What is the recommended treatment plan for a patient with a dementia diagnosis?

Treatment Plan for Dementia

The recommended treatment plan for a patient with dementia should include cholinesterase inhibitors (donepezil, rivastigmine, galantamine) for mild to moderate dementia and memantine for moderate to severe dementia, alongside comprehensive non-pharmacological interventions including exercise, cognitive stimulation therapy, and caregiver support. 1, 2

Pharmacological Management

Cognitive Enhancers

• For mild to moderate dementia (Alzheimer's, Parkinson's dementia, Lewy body dementia, or vascular dementia):

  • Start with cholinesterase inhibitors (ChEIs) 2
  • Donepezil: Start at 5 mg/day, may increase to 10 mg/day after 4 weeks 3
  • Monitor for response over 12 weeks; expect modest improvements in cognition (1.9-2.9 points on ADAS-Cog scale) 4, 5

• For moderate to severe dementia:

  • Memantine is FDA-approved specifically for moderate to severe Alzheimer's dementia 6
  • Consider combination therapy (memantine plus ChEI) for severe cases 2

Deprescribing Considerations

• Consider discontinuing cognitive enhancers if 1:

  • No clinically meaningful benefit observed after 12 months
  • Development of intolerable side effects (nausea, vomiting, dizziness, falls)
  • Severe/end-stage dementia with limited life expectancy
  • Poor medication adherence

• Important: Do not discontinue ChEIs in patients with clinically meaningful psychotic symptoms, agitation, or aggression until these symptoms have stabilized 1

• When discontinuing, taper gradually (reduce dose by 50% every 4 weeks) and monitor for worsening symptoms 1

Non-Pharmacological Interventions

Individual Level Interventions

• Exercise therapy: Implement regular physical exercise (group or individual) 1, 2
• Cognitive stimulation: Offer activities providing general stimulation for thinking, concentration, and memory in a social setting 1, 2
• Sensory interventions: Address hearing, vision, and olfactory deficits that may worsen cognitive symptoms 1

Behavioral Symptom Management

• For agitation or psychosis: Use antipsychotics only when symptoms are severe, dangerous, or cause significant distress, and after non-pharmacological interventions have failed 1
• Before using antipsychotics:
  • Assess for pain and other potentially modifiable contributors to symptoms 1
  • Review clinical response to non-pharmacological interventions 1
  • Discuss potential risks and benefits with patient/surrogate decision maker 1
  • Start at low dose and titrate to minimum effective dose 1
  • Discontinue if no clinically significant response after 4 weeks 1

Caregiver Support

• Provide psychosocial and psychoeducational interventions for caregivers 1
• Include education, counseling, information regarding services, and strategy development 1

Monitoring and Follow-up

• Use quantitative measures to assess response to treatment for agitation or psychosis 1
• Schedule regular follow-up visits to assess:
  • Medication adherence, tolerance, and effectiveness 2
  • Cognitive, functional, and behavioral symptoms 2
  • Need for adjustment of interventions based on disease progression 2

Community-Level Support

• Consider case management to improve coordination and continuity of care 1
• Promote development of dementia-friendly organizations/communities 1

Diagnostic Workup Considerations

• Neuroimaging: MRI is recommended over CT for investigating vascular cognitive impairment 1
• Biomarker testing: Consider in atypical presentations, but discourage amyloid and tau imaging without memory decline outside research settings 1, 2

Common Pitfalls to Avoid

• Inappropriate medication use: ChEIs and memantine should be deprescribed for individuals with mild cognitive impairment 1
• Inadequate assessment: Failure to assess for pain and other modifiable contributors to behavioral symptoms 1
• Premature antipsychotic use: Using antipsychotics before trying non-pharmacological interventions 1
• Inadequate monitoring: Not using quantitative measures to assess treatment response 1
• Inappropriate discontinuation: Stopping ChEIs in patients whose neuropsychiatric symptoms have responded to treatment 1