What is the recommended workup and treatment for dementia?

Comprehensive Workup and Treatment for Dementia

A comprehensive dementia workup should include cognitive assessment using validated tools like MoCA or MMSE, laboratory testing for reversible causes, neuroimaging, and treatment with both non-pharmacological approaches and appropriate medications based on dementia severity. 1, 2

Diagnostic Workup

Cognitive Assessment

• Use standardized cognitive screening tools to document cognitive impairment 1, 2:
  • Mini-Mental State Examination (MMSE) - widely used with high sensitivity for moderate dementia
  • Montreal Cognitive Assessment (MoCA) - more sensitive for mild cognitive impairment
  • Clock Drawing Test - useful supplementary screening tool
  • Mini-Cog or GP Assessment of Cognition (GPCOG) for rapid screening

Informant Assessment

• Obtain corroborative history from a reliable informant about changes in 1:
  • Cognition - using tools like AD8, IQCODE, or Quick Dementia Rating System
  • Function - using Pfeffer Functional Activities Questionnaire (FAQ) or Disability Assessment for Dementia (DAD)
  • Behavior - using Neuropsychiatric Inventory (NPI-Q) or Mild Behavioural Impairment Checklist (MBI-C) 1

Laboratory Testing

• Core laboratory investigations 1, 2, 3:
  • Complete blood count
  • Comprehensive metabolic panel (electrolytes, glucose, calcium)
  • Thyroid function tests
  • Vitamin B12 and folate levels
  • Liver function tests

Neuroimaging

• Anatomical neuroimaging is recommended in most situations 2, 3:
  • MRI preferred over CT, especially for detecting vascular lesions
  • Particularly important with onset of cognitive symptoms within past 2 years, unexpected decline, recent head trauma, unexplained neurological manifestations, or significant vascular risk factors

Additional Assessments

• Sleep history assessment, including sleep time, insomnia, daytime sleepiness, and REM sleep behavior disorder 1
• Hearing assessment - ask about difficulty hearing in everyday life 1
• Assessment for neuropsychiatric symptoms using validated tools 1

Treatment Approaches

Pharmacological Treatment

• For Alzheimer's disease 1, 4, 5, 3:
  • Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) for mild to moderate dementia
  • Memantine for moderate to severe dementia
  • Combination therapy (memantine plus cholinesterase inhibitor) may be considered for severe Alzheimer's disease

Non-Pharmacological Interventions

• Physical activity interventions 1:

  • Aerobic exercise and/or resistance training of at least moderate intensity
  • Consider dance interventions and mind-body exercise (Tai Chi, Qigong)

• Dietary recommendations 1:

  • Mediterranean diet
  • High consumption of mono- and polyunsaturated fatty acids
  • Low consumption of saturated fatty acids
  • Increased fruit and vegetable intake

• Cognitive engagement 1, 3:

  • Reading, playing chess, music or art therapy
  • Reminiscence therapy
  • Socialization activities

Management of Contributing Factors

• Address hearing impairment through audiological examination and appropriate interventions 1
• Optimize sleep through assessment and management of sleep disorders 1
• Review and adjust medications that may contribute to cognitive impairment 1

Follow-up and Monitoring

• Track response to treatment using a multi-dimensional approach 1, 2:
  • Assess cognition, functional autonomy, behavioral symptoms, and caregiver burden
  • Follow-up every 6-12 months, with more frequent assessment for patients with behavioral symptoms
  • Use MMSE or other validated tools to track cognitive changes over time

Special Considerations

• For patients with subjective cognitive decline but normal cognitive testing 1:

  • Conduct appropriate diagnostic workup to identify reversible causes
  • Obtain reliable informant information about changes in cognition, function, and behavior
  • Consider annual follow-ups if corroborative history is positive

• For end-of-life care 1:

  • Focus on improving quality of life and maximizing comfort
  • Provide continuing care for those who can no longer stay at home
  • Consider palliative care for terminal stages

Common Pitfalls to Avoid

• Relying solely on cognitive screening without functional assessment 1
• Failing to obtain corroborative history from a reliable informant 1
• Not considering multiple contributing pathologies (most dementia cases have more than one underlying cause) 3, 6
• Overlooking potentially reversible causes of cognitive impairment 7, 8, 9
• Focusing only on pharmacological treatments without implementing non-pharmacological approaches 1, 3