention tried and adjusting them as needed.” 

Q  |  Do you recommend the use of antipsychotic drugs to treat behavioural symptoms of dementia? 

A  |  “Again there isn’t a simple ‘yes/no’ response to this question. Their use should be limited to only specific types and severity of challenging behaviours that can arise with dementia (e.g., psychotic symptoms, aggression, severe agitation). A decision on their use would be a shared one based on weighing the likely benefits, risks and alternatives. If used, the person treated must be carefully monitored for their response to therapy. The doses used should be kept as low as possible with treatment given for as short a period of time as possible. These drugs do have a number of important adverse effects including a small but definite increase in the risk of death.” [ ]



Aricept and Aricept RDT: 
also known as donepezil

Exeleon and Novo or Teva-Rivastigmine:
also known as rivastigmine

Reminyl ER: 
also known as galantamine


Learn more at alzheimer.ca

Share your questions with us at feedback@dementiaconnections.ca.