Pharmacological interventions for cognitive symptoms are limited. NICE guidelines for dementia recommend three anticholinesterase inhibitors (donepezil, galantamine and rivastigmine) or the glutamate receptor antagonist, memantine.⁸

Acetylcholine is a core neurotransmitter in the brain. Inhibiting cholinesterase enzymes can support cholinergic transmission by slowing down choline clearance. Anticholinesterase is the predominant cholinesterase in the brain, whereas butyrylcholinesterase is present mainly outside the central nervous system.³³

While usually given for Alzheimer, anticholinesterase inhibitors may help with Lewy bodies dementias, and in a mixed dementia diagnosis of Alzheimer's disease with vascular dementia.⁴

Donepezil is a selective acetylcholinesterase inhibitor and is indicated for symptomatic treatment of mild to moderately severe Alzheimer's dementia. Rivastigmine inhibits both acetyl- and butyrylcholinesterases of the carbamate type. It may have an ameliorative effect on cholinergic-mediated cognitive deficits in dementia associated with Alzheimer's and Parkinson's disease.³³

Galantamine is a selective acetylcholinesterase inhibitor and enhances the intrinsic action of acetylcholine on nicotinic receptors to improve cognitive function.³³

Another neurotransmitter implicated in dementia is glutamate. Malfunctioning glutamate neurotransmission, especially at N-methyl-D-aspartate (NMDA) receptors, may contribute to symptoms and disease progression in neurodegenerative dementia. Memantine is an NMDA receptor antagonist which can modify the effects of increased glutamate levels.³³