This guide summarizes commonly used medications for cognitive enhancement in patients with neurodegenerative disorders. It outlines starting doses, titration schedules, symptomatic benefits, common side effects, and practical prescribing tips to promote safe and effective treatment.
1. Cholinesterase Inhibitors
These agents are first-line treatments for many forms of dementia and may stabilize or modestly improve cognitive symptoms.
| Medication | Starting Dose | Titration | Max Dose | Symptomatic Benefits | Common Side Effects |
|---|---|---|---|---|---|
| Donepezil (Aricept) | 5 mg each morning | Increase to 10 mg after 4 weeks | 23 mg/day | May improve or stabilize memory, attention, judgment, and language | Nausea, diarrhea, insomnia, muscle cramps, fatigue, appetite loss |
| Rivastigmine (Exelon) | Patch: 4.6 mg/24h or Oral: 1.5 mg twice daily | Increase patch stepwise every 4 weeks; oral max 6 mg twice daily | Patch: 13.3 mg/24h; Oral: 6 mg twice daily | Similar to donepezil | Nausea, vomiting, weight loss, tremor |
| Galantamine (Razadyne) | 4 mg twice daily | Increase every 4 weeks as tolerated | 12 mg twice daily | Similar to donepezil | Nausea, diarrhea, dizziness, headache |
2. NMDA Receptor Antagonist
This medication is often used in moderate to severe dementia, sometimes in combination with cholinesterase inhibitors.
| Medication | Starting Dose | Titration | Max Dose | Symptomatic Benefits | Common Side Effects |
|---|---|---|---|---|---|
| Memantine (Namenda) | 5 mg daily | Increase by 5 mg weekly | 20 mg/day (divided twice daily) | May enhance awareness, memory, and daily functioning | Dizziness, headache, confusion, constipation |
3. Wakefulness and Attention Enhancers
These agents are considered in select cases to address fatigue, apathy, or attention deficits.
| Medication | Starting Dose | Titration | Max Dose | Symptomatic Benefits | Common Side Effects |
|---|---|---|---|---|---|
| Modafinil | 100–200 mg each morning | Adjust according to response | Typically 200 mg/day | Increases alertness and attention, reduces fatigue | Headache, nausea, nervousness, dizziness |
4. Neuroprotective and Cognitive Modulators
These agents may have adjunctive roles in managing cognitive symptoms or associated behavioral issues.
| Medication | Starting Dose | Titration | Max Dose | Symptomatic Benefits | Common Side Effects |
|---|---|---|---|---|---|
| Levetiracetam (Keppra) | 250 mg at bedtime | Adjust up to 1500 mg twice daily | 3000 mg/day | May modulate neurotransmitters and reduce neuronal hyperexcitability | Somnolence, dizziness, infection |
| Pyridoxine (Vitamin B6) | 300 mg twice daily for 1 month → 200 mg twice daily for 1 month → 100 mg twice daily | Gradually taper to maintenance dose | ≤200 mg/day chronically | May support memory and reduce anxiety in epilepsy | Neuropathy with prolonged high-dose use |
5. Natural Cognitive Adjuncts
Herbal and nutraceutical options can be considered as complementary therapies.
| Medication | Dose | Symptomatic Benefits | Common Side Effects |
|---|---|---|---|
| Bacopa | 300 mg/day (standardized to 55% bacosides) | May improve memory formation and reduce anxiety | Increased bowel movements, cramps, dry mouth |
| Ashwagandha | 300–500 mg/day (root extract) | May reduce stress and support memory | Drowsiness, upset stomach, diarrhea |
General Prescribing Tips
Start low, go slow: Gradually titrate doses based on patient tolerability.
Check contraindications: Avoid use in conditions like severe bradycardia or when significant gastrointestinal side effects are present.
Monitor caregiver feedback: Track functional outcomes and side effects closely.
Assess benefit versus burden: Discontinue if no clear symptomatic improvement is observed.
Integrate non-pharmacologic strategies: Supportive routines, structured activities, and cognitive stimulation are essential components of care.