What is the approach to managing dementia?

Comprehensive Approach to Dementia Management

The DICE approach (Describe, Investigate, Create, Evaluate) should be the primary framework for managing dementia, with non-pharmacological interventions as first-line treatment before considering medications. 1

Initial Assessment and Diagnosis

• Conduct thorough cognitive assessment using standardized tools like the Mini-Mental State Examination (MMSE), with scores ≤23 suggesting dementia 1
• Evaluate for comorbid medical conditions that may worsen cognitive function, including cardiovascular disease, infections, and sensory impairments 1
• Perform neuroimaging to identify structural changes including focal atrophy, infarcts, or tumors that may not be evident on physical examination 2
• Consider additional evaluation with cerebrospinal fluid assays or genetic testing in atypical cases (onset <65 years, rapid progression) 2

Non-Pharmacological Management

Behavioral and Psychological Symptoms of Dementia (BPSD)

• Apply the DESCRIBE step: Characterize specific behaviors by asking caregivers to detail the antecedents, behaviors, and consequences "as if in a movie" 1
• INVESTIGATE step: Examine for underlying causes including undiagnosed medical conditions, pain, medication side effects, and environmental triggers 1
• CREATE step: Develop personalized interventions addressing patient, caregiver, and environmental factors 1
• EVALUATE step: Assess effectiveness of interventions and adjust as needed 1

Environmental and Behavioral Modifications

• Establish structured daily routines with predictable activities to reduce confusion and anxiety 3
• Ensure adequate daytime light exposure (2 hours in morning at 3,000-5,000 lux) to regulate circadian rhythms 3
• Increase daytime physical activities and social engagement to promote better sleep-wake cycles 3
• Implement cognitive training activities such as reading, playing chess, music therapy, and reminiscence therapy 1
• Encourage Mediterranean diet rich in nuts, berries, green leafy vegetables, and fish 1

Caregiver Support

• Educate caregivers that behaviors are symptoms of the disease, not intentional actions 3
• Improve communication techniques: use calmer tones, simple single-step commands, and reassuring touch 3
• Avoid negative interactions such as harsh tones, complex multi-step commands, and open-ended questioning 3
• Provide respite services and support programs for caregivers to reduce burden 1

Pharmacological Management

Cognitive Symptoms

• For mild to moderate Alzheimer's disease: Cholinesterase inhibitors like donepezil (starting at 5mg/day, may increase to 10mg/day) 4, 1
• For moderate to severe Alzheimer's disease: Consider memantine alone or as add-on therapy to cholinesterase inhibitors 2, 1
• For Parkinson's disease dementia: Rivastigmine can be used to treat symptomatic manifestations 2

Behavioral Symptoms

• Investigate potential medical causes (UTIs, dehydration, constipation) before initiating medications 3
• Use atypical antipsychotics only after all non-pharmacological measures have failed or in cases of severe self-harm or harm to others 5
• Discontinue antipsychotics after cessation of behavioral disturbances or if side effects develop 5
• Consider SSRIs for managing disinhibition and compulsive behaviors 3
• For sleep disturbances, melatonin may be considered, though evidence is inconsistent (10mg dose showed trend toward improvement) 3

Continuous Care and Follow-up

• Implement regular, preplanned medical follow-up for all patients with dementia 5
• Evaluate response to interventions within 30 days and adjust treatment plan accordingly 3
• For patients on psychotropics, conduct close monitoring for adverse effects 3
• Consider tapering or discontinuing pharmacological treatments after 6 months of symptom stabilization 3
• Reassess for drug toxicity and new medical, psychiatric, or environmental problems every six months as new behaviors emerge over the course of dementia 1

End-of-Life Care

• Provide palliative care focused on improving quality of life, maintaining function, and maximizing comfort 1
• Comprehensively evaluate health and function when prolonging life is no longer meaningful 1
• Address issues related to nutrition, feeding difficulties, bowel and urinary disorders, mobility problems, and pressure ulcerations 1

Common Pitfalls to Avoid

• Rushing to pharmacological interventions before adequately trying non-pharmacological approaches 1
• Failing to identify underlying medical conditions or pain that may be causing or exacerbating behavioral symptoms 1
• Misinterpreting symptoms (e.g., "agitation" may encompass anxiety, repetitive questions, aggression, or wandering) 1
• Using medications with anticholinergic properties that may worsen cognitive symptoms 1
• Overlooking caregiver stress and depression that may inadvertently exacerbate patient behaviors 1