What is the initial workup and treatment for a patient with dementia or worsening cognition?

From the Guidelines

The initial workup for a patient with dementia or worsening cognition should include a comprehensive evaluation to identify potentially reversible causes while establishing a baseline for future comparison, starting with a detailed history and physical examination, laboratory tests, neuroimaging, and formal cognitive assessment. Begin with a detailed history and physical examination, focusing on cognitive symptoms, functional abilities, and behavioral changes. Laboratory tests should include complete blood count, comprehensive metabolic panel, thyroid function tests, vitamin B12 level, folate level, and syphilis serology. Neuroimaging with either CT or MRI of the brain is recommended to rule out structural abnormalities. Formal cognitive assessment using standardized tools such as the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), or Saint Louis University Mental Status (SLUMS) examination helps quantify cognitive deficits. Some key points to consider in the workup and treatment of dementia include:

• The use of blood biomarker tests for amyloid pathology, which can help identify patients with Alzheimer's disease and guide treatment decisions 1
• The importance of addressing reversible causes of cognitive decline, such as vitamin deficiencies or thyroid disorders, before initiating treatment for dementia
• The role of cholinesterase inhibitors and memantine in the treatment of Alzheimer's disease, and the need for careful consideration of the benefits and risks of these medications in individual patients 1
• The importance of non-pharmacological interventions, such as establishing routine, providing cognitive stimulation, and addressing safety concerns, in the management of dementia
• The need for caregiver education and support, as caregivers play a critical role in the care and management of patients with dementia. Treatment initially focuses on addressing any reversible causes identified during workup. For Alzheimer's disease, cholinesterase inhibitors like donepezil (starting at 5mg daily, increasing to 10mg after 4-6 weeks if tolerated), rivastigmine (patch starting at 4.6mg/24hr, increasing to 9.5mg/24hr after 4 weeks), or galantamine (starting at 4mg twice daily, gradually increasing to 12mg twice daily) may be prescribed. For moderate to severe Alzheimer's, memantine (starting at 5mg daily, titrating to 10mg twice daily) may be added. These interventions are recommended because they address the multifactorial nature of cognitive decline and provide symptomatic relief while potentially slowing progression in some cases.

From the FDA Drug Label

The effectiveness of treatment with 23 mg/day was determined using a dual outcome assessment strategy that evaluated cognitive function using an instrument designed for more impaired patients and overall function through caregiver-rated assessment.

The initial workup and treatment for a patient with dementia or worsening cognition may involve a comprehensive diagnostic evaluation, including:

• Cognitive function assessment using instruments such as the Severe Impairment Battery (SIB) or the Mini-Mental State Examination (MMSE)
• Caregiver-rated assessment using instruments such as the Clinician’s Interview-Based Impression of Change (CIBIC-plus)
• Medical history and physical examination to rule out other potential causes of cognitive decline
• Laboratory tests and imaging studies as needed to support the diagnosis

Treatment may involve the use of cholinesterase inhibitors such as donepezil, which has been shown to be effective in improving cognitive function in patients with moderate to severe Alzheimer's disease 2. However, the specific treatment approach will depend on the individual patient's needs and circumstances.

From the Research

Initial Workup for Dementia or Worsening Cognition

• A thorough medical history and physical examination are essential in evaluating patients with suspected dementia, including a discussion with family members to corroborate cognitive decline and impairment in daily activities 3, 4.
• A baseline measurement of cognitive function should be obtained, with the Mini-Mental State Examination being the most commonly used instrument to document cognitive impairment 5.
• Initial laboratory evaluation includes tests for:
  • Thyroid-stimulating hormone levels 5, 6
  • Vitamin B12 levels 5, 6
  • Complete blood count and electrolyte, glucose, calcium levels 6
• Structural neuroimaging with noncontrast computed tomography or magnetic resonance imaging is also recommended 5, 6.
• Neuropsychologic testing can help determine the extent of cognitive impairment, but it is not recommended on a routine basis, and may be most helpful in situations where screening tests are normal or equivocal 5, 3.

Additional Evaluation and Treatment

• Additional evaluation with cerebrospinal fluid assays or genetic testing may be considered in atypical dementia cases, such as age of onset younger than 65 years, rapid symptom onset, and/or impairment in multiple cognitive domains but not episodic memory 3.
• Patients may benefit from nonpharmacologic approaches, including cognitively engaging activities, physical exercise, and socialization 3.
• Pharmacologic approaches can provide modest symptomatic relief, with options including:
  • Acetylcholinesterase inhibitors such as donepezil for mild to severe dementia 3
  • Memantine for moderate to severe dementia 3
  • Rivastigmine for symptomatic Parkinson disease dementia 3