Acetylcholine is the neuro-transmitter most involved in creating new memories. As dementia progresses, acetyl-choline levels fall steeply. This decline is corrected by cholinesterase inhibitors, which boost the levels of available acetylcholine.
Three cholinesterase inhibitors are approved for treatment of Alzheimer's dis-ease: donepezil (Aricept), galantamine (Reminyl) and rivastigmine (Exelon). Mar-keting claims aside, there is little to distinguish between them in terms of efficacy.
Starting on half the rec-ommended dose reduces side effects (nausea, loose bowel motions, leg cramps and vivid dreams), which often settle within weeks. Gas-trointestinal symptoms are also mitigated by the use of Exelon patches. Cholinesterase inhibitors can aggravate peptic ulcer, asthma and bradycardia. The last of these is a particu-lar concern in patients taking beta blockers, which may need to be stopped. They also prolong the action of succinylcholine and other muscle-paralysing agents. Treatment must therefore be stopped briefly a day before surgery requir-ing the use of such agen
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