How should a patient with dementia, presenting with mobility and coordination issues, and an old basal ganglia infarct (cerebral vascular accident) on computed tomography (CT) scan, be further evaluated and managed?

From the Guidelines

The patient with dementia and mobility issues should undergo a comprehensive evaluation, including a complete neurological examination, assessment for parkinsonism, and evaluation for normal pressure hydrocephalus, to identify potentially treatable causes of their symptoms. This approach is supported by the Canadian Stroke Best Practice Recommendations: Vascular Cognitive Impairment, 7th edition practice guidelines update, 2024 1, which emphasizes the importance of recognizing the signs and symptoms of vascular cognitive impairment (VCI) and providing evidence-based guidelines for its management.

Key Components of Evaluation

• Complete neurological examination to assess cognitive and motor function
• Assessment for parkinsonism, given the patient's mobility issues and basal ganglia infarct
• Evaluation for normal pressure hydrocephalus, a potentially treatable cause of gait disturbance and dementia
• Additional imaging with MRI brain to better visualize white matter disease, atrophy patterns, and vascular pathology 1
• Laboratory tests, including vitamin B12, folate, thyroid function, complete blood count, comprehensive metabolic panel, and syphilis serology, to rule out other potential causes of cognitive decline

Management

• Management of underlying dementia with cognitive medications, such as donepezil 5-10mg daily or memantine 10mg twice daily, is recommended for patients with moderate-to-severe dementia 1
• Physical therapy for gait training and fall prevention
• Occupational therapy for home safety modifications
• Formal falls risk assessment and use of assistive devices, such as a walker, as needed
• Secondary stroke prevention measures, including antiplatelet therapy (aspirin 81mg daily), blood pressure control, lipid management, and lifestyle modifications, to address vascular risk factors 1

This comprehensive approach prioritizes the patient's morbidity, mortality, and quality of life, and is guided by the most recent and highest-quality evidence available 1.

From the FDA Drug Label

Figure 6 shows the cumulative percentages of patients from each of the treatment groups who had attained at least the measure of improvement in the ADCS-ADL shown on the X axis Figure 7 shows the time course for the change from baseline in SIB score for the two treatment groups over the 24 weeks of the study Figure 8 shows the cumulative percentages of patients from each treatment group who had attained at least the measure of improvement in SIB score shown on the X axis In a double-blind study of 12 weeks duration, conducted in nursing homes in Latvia, 166 patients with dementia according to DSM-III-R, a Mini-Mental State Examination score of < 10, and Global Deterioration Scale staging of 5 to 7 were randomized to either memantine hydrochloride or placebo

The patient with dementia, presenting with mobility and coordination issues, and an old basal ganglia infarct on computed tomography (CT) scan, cannot be directly evaluated and managed based on the provided information. The studies mentioned do not directly address the evaluation and management of a patient with these specific conditions.

• The provided text does not offer guidance on how to further evaluate and manage this patient.
• No conclusion can be drawn from the provided information regarding the evaluation and management of this patient. 2

From the Research

Evaluation and Management of Dementia with Mobility and Coordination Issues

The patient's presentation of dementia with mobility and coordination issues, along with an old basal ganglia infarct on CT scan, suggests a complex clinical picture that may involve vascular cognitive impairment or Alzheimer's disease.

• The diagnosis of dementia is clinical, but laboratory tests and imaging are used to rule out secondary causes 3.
• Vascular cognitive impairment describes a broad spectrum of cognitive impairments caused by cerebrovascular disease, and there are currently no pharmacological treatments recommended for improving cognition or function in people with vascular cognitive impairment 4.
• Cholinesterase inhibitors, such as donepezil, galantamine, and rivastigmine, are licensed for the treatment of dementia due to Alzheimer's disease and may have a slight beneficial effect on cognition in people with vascular cognitive impairment 4, 5.
• The treatment of severe Alzheimer's disease may involve the use of cholinesterase inhibitors, such as donepezil and rivastigmine, and the N-methyl-D-aspartate receptor antagonist memantine 6.
• Stroke risk factors, such as hypertension and diabetes, are independently associated with an increased risk of Alzheimer's disease and vascular cognitive impairment, and physicians should be aware of the importance of post-stroke care, including cognitive assessment 7.

Pharmacological Management

• Donepezil, galantamine, and rivastigmine are cholinesterase inhibitors that may be used to improve cognition in patients with Alzheimer's disease and vascular cognitive impairment 3, 4, 5.
• Memantine is an N-methyl-D-aspartate receptor antagonist that may be used to treat moderate-to-severe Alzheimer's disease 3, 6.
• The choice of medication and dosage should be individualized, and patients should be monitored periodically for clinical response and tolerability of medication 3.

Non-Pharmacological Management

• Patients with dementia and mobility and coordination issues may require assistance with daily functioning and may benefit from physical therapy and occupational therapy to improve mobility and coordination.
• Caregivers should be educated on how to support patients with dementia and mobility and coordination issues, and patients should be encouraged to participate in activities that promote cognitive and physical function.