Galantamine Eases the Burden on Patients and Caregivers

Galantamine Helps Maintain Our Independence
As people who love freedom, we should embrace anything that will help preserve it
By Will Block

ne of the best things about getting old is the growing sense of independence we achieve from many of the burdens and responsibilities of our younger years, such as going to work, paying the mortgage, raising the kids, keeping up with the Joneses, and worrying about what others think of us. For most people, if they’ve worked hard and had a modicum of good luck, old age brings liberation from most of those things, and with it the opportunity to enjoy the fruits of their labors while they still can.

While they still can. Those are chilling words, reminding us that old age, like many other aspects of life, is fraught with peril and paradox. At the same time that we’re starting to enjoy the privileges and perks of old age, old age is catching up with us, slowly gnawing at our faculties, both physical and mental. We resist, of course, by using our brains and willpower: we try hard to eat sensibly, exercise regularly, minimize stress, and avoid substance abuse. And we take judiciously chosen nutritional supplements to give us that extra edge.

Doing those things reduces our risk for the chronic degenerative diseases of aging, so that we’ll have a statistically better chance of living long, healthy, happy lives before our time finally comes.* It is inevitable, however, that some degree of physical and mental deterioration will slow us down as we get older—if for no other reason than that we did not lead lives of perfect diet, perfect exercise, perfect emotional balance, and perfect abstinence from enticing substances that are less than healthful. Perfection is in short supply.

*How long is long? It seems always to have been about 120, but recent scientific advances point to the possibility that this ancient barrier could be breached. How far beyond 120 might life extend? No one knows—yet. Stay tuned!

We Treasure Our Independence …

A certain amount of what might be called benign deterioration (aka normal aging) is nothing to worry about, as long as it doesn’t impede our capacity to perform and enjoy the normal activities of daily living—driving, for example. Especially in America, the automobile is a powerful symbol of our freedom and independence: it is both the instrument and the metaphor for our ability to go anywhere we want and do anything we want—because we’re Americans, by gum, and we’re free. Whether we’re breezing through the wide open spaces of the West on a trip to nowhere in particular, or just going downtown for some shopping, we treasure the independence our car gives us to direct our own affairs.

It’s hardly surprising, then, that one of the worst things that can happen to aging people, when physical faculties such as eyesight or reflexes have faltered, is to have to give up driving. Suddenly they’re no longer in control of their own lives, but are dependent on others in ways they haven’t experienced since childhood. It can be a devastating experience, requiring compassionate understanding from family and friends.

. . . the Loss of Which Is a Tragedy

But there are other reasons for having to give up driving. Even if the physical faculties remain sharp, what if the mental ones are getting fuzzy? If memory begins to fail in serious ways, or if confusion about the rules of the road sets in, it’s time to stop driving. That’s already a huge blow to an aging person’s self-esteem and feeling of independence, but these symptoms of dementia portend even worse consequences. Eventually the patient may no longer be able to go for a walk unattended without the risk of becoming lost and wandering off. Mundane tasks such as balancing a checkbook or cooking a meal may become too difficult to handle.

As the condition becomes progressively worse, the patient may forget to bathe and get dressed, or even how to bathe and get dressed. Even remembering how to eat may become a challenge, as well as how to use the toilet. The patient is reverting to a kind of infancy.

The researchers found that
galantamine was associated with a
significantly smaller decline in ADL
independence over the 5-month
period, compared with placebo.

It is indescribably sad to see someone’s capabilities and sense of independence being slowly crushed out of existence, as the victim becomes ever more helpless and demanding. The burden on the caregivers—both physically and emotionally—can be overwhelming, particularly when (as in about 90% of cases) behavioral problems, such as agitation, irritability, and delusions, compound the functional problems. Often this leads the caregivers, in desperation, to institutionalize the patient—the final nail in the coffin of independence.

Galantamine Is the Best Hope Against Alzheimer’s

The most common form of dementia is Alzheimer’s disease. There is no cure, and the disease is invariably fatal if the patient doesn’t succumb to some other disease first. The best that can be hoped for is to alleviate its symptoms and retard its progression for as long as possible so as to give the patient more of what is called “quality time” before the inevitable end.

Much scientific evidence points to galantamine as the best agent for this purpose. With its dual mode of action in the brain, galantamine helps maintain cognitive function in patients with mild to moderate (and even moderately advanced) Alzheimer’s by enhancing acetylcholine-based neurotransmission. One study (randomized, double-blind, placebo-controlled) published by American researchers in 2000 showed that, in elderly patients with mild to moderate Alzheimer’s disease, galantamine at 16 and 24 mg/day produced significantly greater benefits than placebo, over a 5-month period.1 Benefits were seen in terms of cognitive, functional, and behavioral symptoms. Similar results have been obtained in other studies, including a two-part study that lasted for 1 year.2,3

Maintaining Activities of Daily Living Is Crucial …

Hitherto, most clinical trials on Alzheimer’s disease, including those using galantamine, have focused mainly on quantitative measurements of the patients’ cognitive functions (memory, learning, attention, judgment, executive skills, etc.) as a means of assessing their status. Few studies have included detailed assessments of the patients’ ability to function in the activities of daily living (ADL). From the patients’ own perspective, however—and certainly from that of their caregivers—functional impairment in ADL may be a more acute problem (and it’s usually a more obvious one) than cognitive deficits.

Researchers and practicing physicians are therefore becoming ever more concerned about evaluating and maximizing Alzheimer’s patients’ ADL abilities so that institutionalization can be postponed for as long as possible. This should tend to reduce the societal cost of caring for the patients and improve the quality of life for them and their caregivers (see “Galantamine Eases the Burden on Alzheimer’s Caregivers” in the July 2004 issue).

. . . and Galantamine Helps Achieve That

Members of the same team of American researchers cited above recently reevaluated their data on 659 elderly patients from the 2000 study (which did include in-depth functional assessments of ADL).4 They used a protocol called the Alzheimer’s Disease Cooperative Study ADL Inventory, or ADCS/ADL, which comprises questions about 23 specific ADL. These fall into two categories: basic and instrumental, the latter having to do with more complex activities, such as shopping and using devices:

Basic ADL: Eating • Walking • Toileting • Bathing • Grooming • Dressing

Instrumental ADL: Telephone • Television • Conversation • Dishes • Managing personal belongings • Obtaining beverages • Making a meal or snack • Disposal of garbage • Travel outside home • Shopping • Keeping appointments • Ability to be left alone • Current events • Reading • Writing • Hobbies • Household appliances

The researchers’ aim was threefold:

1. To assess the relationship between the severity of the patients’ dementia and changes in their ADL in response to treatment. The researchers found that, regardless of the severity of dementia (which was in the mild to moderate range) at baseline, patients treated with galantamine showed little or no decline in ADL, on average, whereas patients on placebo declined significantly, even in the relatively short span of 5 months.

2. To assess the association between ADL and cognitive changes. The researchers found a significant correlation between these two factors, but it was not very strong. They were able to establish that the improvements in cognitive function played only a very small part in the ADL changes, demonstrating that these changes were largely independent of the measured cognitive changes.

3. To assess the effect of galantamine on specific ADL and on maintaining ADL independence. The researchers found that galantamine treatment was associated with statistically significant improvements (relative to placebo) in the patients’ ability to perform ADL, in both the basic and instrumental categories. Correlations were also found between galantamine treatment and various specific ADL. Finally, they found that galantamine treatment was associated with a significantly smaller decline in ADL independence over the 5-month period, compared with placebo.

The authors concluded:

Data from the current analyses show that the beneficial effects of galantamine treatment extend to both types of ADL, and furthermore that initiating treatment early, at the stage of mild Alzheimer’s disease, could help maintain patients’ abilities to perform complex instrumental ADL.
Galantamine Also Improves Behavioral Problems

A recently published study in Switzerland examined the benefits of galantamine on behavioral problems in patients with mild to moderate Alzheimer’s disease,5 but it differed in important ways from the study discussed above. In controlled clinical trials, the patient population is typically subject to stringent exclusion criteria to make it as homogeneous a group as is reasonably possible; this minimizes confounding factors that make statistical analysis of the data more difficult and the conclusions less reliable. Although this is necessary in evaluating the safety and efficacy of a pharmacological agent, it tends to exclude a large and representative portion of patients seen in actual clinical practice.

In the Swiss study, by contrast, the patients (124 individuals, average age 75) were subject to only minimal exclusion criteria and were thus more representative of the real-world Alzheimer’s population. This advantage must be weighed against the disadvantage of the greater difficulty in analyzing the data, making the conclusions less reliable. Furthermore, this particular study was inherently flawed by being open-label, i.e., non-placebo-controlled (it was also funded by a manufacturer of galantamine—an invitation to bias).

In any case, the results were positive: after treatment for 3 months with up to 24 mg/day of galantamine, the patients showed substantial improvement in 11 of the 12 behavioral disturbances evaluated: aberrant motor behavior, agitation, anxiety, apathy, delusions, depression, disinhibition, euphoria, hallucinations, irritability, and nighttime behavior. Only appetite/eating disorders failed to improve (in fact, they deteriorated). As in other clinical trials, galantamine showed good tolerability: adverse events were almost exclusively gastrointestinal and occurred primarily during the initial dose-escalation phase of the therapy.

Earth to Brain: Take Care of Yourself!

We’re all getting older, and we all want to enjoy the fruits of our labors while we still can. Although we use our brains to decide how best to take care of our bodies, we sometimes forget to use our brains to take care of themselves. Some enlightened self-interest here would be a good thing! With the enlightenment of knowing about the benefits of galantamine in holding the demons of dementia at bay, it makes sense to avail ourselves of this marvelous substance, especially if it can help preserve the precious independence we too often take for granted.


  1. Tariot PN, Solomon PR, Morris JC, Kershaw P, Lilienfeld S, Ding C. A 5-month, randomized, placebo-controlled trial of galantamine in Alzheimer’s disease. Neurology 2000;54:2269-76.
  2. Erkinjuntti T, Kurz A, Gauthier S, Bullock R, Lilienfeld S, Damaraju CV. Efficacy of galantamine in probable vascular dementia and Alzheimer’s disease combined with cerebrovascular disease: a randomised trial. Lancet 2002 Apr 13;359:1283-90.
  3. Erkinjuntti T, Kurz A, Small GW, Bullock R, Lilienfeld S, Damaraju CV. An open-label extension trial of galantamine in patients with probable vascular dementia and mixed dementia. Clin Ther 2003;25(6):1765-82.
  4. Galasko D, Kershaw PR, Schneider L, Zhu Y, Tariot PN. Galantamine maintains ability to perform activities of daily living in patients with Alzheimer’s disease. J Am Geriatr Soc 2004;52:1070-6.
  5. Monsch AU, Giannakopoulos P. Effects of galantamine on behavioural and psychological disturbances and caregiver burden in patients with Alzheimer’s disease. Curr Med Res Opin 2004;20(6):931-8.

Galantamine Helps Elderly Woman with LBD

Not all dementias are of the Alzheimer’s type. Vascular dementia, which is typically caused by ministrokes resulting from cerebrovascular disease, was once thought to be the second most common type of dementia, but we now know that that dubious distinction belongs to Lewy body dementia (LBD), which is even more severe (and more rapidly fatal) than Alzheimer’s disease. Because LBD (whose recognition as a distinct disease is relatively recent) is similar to Alzheimer’s in important ways and often coexists with it, it’s not surprising that galantamine is helpful in treating LBD as well. Indeed, many “Alzheimer’s” patients successfully treated with galantamine may have been suffering more from LBD than from Alzheimer’s.*

*For a discussion of LBD and the role galantamine plays in its therapy, see “Galantamine’s Antidementia Action Expands—Sort Of” in the March 2004 issue.

An expert on LBD has published a case history of an 89-year-old woman who had LBD as well as a raft of other major health problems, for which she was taking about a dozen drugs.1 Among them had been the Alzheimer’s drugs donepezil and rivastigmine, but both were discontinued. The former appeared not to have helped her dementia, and the latter to have made it worse, in terms of agitation and motor symptoms.

Finally she was put on galantamine (8 mg/day), which improved her condition. Her family members reported that she showed improvements in mood and personality, and she became more sociable. Also, her visual hallucinations (a hallmark of LBD) became less frequent and easier to redirect by the family. Although her fate was not altered, her life—and that of her family—was made a little more pleasant by galantamine.

  1. Kaufer DI. A case study in the treatment of dementia with Lewy bodies. Acta Psychiatr Scand 2004;110:73-6.

Dual-Action Galantamine

Galantamine provides a heralded dual-mode action for boosting cholinergic function: it inhibits the enzyme acetylcholinesterase, thereby boosting brain levels of acetylcholine, and it modulates the brain's nicotinic receptors so as to maintain their function. The recommended daily serving ranges from a low of 4 to 8 mg of galantamine to begin with to a maximum of 24 mg, depending on the individual's response.

For an added measure of benefit, it is a good idea to take choline, the precursor molecule to acetylcholine, as well as pantothenic acid (vitamin B5), an important cofactor for choline. Thus it is possible to cover all bases in providing the means to enhance the levels and effectiveness of your acetylcholine.

Will Block is the publisher and editorial director of Life Enhancement magazine.

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