Dementia Pharmacotherapy Guidelines: Emphasizing Non-Pharmacological Approaches in Dutch Care

Dementia Pharmacotherapy Guidelines in the Netherlands continue to emphasize a primarily non-pharmacological approach to care. The revised Dutch pharmacotherapeutic consultation document highlights the modest clinical benefits of available drug treatments and assigns cholinesterase inhibitors (donepezil, galantamine, and rivastigmine) and memantine only a restricted place in therapy.

Cholinesterase inhibitors and memantine are consistently characterized as having small, often non-clinically meaningful benefits on cognition, daily functioning, and neuropsychiatric symptoms. For mild-to-moderate Alzheimer’s disease, these agents may be considered in secondary care as adjuncts to non-drug interventions, with rivastigmine patches preferred for their better gastrointestinal tolerability. In moderate-to-severe stages, memantine’s effect on functional status is even smaller, and its long-term effectiveness remains unknown. Dementia pharmacotherapy guidelines give cholinesterase inhibitors a somewhat stronger position for neuropsychiatric symptoms in Lewy body dementia and Parkinson’s disease dementia, although the supporting evidence is rated low to very low. Clear stop criteria are defined, including lack of response, rapid decline, severe side effects, poor adherence, or frailty.

Non-Pharmacological Care as the Foundation

All treatment pathways begin with mandatory comprehensive non-pharmacological management. This includes patient and caregiver education, case management from the moment dementia is suspected, biannual evaluation of individualized care plans focused on patient goals, and tailored interventions such as occupational therapy, music therapy, physical exercise, and cognitive training. A structured medication review is required, with particular attention to stopping anticholinergic drugs. Physical health, oral care, nutrition, fall prevention, caregiver burden, and signs of neglect are all explicitly addressed before any drug treatment is considered. Pharmacotherapy is reserved for secondary care specialists experienced in dementia.

Cautious Use in Acute Situations

In acute crisis situations, benzodiazepines or haloperidol are recommended only when non-drug de-escalation strategies have failed. Haloperidol carries clear contraindications in Lewy body dementia and Parkinson’s disease dementia.

Implications for Reimbursement and Market Access

This conservative stance, including the explicit exclusion of donanemab despite its recent European approval, reinforces the high evidentiary bar set by Dutch payers. The consultatiedocument FK Dementie herziening signals that only therapies demonstrating substantial added value over well-implemented supportive care are likely to achieve favorable reimbursement in the Netherlands.