Dementia Treatment in 2026 — What Is Possible Today and What Remains Realistic

Effective treatment of dementia rests on four pillars that are combined on an individual basis—no single pillar is sufficient on its own.

For most patients, this is the most important pillar. The evidence for non-pharmacological interventions is, in some cases, just as robust as that for medications.

Structured group programs such as Cognitive Stimulation Therapy (CST) have been shown in studies to have effects on cognitive performance comparable to those of cholinesterase inhibitors. CST is typically conducted over 14 weekly sessions at specialized day centers or dementia centers.

Endurance and strength training slow the progression of cognitive deficits and improve mood, sleep, and daily functioning. The recommendation: at least 150 minutes of moderate activity per week plus strength training twice a week. For advanced dementia, adapted exercise programs—such as dance, music, and guided movement—are recommended.

According to the Lancet Commission 2024, loneliness is one of the greatest modifiable risk factors for the progression of dementia. Day care, dementia cafés, and structured activity programs are not merely a relief for family members—they are therapeutically effective.

Observational studies show that the Mediterranean and MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay) diets have protective effects. Key elements: vegetables, berries, nuts, legumes, fish, olive oil, whole grains, moderate amounts of poultry, little red meat, and minimal sugar and processed foods. Early intervention is particularly important in cases of malnutrition among the elderly.

Uncorrected hearing and vision loss significantly accelerates cognitive decline. Hearing aids, eyeglasses, and cataract surgery are therefore integral parts of dementia treatment.

Healthy sleep plays a key role in the breakdown of beta-amyloid—the so-called glymphatic clearance occurs primarily during deep sleep. Treat sleep disorders specifically, but avoid benzodiazepines and Z-drugs whenever possible.

Chronic stress negatively affects cognitive functions through cortisol and chronic inflammation. Regular daily schedules, familiar surroundings, and calm routines reduce stress and prevent behavioral disturbances.

→ For an overview of dementia disorders: Dementia in Older Adults.

Donepezil, rivastigmine, and galantamine have been approved for over 20 years for mild to moderate Alzheimer’s dementia. They enhance the cholinergic system, which is impaired early on in Alzheimer’s. In studies, they have been shown to:

• Stabilization or slight improvement in cognitive function for 6 to 12 months
• A moderate slowing of disease progression
• Partial improvement in daily functioning and mood

They do not cure the disease. They moderate its progression. And they are not tolerated by all patients—the most common side effects are nausea, diarrhea, and sleep disturbances; bradycardia is less common.

Rivastigmine is also available as a transdermal patch, which reduces gastrointestinal side effects. Rivastigmine and galantamine are also used to treat Lewy body dementia and dementia associated with Parkinson’s disease.

An NMDA receptor antagonist, approved for moderate to severe Alzheimer’s dementia. It acts on a different neurotransmitter pathway than cholinesterase inhibitors, which is why both medications are often used in combination. Well tolerated, with a moderate effect on activities of daily living and behavioral symptoms in advanced stages.

High-dose standardized ginkgo extract (EGb 761) has shown moderate effects in some studies for mild to moderate dementia. The S3 guideline lists it as an option, not as standard therapy. The evidence is weaker than for cholinesterase inhibitors and memantine.

The biggest change in the last two years. Both drugs are monoclonal antibodies that specifically remove beta-amyloid from the brain. They represent the first disease-modifying therapeutic approach—not merely symptom relief, but intervention in the underlying pathomechanism. This requires early, biomarker-based dementia diagnosis.

The CLARITY-AD study (van Dyck et al., NEJM 2023), involving approximately 1,800 patients, demonstrated a 27 percent slowdown in cognitive decline over 18 months. Approved in the U.S. and a number of other countries; in Germany, it is available through specialized centers.

The TRAILBLAZER-ALZ 2 study (Sims et al., JAMA 2023) demonstrated a similar, and in some cases greater, slowing of cognitive decline, particularly in patients with early Alzheimer’s pathology.

• Suitable only for mild cognitive impairment (MCI) or mild Alzheimer’s dementia—not for moderate or severe dementia
• Requires biomarker evidence of amyloid pathology (cerebrospinal fluid or amyloid PET)
• Contraindicated in patients with two copies of the APOE-ε4 variant due to increased risk of ARIA
• Caution is advised in patients with a history of microbleeds on MRI
• Regular MRI follow-ups are required due to the possibility of amyloid-related imaging abnormalities (ARIA)
• Infusion therapy should be administered at specialized centers with appropriate expertise
• Not effective for other forms of dementia (vascular, Lewy body, frontotemporal dementia)

The new antibodies are a first step, not an end goal. The slowdown of about one-third over 18 months is real and significant—but it does not reverse cognitive deficits. After twelve months of treatment, the patient has experienced less cognitive decline than she would have without treatment. However, she still has Alzheimer’s, and the disease continues to progress.

For most current dementia patients in Germany, the new therapies are not an option—either because the diagnosis was made too late, the pathology does not match, or the side effect profile is too risky.

→ For a detailed overview of Alzheimer’s disease: Alzheimer’s disease.

→ For information on the precursor to dementia: Mild Cognitive Impairment (MCI).

In addition to the core cognitive symptoms, behavioral symptoms and comorbid mental health conditions are among the most distressing aspects of dementia. Treating these symptoms presents its own challenges.

30 to 50 percent of people with dementia develop depression in old age—often during the phase when they are still aware of the changes in their condition. Treatment of choice is with SSRIs (sertraline, citalopram). Tricyclic antidepressants are on the PRISCUS list and should be avoided in older adults.

Common and distressing. Primary approach: sleep hygiene, day-night routine, light therapy. If necessary, low-dose mirtazapine; Z-drugs should be used rarely and only for a short time. Benzodiazepines should generally be avoided in the treatment of dementia—including as part of a consistent deprescribing strategy.

The most challenging situations. Primary approach: Identify the cause—pain, thirst, hunger, urinary retention, undiagnosed infection, inappropriate medications? Non-pharmacological interventions are the treatment of choice: a quiet environment, familiar people, music, validation.

If medication becomes unavoidable: low-dose risperidone or olanzapine for a short period, under close monitoring. Important to know: Neuroleptics increase mortality and the risk of stroke in patients with dementia. They are not intended for long-term use.

→ To distinguish between comorbid depression and dementia: Dementia or depression?

Focus: Cholinesterase inhibitors (if Alzheimer’s is diagnosed), non-pharmacological therapy, cognitive stimulation, social participation, early estate planning. In cases of early-stage Alzheimer’s disease confirmed by biomarkers, evaluate the indication for anti-amyloid antibodies.

Focus: Continuation or expansion of basic drug therapy (supplementing or switching memantine), structured daily support, day care, home care, clear daily structure, treatment of sleep and behavioral problems. Geriatric assessment helps to systematically identify support needs.

The focus shifts to comfort, dignity, pain relief, and the prevention of complications. Basic pharmacological therapy is critically reviewed—a gradual tapering off is often appropriate. Palliative care aspects become increasingly important. Discussions about treatment goals, advance directives, and care arrangements take center stage.

→ How to effectively conduct end-of-life conversations: Palliative care in older adults.

• Seek an early evaluation: Modern diagnostics—including biomarkers—open up treatment options that did not exist ten years ago. Start with a dementia evaluation.
• Have realistic expectations: None of the available medications cure dementia. All have only moderate effects.
• Take non-pharmacological therapy seriously: For most patients, it is the most important component.
• Arrange for advance care planning: Draw up a power of attorney for healthcare, a living will, and a guardianship directive early on.
• Take care of yourself: Family caregivers have a significantly increased risk of depression and exhaustion.
• Have medication reviewed regularly: Keyword: polypharmacy in older adults.

The most important question you should ask when making any treatment decision: What is the realistic goal of this treatment—and how will we assess whether it’s working?

Modern dementia treatment is significantly more effective when started early. Clear indications for a specialist evaluation:

• Onset of forgetfulness lasting weeks or months
• Disorientation that noticeably interferes with daily life
• Personality changes or social withdrawal
• Existing dementia without ongoing specific treatment
• Newly emerging behavioral abnormalities
• Unexplained deterioration despite ongoing treatment
• Questions regarding suitability for the new anti-amyloid antibodies

The first point of contact is the primary care physician, who will refer the patient to a memory clinic, a neurologist, a psychiatrist, or a geriatrician as needed. For complex situations—such as multimorbidity, polypharmacy, and accompanying frailty—the geriatric perspective is particularly valuable.

→ For detailed dementia diagnosis: Dementia Diagnosis.

→ For a comprehensive geriatric assessment: Geriatric Assessment.