Medications approved for dementia in Canada

There are no medications today that can cure irreversible types of dementia. But there are medications approved by Health Canada which can help with some of the symptoms or slow the rate of progression of the condition. When you or someone you support is diagnosed with dementia, it’s important to talk to a health-care team about whether the medications available are right for you or the person you support. Here you will find information about medications for dementia. The information includes a list of available medications, potential benefits, common side effects and details on when to start or stop taking medications. Knowing what to expect from medications can help you or the person you support make informed decisions about taking them.

What medications are available?

The medications approved by Health Canada to treat dementia include cholinesterase inhibitors, memantine and lecanemab.

Cholinesterase inhibitors work by preventing the breakdown of a chemical in the brain called acetylcholine, which is important for learning and memory. In Alzheimer’s disease, nerve cells that make acetylcholine are lost, causing lower levels of acetylcholine in the brain. These medications increase acetylcholine, which may temporarily ease or stabilize some dementia symptoms.

The cholinesterase inhibitors are:

Aricept™(brand name) or donepezil (generic name — pronounced doe-NEP-uh-zil). When donepezil is prescribed, the name may have a prefix in front of it, such as Apo-Donepezil.
Galantamine (pronounced ga-LAN-ta-meen). When galantamine is prescribed, the name may have a prefix in front of it, such as Auro-Galantamine.
Exelon™ (brand name) or rivastigmine (generic name — pronounced RIV-uh-STIG-meen). When rivastigmine is prescribed, the name may have a prefix in front of it, such as Apo-Rivastigmine.

Cholinesterase inhibitors are approved for people in the early, middle and late stages of Alzheimer’s disease. Donepezil and rivastigmine can be used to treat Lewy body dementia. Rivastigmine can also be used to treat Parkinson’s disease dementia.

There is not enough evidence to support the use of cholinesterase inhibitors in people with vascular dementia. However, for people with a combination of Alzheimer’s disease and vascular dementia, cholinesterase inhibitors may be used when Alzheimer’s disease is thought to be the main cause of the dementia symptoms.

Memantine (pronounced muh-MAN-teen) works by blocking the effect of too much glutamate, a brain chemical which helps to send messages between brain cells. When brain cells are damaged by Alzheimer’s disease, too much glutamate is released, disrupting brain signalling. Memantine helps prevent this. This medication is only approved for people in the middle to late stages of Alzheimer’s disease. It is often used when people have trouble taking cholinesterase inhibitors. The brand name for memantine is called Ebixa™. When memantine is prescribed, the name may have a prefix in front of it, such as Apo-Memantine.

Lecanemab (pronounced luh-CAN-uh-MAB) is a disease-modifying treatment, which means it targets the underlying cause of the disease. Lecanemab slows the progression of disease by removing amyloid plaques (often connected to Alzheimer’s disease). This type of treatment is only approved for people with mild cognitive impairment (MCI) or early-stage Alzheimer’s disease. The brand name for lecanemab is called Leqembi™.

Note: Lecanemab should not be used to treat people with two copies of the ApoE4 gene or people taking anticoagulants (blood thinners).

Dementia affects each person differently and what works for one person may not work for another. For more information about medications available to treat a particular type of dementia, or symptoms that are affecting you or the person you support, talk to a health-care team. They can be helpful in assessing signs of dementia and prescribing treatment.

Are these medications covered by provincial/territorial health insurance plans?

Medication coverage varies depending on the province/territory you live in. Individuals may be required to cover some of the costs associated with these medications. The person must meet specific criteria in their province/territory to be entitled to coverage for medications. These medications may also be covered by private insurance plans. It is also important to know that as a person’s condition progresses, some insurance plans may stop covering the costs associated with these medications. If this happens, you will have to decide (after discussing with your health-care team) whether taking these medications is worth the cost.

How effective are these medications?

Benefits can be small and difficult to notice, even for a health-care provider or someone who knows the person with dementia well. Some people will benefit from taking these medications, and others will not. Some of the improvements that you might notice include:

Less cognitive decline. There may be improvements in memory, concentration and attention.
Less functional decline. The person may be more engaged in daily activities (such as cooking and personal care), more motivated to do things, calmer and more communicative.

Some people treated with these medications will not show any significant improvement, but their condition may remain the same or not progress as quickly as it did before starting treatment. Because dementia is progressive and gets worse over time, it may take more than six months to notice a change. Individuals may tolerate or experience more benefits with one medication over another because each medication is slightly different.

When trying to see if the medication is helping, looking for positive changes in the person’s abilities and interactions with others can be better than cognitive testing. Tests may not be sensitive enough to show the small benefits that a person could be experiencing from taking medication.

Here are some things to look out for to find out if the medication is working:

Does the person seem more engaged, communicative, social or alert?
Is the person more motivated to do some of the things that they enjoyed doing in the past?
Is the person able to complete tasks such as personal care?
Does the person seem happier, less anxious or less easily frustrated?

These small improvements may have a significant benefit on the person’s daily quality of life and may also help reduce caregiver stress. Noticing no change in the person for a long time may also be a benefit because it suggests that the medication is slowing the progression of the condition, especially if the person had been noticing changes before starting treatment.

What are the common side effects of medications for dementia?

Some of the common side effects of medications for dementia are listed below.

Donepezil, galantamine and rivastigmine*

Nausea, vomiting, and/or diarrhea
Loss of appetite and anorexia
Dizziness
Fatigue
Insomnia, abnormal dreams

*Note: Rare but more serious side effects can include losing consciousness from a slow heart rate, muscle breakdown, and a serious skin reaction.

Memantine

Constipation or diarrhea
Headaches
Dizziness
Depression
Confusion
High blood pressure

Lecanemab

“Amyloid-related imaging abnormalities”, or ARIA (swelling and bleeding in the brain)
Headache
Confusion that gets worse
Dizziness
Vision changes
Nausea/vomiting
Difficulty walking and/or speaking
Seizures
Muscle weakness
Infusion-related reactions (fever; flu-like symptoms; fast or slow heart rate, or pounding feeling in chest; difficulty breathing or shortness of breath; and/or changes in blood pressure)

Some side effects (such as stomach upset often experienced with cholinesterase inhibitors) may lessen or go away over time or with reduced dosage. Medications are usually started at the lowest dose available to minimize side effects. If the person is tolerating the medication when started, the dosage is usually increased slowly to an effective amount. How these medications are taken and whether the person is taking other medications can influence the risk of side effects. If the side effects outweigh the benefits or are intolerable, the medication should be stopped. It is important to discuss any side effects with your health-care team, as well as interactions of the medication with any other drugs you may be taking. If the person experiences dizziness, a slower heart rate, falls, headaches, or unintended weight loss, contact your health-care team as soon as possible.

When should you start taking a medication for dementia and for how long?

After being diagnosed, if there are no other symptoms or health conditions that could make taking these medications too dangerous or inappropriate for the person living with dementia, doctors often suggest a trial of one of the medications. Most people treated with the medications can tolerate them and will experience some benefit. This is why it is important to start treatment as soon as possible after dementia symptoms are experienced.

The decision about whether to start treatment should be decided by the person who will take the medication and/or their substitute decision-maker. The person taking the medication and/or their substitute decision-maker can also choose to stop treatment at any time. Reasons for not taking the medication might include: no clear benefit, a safety concern, side effects that are too difficult to manage, or the person disliking or not wanting to take the medication. Before changing the dosage of medication or stopping treatment, check with your health-care team.

It can be helpful to talk with your health-care team about any changes noticed since taking the medication. Make notes about any changes in symptoms, particularly ones that you were concerned about before treatment. This information will be useful for making the right decisions about continuing, changing or stopping treatment. If the medication is stopped because it does not seem to be helping, the person being treated should be watched for the next few weeks to see if they experience significant negative changes. This would suggest that there were benefits from the medication that were not easy to notice before. If this happens, consider restarting the medication. If a long time has passed since taking the medication, when restarted the dosage will have to be slowly increased.

To benefit from the medication and minimize side effects, the person should take the medication as prescribed. If taking the medication is challenging, ask your pharmacist for advice, such as having the medication blister packaged. If the person is benefiting from the medication without any significant side effects, it is often recommended that they continue taking it until they are in an advanced stage of the condition. At this stage they may be no longer able to communicate, be bed-bound and/or need assistance for care.

What other treatment options are available?

As medications are only one part of the overall care for a person, people living with dementia should also consider taking care of their brain health through maintaining a healthy diet and participating in physically, cognitively and socially stimulating activities.

You may also have heard about alternative therapies for dementia, such as:

pet therapy, music therapy, aromatherapy or massage therapy
cognitive behavioural therapy (CBT) or cognitive rehabilitation

These recreational, complementary or alternative treatments are being increasingly used in combination with medications; however, more research is needed to determine their effectiveness.

Be cautious about taking supplements or health products for Alzheimer’s disease or other dementias. More research is needed to confirm the potential benefits and risks of taking supplements to reduce the symptoms of dementia. Before taking any supplements or health products, talk with your health-care team to find out whether there are any risks.

For more information see alzheimer.ca/alternativetreatments or contact your local Alzheimer Society at alzheimer.ca/find or 1-855-705-4636.

Ready to talk with your health-care team?

If the person living with dementia does not have any other health conditions that could make taking these medications a risk, these medications are an option. If you have accurate information and realistic expectations about the potential benefits and possible side effects of these medications, you’ll be ready and prepared to talk with your health-care team about whether these medications are right for you.

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