What are the diagnostic criteria and management strategies for Dementia (Degenerative Cognitive Disorder)?

From the Guidelines

Dementia diagnosis and management requires a comprehensive approach beginning with early recognition of cognitive decline through standardized assessments like the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA) 1. Diagnosis should include a thorough medical history, physical examination, cognitive testing, laboratory tests (complete blood count, thyroid function, vitamin B12, folate levels), and brain imaging (MRI or CT scan) to identify the cause and rule out reversible conditions. The diagnostic criteria for dementia involve detecting cognitive impairment through medical history and cognitive examination, with commonly used screening tools including MMSE and MoCA, which have high sensitivity and specificity in distinguishing elderly with dementia 1. For Alzheimer's disease, acetylcholinesterase inhibitors including donepezil (5-10mg daily), rivastigmine (1.5-6mg twice daily), and galantamine (8-12mg twice daily) are first-line medications that can temporarily improve cognitive symptoms 1. Memantine (5-10mg twice daily) may be added in moderate to severe cases. Vascular dementia management focuses on controlling cardiovascular risk factors with antihypertensives, statins, and antiplatelet therapy as appropriate. Non-pharmacological interventions are essential and include:

• Cognitive stimulation therapy
• Physical exercise
• Structured daily routines
• Caregiver education Behavioral symptoms should first be addressed with environmental modifications and behavioral strategies before considering medications like low-dose antipsychotics (quetiapine 25-50mg or risperidone 0.25-0.5mg) for severe agitation, used cautiously due to increased stroke and mortality risk 1. Regular monitoring of cognitive function, medication effectiveness, and side effects is crucial, with care plans adjusted as the disease progresses. Early advance care planning discussions are recommended to respect patient preferences regarding future medical interventions 1. Overall, the management of dementia should prioritize a person-centered and integrated approach, focusing on improving the quality of life of people with dementia and maintaining their functions, while also addressing the challenges of reducing the disease burden in the context of an aging population 1.

From the FDA Drug Label

The diagnosis of dementia was based on the criteria stipulated under the DSM-IV category “Dementia Due To Other General Medical Condition” (code 294. 1x), but patients were not required to have a distinctive pattern of cognitive deficits as part of the dementia. The diagnosis of idiopathic Parkinson's disease was based on the United Kingdom Parkinson's Disease Society Brain Bank clinical criteria.

The diagnostic criteria for Dementia include:

• DSM-IV category “Dementia Due To Other General Medical Condition” (code 294. 1x)
• United Kingdom Parkinson's Disease Society Brain Bank clinical criteria for idiopathic Parkinson's disease Management strategies for Dementia include:
• Rivastigmine tartrate treatment, which has been shown to improve cognitive performance in patients with mild-to-moderate Alzheimer's disease and Parkinson's disease dementia
• Memantine hydrochloride treatment, which has been shown to improve cognitive function and day-to-day function in patients with moderate to severe Alzheimer’s disease Key considerations:
• Patients with dementia should be assessed using instruments such as the ADAS-cog, ADCS-ADL, and SIB to evaluate cognitive function and day-to-day activities
• Treatment should be initiated and monitored by a healthcare professional, with regular assessments to determine the effectiveness of treatment and adjust the dose as needed 2, 3

From the Research

Diagnostic Criteria for Dementia

• Dementia can be accurately diagnosed through clinical evaluation, cognitive screening, basic laboratory evaluation, and structural imaging 4
• A standard diagnostic evaluation can be performed by family physicians over multiple visits, involving a clinical history, physical examination, and brief cognitive testing 4
• The diagnosis of dementia remains clinically integrative based on history, physical examination, and brief cognitive testing, with a number of core laboratory tests also recommended 4
• Diagnosing dementia requires a history evaluating for cognitive decline and impairment in daily activities, with corroboration from a close friend or family member, in addition to a thorough mental status examination by a clinician 5

Management Strategies for Dementia

• Management should include both nonpharmacologic and pharmacologic approaches, although efficacy of available treatments remains limited 5
• Nonpharmacologic approaches can include cognitively engaging activities, physical exercise, and socialization 5
• Pharmacologic approaches can provide modest symptomatic relief, with options including acetylcholinesterase inhibitors and memantine for Alzheimer disease 5
• Recognition and effective management strategies are necessary to provide comprehensive care for patients with dementia and their families 6

Assessment Tools for Dementia

• High-quality assessment tools are necessary to aid in the diagnosis of dementia and the management of its associated symptoms 7
• A comprehensive review of dementia-related tools has identified a set of recommended tools, the Dementia Outcomes Measurement Suite 7
• More research is needed to develop and validate tools to assess health-related quality of life and specific symptoms of dementia, including anxiety, wandering, and repetitive vocalizations 7