Follow-up Visit Components for Patients with Dementia
A comprehensive follow-up visit for a patient with dementia should include assessment of cognition, functional autonomy, behavior, and caregiver burden, with all domains evaluated at least annually. 1
Core Assessment Areas
Cognitive Assessment
- Use standardized cognitive screening tools to track changes over time 1
- Mini-Mental State Examination (MMSE) is recommended as a primary tool for tracking cognitive response due to its widespread use in clinical trials 1
- Alternative tools include Montreal Cognitive Assessment (MoCA), Modified MMSE (3MS), Rowland Universal Dementia Assessment Scale (RUDAS), or Clock Drawing Test 1, 2
- Longitudinal assessment with these scales is more meaningful than single time point evaluations 1
Functional Assessment
- Evaluate performance on both Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs) 1
- Use validated, familiar tools such as:
- Assessment should include impact on ability to manage finances, medications, transportation, household management, cooking, and shopping 2
Behavioral Assessment
- Evaluate for presence of behavioral and psychological symptoms of dementia 1
- Use validated tools such as:
- Patients with behavioral symptoms may require more frequent reassessment than the standard 6-12 month interval 1
Caregiver Assessment
- Evaluate caregiver burden at each follow-up visit, as it is a major determinant of hospitalization and nursing home placement 1, 3
- Consider using structured scales such as the Zarit Burden Interview 1
- Assess caregiver needs for education, support, and respite services 1, 3
Medication Review
- Evaluate response to cognitive enhancing medications (cholinesterase inhibitors, memantine) 4, 5
- Assess for side effects, adherence, and need for dose adjustments 4, 5
- Review all medications for potential inappropriate prescribing, drug interactions, and opportunities for deprescription 6
- For patients with moderate to severe Alzheimer's disease, consider combination therapy with cholinesterase inhibitor and memantine 5, 7
- Evaluate the ongoing need for antipsychotics if prescribed for behavioral symptoms, with aim to discontinue after resolution of symptoms 8
Medical Assessment
- Monitor and manage vascular risk factors (hypertension, diabetes) as they impact dementia progression 1, 8
- Assess for pain using validated tools, as pain may present as behavioral disturbances in patients with dementia 8
- Screen for new medical conditions that could worsen cognitive function (infections, metabolic disorders, etc.) 9
- Consider neuroimaging in cases of unexpected decline in cognition/function, new neurological symptoms, or significant head trauma 1
Follow-up Planning
- Schedule follow-up visits every 6-12 months for stable patients 1, 3
- Consider more frequent visits (every 3-4 months) for patients with behavioral symptoms or rapid decline 1, 2
- Ensure all domains (cognition, function, behavior, caregiver burden) are assessed at least annually 1
- Consider referral to specialists for atypical presentations, rapid progression, or complex behavioral symptoms 3
Common Pitfalls to Avoid
- Relying on a single tool or clinical domain for assessment 1
- Failing to obtain reliable informant input about changes in cognition, function, and behavior 1, 3
- Overlooking caregiver burden assessment, which strongly predicts institutionalization 1, 3
- Neglecting to assess medication management abilities as cognitive impairment progresses 6
- Delaying specialist referral for patients with atypical or rapidly progressive symptoms 3
By following this structured approach to follow-up visits, clinicians can effectively monitor disease progression, optimize treatment, support caregivers, and ultimately improve outcomes for patients with dementia.