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Clinical Review State of the Art Review

Cognitive symptoms of Alzheimer’s disease: clinical management and prevention

BMJ 2019; 367 doi: (Published 06 December 2019) Cite this as: BMJ 2019;367:l6217
  1. Elizabeth Joe, assistant professor of clinical neurology1,
  2. John M Ringman, Helene and Lou Galen professor of clinical neurology1
  1. 1Alzheimer Disease Research Center, Department of Neurology, Keck School of Medicine at USC, 1520 San Pablo Street Suite 3000, Los Angeles, CA 90033, USA
  1. Correspondence to: E Joe Elizabeth.Joe{at}


Alzheimer’s disease (AD) is a progressive neurodegenerative disease characterized by the accumulation of amyloid β in the form of extracellular plaques and by intracellular neurofibrillary tangles, with eventual neurodegeneration and dementia. There is currently no disease-modifying treatment though several symptomatic medications exist with modest benefit on cognition. Acetylcholinesterase inhibitors have a consistent benefit across all stages of dementia; their benefit in mild cognitive impairment and prodromal AD is unproven. Memantine has a smaller benefit on cognition overall which is limited to the moderate to severe stages, and the combination of a cholinesterase inhibitor and memantine may have additional efficacy. Evidence for the efficacy of vitamin E supplementation and medical foods is weak but might be considered in the context of cost, availability, and safety in individual patients. Apparently promising disease-modifying interventions, mostly addressing the amyloid cascade hypothesis of AD, have recently failed to demonstrate efficacy so novel approaches must be considered.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.

  • Contributors: Both authors participated in formulating the search queries, reviewing the literature, and drafting and revising the manuscript. Both authors accept full responsibility for the work, had access to the data, and controlled the decision to publish.

  • Funding: This work was supported by NIH P50 AG-005142.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • Patient involvement: No patients were involved in the drafting or review of this manuscript.

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