What are the management options for dementia?

Management of Dementia: A Comprehensive Approach

The management of dementia requires a comprehensive approach combining pharmacological and non-pharmacological interventions, with exercise and cognitive stimulation therapy as first-line treatments, followed by appropriate medication based on dementia type and severity. 1

Pharmacological Management

Medication Selection Based on Dementia Severity

• Mild to Moderate Dementia:

  • Cholinesterase inhibitors (ChEIs) are first-line pharmacological treatments 1
    • Donepezil: Start at low dose, titrate as tolerated
    • Rivastigmine: Start at 1-4 mg daily, can increase to 6-12 mg daily (more effective at higher doses) 2
    • Galantamine: Start at low dose, titrate as tolerated

• Moderate to Severe Dementia:

  • Memantine is indicated for moderate to severe Alzheimer's dementia 3
  • Consider combination therapy with ChEI plus memantine for severe Alzheimer's disease 1

Medication Monitoring

• Regularly assess cognitive, functional, neuropsychiatric, and behavioral symptoms during treatment 1
• Consider deprescribing ChEIs if:
  • Clinically meaningful worsening despite 12+ months of treatment
  • No observed benefit at any point during treatment
  • Development of severe/end-stage dementia
  • Intolerable side effects
  • Poor medication adherence 1

Behavioral and Psychological Symptoms of Dementia (BPSD) Management

Assessment

• Document type, frequency, severity, pattern, and timing of symptoms 4
• Rule out delirium and other medical causes 4
• Assess for pain and other potentially modifiable contributors 4

Non-Pharmacological Approaches (First Line)

• Environmental modifications
• Behavioral approaches
• Cognitive interventions 4

Pharmacological Approaches (Second Line)

• Antipsychotics only when symptoms are severe, dangerous, or cause significant distress:

  • Start with lowest effective dose of preferred antipsychotic (risperidone, olanzapine, or quetiapine)
  • Monitor closely for adverse effects (extrapyramidal symptoms, sedation, orthostatic hypotension)
  • All antipsychotics carry black box warnings for increased mortality in elderly patients with dementia 4

• SSRIs (citalopram, sertraline) may be used for depression/anxiety 4

Non-Pharmacological Interventions

Individual Level Interventions

1. Exercise (Strong Recommendation)

   • Group or individual physical exercise is strongly recommended 1, 5
   • Aerobic exercise shows significant benefits for cognitive function 5, 6
   • Combined aerobic and non-aerobic exercise interventions are most effective 5
   • Open-skill exercises (interactive activities requiring adaptation) may have stronger protective effects than closed-skill exercises 6

2. Cognitive Stimulation Therapy

   • Recommended for mild to moderate dementia 1
   • Provides general stimulation for thinking, concentration, and memory in a social setting 1
   • Can improve cognitive function and quality of life 7

3. Multifactorial Interventions

   • Combining physical activity, cognitive training, educational components, and social engagement shows benefits for:
     • Depression reduction
     • Improved sleep quality
     • Enhanced daily functioning
     • Better quality of life 7

4. Technology-Based Interventions

   • Digital health interventions providing music and reminiscence therapy
   • Social robots for interaction
   • Telehealth-based coaching or counseling
   • These show moderate to large effects on overall BPSD symptoms, particularly depression and agitation 8

Caregiver Support

• Psychosocial and psychoeducational interventions for caregivers 1
• Education about disease progression and management
• Connection with support resources
• Regular assessment of caregiver burden 4

Community Level Interventions

1. Dementia-Friendly Communities

   • Promotes inclusion of people with dementia and their caregivers 1
   • Improves outcomes for persons with dementia and caregivers 1

2. Case Management

   • Improves coordination and continuity of service delivery 1
   • Includes social aspects of care 1

End-of-Life Care

• Continuing care when symptoms worsen
• Palliative care for terminal stage
• Focus on improving quality of life, maintaining function, and maximizing comfort 1
• Comprehensive evaluation of health and function 1

Common Pitfalls to Avoid

• Using antipsychotics as chemical restraints
• Overlooking treatable causes of cognitive decline
• Neglecting caregiver needs and burden
• Failing to periodically reassess medication efficacy and side effects
• Not addressing comorbid medical conditions that can worsen dementia symptoms 4
• Using ChEIs for indications other than AD, PDD, DLB, or VD (e.g., frontotemporal dementia) 1

Personalized Approach Based on Dementia Type

• Alzheimer's Disease: Combination of ChEIs, possibly memantine, with exercise to enhance cerebral blood flow 9
• Lewy Body Dementia: Combination of pharmacological and physical therapies for cognitive and motor functions 9
• Frontotemporal Dementia: Focus on emotion regulation exercises and aerobic activities 9
• Mild Cognitive Impairment: Aerobic and functional exercises to delay cognitive decline 9