Integration of drugs and non-pharmacological intervention to Alzheimer patients


  • Masatoshi TAKEDA

    Corresponding author
    1. Department of Psychiatry, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
      Professor Masatoshi Takeda, MD, PhD, Department of Psychiatry, Osaka University Graduate School of Medicine, D3, 2-2 Yamadaoka, Suita City, Osaka 565-0879, Japan. Email:
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Professor Masatoshi Takeda, MD, PhD, Department of Psychiatry, Osaka University Graduate School of Medicine, D3, 2-2 Yamadaoka, Suita City, Osaka 565-0879, Japan. Email:

The Great East Japan earthquake struck the Tohoku area of northern Japan at 1446 hours (Japan Standard Time) on 11 March 2011. It was the fourth largest earthquake by magnitude in the world in the past 100 years. From the earthquake and the following tsunami, 19 334 lives were lost (as of December 2011), which is the third largest loss of life and the most missing as a result of a natural disaster in Japan since 1868. In Japan since the Meiji Restoration (1868), the greatest number of deaths (105 385) occurred in the Great Kanto earthquake on 1 September 1923, and the second highest (21 959) was in Meiji-Sanriku earthquake on 15 June 1896. It is so sad that the Tohoku area was struck by the second largest earthquakes in 1896 and the third in 2011.1 The victims of natural disasters, including earthquakes, are always the weaker members of society such as the elderly, children and the ill.2 The Great East Japan earthquake killed many elderly people, and the high proportion of the elderly victims is one of the features of this disaster.3 We express our sincere condolences to the victims of this tragedy and wish that those in the affected will soon be able to return to their normal day-to-day lives.

The Japanese Psychogeriatric Society celebrated its 25th Anniversary last year (2011) and is at its best as it starts its second quarter century. Japanese society is now super-aged and has the world's highest proportion of the elderly aged 65 years and older (23.1% in 2010). This proportion is expected to further increase to 30.5% by 2025 and to 40.5% by 2055. The proportion of old elderly (75 years and above) exceeded 10% in 2010, which will increase to 26.5% by 2055. The ageing of society has been observed in many Asian countries, and one burden of the super-aged society is the growing prevalence of dementia.

In 2005, there were 13.7 million dementia patients in Asia (5.5 million in China, 3.2 million in India and 1.9 million in Japan), and this number is expected to increase to 64.6 million (27.0 million in China, 16.3 million in India and 4.9 million in Japan) by 2050. In light of the growth in elderly populations in developing countries, more dementia patients will be observed in Asia and in developing countries than in developed countries in near future.4

Donepezil, a choline esterase inhibitor, was developed and approved in Japan in November 1999, and it has been the only drug in Japan for Alzheimer's disease for just over 12 years. In 2011, three new compounds (galantamine, rivastigmine and memantine) were approved for Alzheimer's disease by the Japanese government, which will present new alternatives to patients.5 Even though all of these drugs, including donepezil, are only symptomatic drugs, these new treatments have been favourably received by patients and doctors. However, these drugs will not cure Alzheimer's disease, which means that a similar or even higher number of patients will still require treatment. Given the limited benefits of the symptomatic drugs, non-pharmacological intervention, integrating social and psychological factors, should be combined with pharmacological intervention in the treatment of Alzheimer patients.

There are many complementary and alternative medicines (CAM) for dementia. Because the symptoms of dementia are influenced by each patient's social factors, the effectiveness of CAM is not guaranteed in all of the patients. CAM that may be effective for some patients are ineffective in others. There are scarce data with scientifically verified statistical analysis on the effectiveness and usefulness of CAM, which could be one of the reasons why there are so many CAM options available to the public.6

CAM for dementia include off-label use of drugs, Chinese herbal medicine, natural supplements, food, exercise, leisure activities, life styles and non-pharmacological interventions. Examples of off-label use of approved drugs (alternative medicine) for dementia are Ginkgo biloba, acetyl-L-carnitine, lecithin, piracetam, curcumin, vinpocetine and phosphatidylserine.7

Patients, caregivers and medical professionals have been searching for effective interventions for Alzheimer's disease, and there are a variety of non-pharmacological interventions. The limited efficacy of drug therapy and the plasticity of the human brain are the two main reasons that explain this growing interest in non-pharmacological intervention for dementia patients. In Table 1, non-pharmacological interventions are listed along with which treatments have had positive results on target symptoms according to published reports of random controlled trials.8 The symptoms are grouped under three headings: cognitive function, activities of daily living, and behavioural and psychological symptoms of dementia. We hope Japanese clinicians treating Alzheimer's patients will pay greater attention to patients' psychological and social wellbeing and make use of these non-pharmacological interventions .

Table 1.  Non-pharmacological intervention to Alzheimer's patients
  1. ADL, activities of daily living; BPSD, behavioural and psychological symptoms of dementia.

Cognitive training+++
Cognitive rehabilitation+++
Cognitive stimulation therapy+++
Snoezelen/multisensory stimulation+++
Reality orientation+++
Reminiscence therapy++
Validation therapy++
Physical activity+++
Light therapy++
Music therapy++
Animal-assisted therapy+