Cognitive decline is a hallmark characteristic of Alzheimer’s disease that is typically managed with multiple treatment strategies. Both drug and nondrug approaches as a whole have demonstrated the ability to mitigate cognitive decline in patients with Alzheimer’s disease, particularly when used early in the disease course.

There are different treatments available to slow the progression of cognitive decline in patients with Alzheimer’s disease. We encourage providers to “run toward the diagnosis rather than away from it” because, with both drug and nondrug therapies as a whole, patients experience more benefits from treatments earlier in the disease course.

The benefits of cholinesterase inhibitors are generally seen early in the disease when there is only cognitive decline. There may be very little benefit to starting this treatment in a patient who has moderate disease demonstrating functional or behavioral difficulties. And, by the time a patient with Alzheimer’s disease requires nursing home care, you have probably already exhausted whatever benefits were there, so there is no point in continuing the therapy. Memantine is available for patients with moderate to severe Alzheimer’s disease as an additional symptomatic therapy. However, there are relatively few studies on memantine, and there are varying clinical approaches to its use (eg, some people hardly use it, and others use it alone in specific circumstances).

The most recently available treatment is disease-modifying therapy, which has been shown to reduce markers of amyloid in the brain and impact clinical progression. The US Food and Drug Administration (FDA)–approved drug lecanemab demonstrated that once you remove the amyloid burden in the brain, the beneficial effects of slowing the progression of decline seem to be on more than just cognition. There were also changes seen in a composite end point measuring multiple areas, such as executive function, problem solving, orientation, and activities of daily living. However, it is important to note that most of the patients in these trials were also on a cholinesterase inhibitor or memantine. Moreover, the studies of these drugs were carried out for only 18 months, so we are not sure what will happen after 18 months. Do you stop the drug? Do you continue the drug? No one really knows that yet.

Nondrug therapies should also be considered for slowing the progression of cognitive decline, including engaging in regular exercise, maintaining appropriate sleep, refraining from smoking, and maintaining social connections. In addition, optimizing the management of comorbidities, including diabetes, hypertension, and heart disease, is important. You do not want to give up on any of these diseases or treatments.

Because there is a background of vascular disease in most individuals with Alzheimer’s disease, taking care of the vascular component is important. So, even when we say that the patient has Alzheimer’s disease, if we treat their hypertension or heart disease better, they tend to do better in general compared with those who do not get treated. Further, older people need 7 or 8 hours of good sleep, and we need to counsel them on how to get and maintain that amount and level of sleep. We also talk about socialization because there is a value in not being isolated. However, we caution patients not to take on new social activities that make them uncomfortable. Why put yourself through failing at a new social activity when you can pursue the ones that really give you satisfaction and enjoyment? Those are the kinds of strategies that we prioritize when we talk about nondrug interventions.