What is the protocol for managing dementia?

Comprehensive Protocol for Managing Dementia

Non-pharmacological interventions should take precedence over pharmacotherapy in the management of dementia, especially for behavioral and psychological symptoms of dementia (BPSD). 1

Diagnosis Protocol

Initial Screening

• Use validated cognitive screening tools:
  • Mini-Mental State Examination (MMSE) - sensitivity and specificity >80% for dementia detection
  • Montreal Cognitive Assessment (MoCA) - superior sensitivity and specificity for mild cognitive impairment (MCI) and mild Alzheimer's Disease 1

Comprehensive Diagnostic Evaluation

1. Medical History

   • Document progressive cognitive decline
   • Evaluate for impairment in daily activities
   • Obtain corroboration from family member/caregiver 2

2. Cognitive Domain Assessment

   • Memory (particularly episodic memory)
   • Language
   • Visuospatial abilities
   • Executive function
   • Attention 1, 2

3. Physical and Neurological Examination

   • Look for focal neurological abnormalities that might suggest stroke or other conditions 2

4. Laboratory Testing

   • Complete blood count
   • Comprehensive metabolic panel
   • Thyroid function tests
   • Vitamin B12 level
   • Folate level

5. Brain Imaging

   • MRI preferred to identify:
     • Focal atrophy
     • Infarcts
     • Structural lesions
     • Disease-specific patterns of atrophy 1, 2

6. Additional Testing for Atypical Presentations

   • Consider cerebrospinal fluid analysis for biomarkers
   • Genetic testing for early-onset cases (before age 65)
   • Neuropsychological testing when cognitive assessment is inconclusive 2

Treatment Protocol

Non-Pharmacological Interventions (First-Line)

1. Cognitive Engagement Activities

   • Reading
   • Playing chess or card games
   • Music therapy
   • Art therapy
   • Reminiscence therapy 1, 2

2. Physical Exercise

   • Aerobic exercise (walking, swimming)
   • Anaerobic exercise (weightlifting) as appropriate
   • Adapt exercise to patient's functional abilities 1, 3

3. Dietary Recommendations

   • Mediterranean diet
   • Brain-healthy foods (nuts, berries, green leafy vegetables, fish) 1

4. Social Engagement

   • Family gatherings
   • Community activities
   • Support groups 2

Pharmacological Management

1. Alzheimer's Disease

   • Mild to Moderate AD:

     • Cholinesterase inhibitors (ChEIs):
       • Donepezil 5-10 mg daily (first-line)
       • Rivastigmine
       • Galantamine 1, 4, 2

   • Moderate to Severe AD:

     • Continue ChEIs
     • Add Memantine
     • Consider Donepezil 23 mg for patients stabilized on 10 mg with moderate-severe symptoms 1, 4

2. Parkinson's Disease Dementia

   • Rivastigmine (preferred) 2

3. Vascular Dementia

   • Address underlying vascular risk factors
   • ChEIs may provide modest benefit

4. Dementia with Lewy Bodies

   • ChEIs (careful with antipsychotics due to sensitivity)
   • Combination of pharmacological and physical therapies 3

5. Frontotemporal Dementia

   • Limited medication efficacy
   • Focus on symptom management
   • Combine with exercises aimed at emotion regulation 3

Management of Behavioral and Psychological Symptoms

1. First-Line: Non-Pharmacological Approaches

   • Identify and address triggers
   • Environmental modifications
   • Caregiver education and support
   • Structured daily routines 1

2. Second-Line: Pharmacological Management

   • Use medications only when non-pharmacological approaches have failed and symptoms cause significant distress
   • Target specific symptoms (agitation, psychosis, depression)
   • Use lowest effective dose for shortest duration
   • Monitor closely for adverse effects

End-of-Life Care

1. Palliative Care Focus

   • Improve quality of life
   • Maintain function
   • Maximize comfort 1

2. Symptom Management

   • Address pain, restlessness, constipation
   • Avoid unnecessary tests and interventions 1

3. Family Support

   • Caregiver education
   • Emotional support
   • Respite services 1

Caregiver Support

1. Education on Care Methods

   • Disease progression
   • Management techniques
   • Available resources 1

2. Support Services

   • Hotlines
   • Support groups
   • Respite care 1

Common Pitfalls to Avoid

1. Delayed Diagnosis

   • Early screening is crucial as symptoms progress in stages
   • Many cases remain undiagnosed until advanced stages 1

2. Overmedication

   • Prioritize non-pharmacological approaches before medications
   • Monitor for adverse effects of medications 1

3. Inadequate End-of-Life Care

   • Either too much intervention with little effect (tube feeding, unnecessary tests)
   • Or too little intervention (poor pain control, dehydration) 1

4. Neglecting Caregiver Needs

   • Caregiver burnout leads to poorer patient outcomes
   • Implement respite services and support systems 1