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These three cholinesterase
inhibitors are approved by the U.S. Food and Drug Administration
(FDA) for the treatment of the cognitive symptoms of mild to moderate
Alzheimer's disease and are commonly used.
Given the possible risks of long-term high-dose vitamin
E and selegiline and the minimal evidence for their benefit, they
are no longer recommended. Nonsteroidal anti-inflammatory agents, statin
medications, and estrogen supplementation have shown a lack of efficacy
and safety in placebo-controlled trials in patients with Alzheimer's
disease and therefore are not recommended.
A cholinesterase inhibitor should also be considered
for patients with mild to moderate dementia associated with Parkinson's
disease. Only rivastigmine has been FDA approved for this indication,
but there is no reason to believe the benefit is specific to rivastigmine.
A cholinesterase inhibitor can be considered for patients
with dementia with Lewy bodies.
The constructs of mild cognitive impairment and vascular
dementia are evolving and have ambiguous boundaries with Alzheimer's
disease. The efficacy and safety of cholinesterase inhibitors for
patients with these disorders is uncertain; therefore, no specific
recommendation can be made at this time, although individual patients
may benefit from these agents.
There is some evidence of the benefit of memantine in
mild Alzheimer's disease and very limited evidence of its
benefit in vascular dementia.
Patients may be interested in referrals to local research
centers for participation in clinical trials of experimental agents.