What is the recommended management plan for patients with dementia?

Management of Dementia

Exercise (group or individual physical activity) should be implemented for all patients with dementia, as this is the strongest evidence-based non-pharmacological intervention. 1

Non-Pharmacological Management (First-Line Approach)

Individual-Level Interventions

• Implement exercise programs (group or individual physical exercise) for all people living with dementia, though specific duration or intensity cannot be recommended at this time 1

• Consider group cognitive stimulation therapy for patients with mild to moderate dementia, which provides enjoyable activities offering general stimulation for thinking, concentration, and memory in a social setting 1

• Provide psychoeducational and psychosocial interventions for caregivers, including education, counseling, information about services, enhancing care skills, problem-solving, and strategy development 1

Medication Rationalization

• Conduct multidimensional health assessment focusing on medication use to identify reversible or modifiable health conditions and rationalize medications 1

• Avoid or discontinue medications with anticholinergic properties when alternatives exist for conditions like depression, neuropathic pain, or urge incontinence 1

Community-Level Support

• Consider case management to improve coordination and continuity of service delivery, including social aspects of care 1

• Develop dementia-friendly organizations/communities that promote inclusion of people with dementia and caregivers in decisions and discussions 1

Pharmacological Management

Cognitive Enhancers for Alzheimer's Disease, Parkinson's Disease Dementia, Lewy Body Dementia, or Vascular Dementia

• Use cholinesterase inhibitors (donepezil, rivastigmine) at optimal therapeutic doses for mild to moderate dementia 1, 2

• Use memantine (alone or as add-on therapy to cholinesterase inhibitors) for moderate to severe dementia 1, 3, 2

• Consider rivastigmine specifically for patients with rapid cognitive decline (MMSE loss ≥3 points in 6 months), particularly those with vascular risk factors, as it may offer additive benefit over donepezil 1

• Consider combination therapy of cholinesterase inhibitor plus memantine for moderate to severe disease, though evidence for this combination is equivocal 1

Special Considerations for Rapid Cognitive Decline

When patients exhibit rapid decline (MMSE loss ≥3 points in 6 months):

• Rule out delirium from infections, toxic-metabolic causes, stroke, depression, and anticholinergic drug effects 1

• Perform or repeat brain imaging (CT or MRI) to identify white matter changes, lacunar infarctions, or other structural changes 1

• Implement more frequent follow-up to anticipate rapid loss of autonomy and increased caregiver burden 1

• Systematically control vascular risk factors, as these are often present in rapid decliners 1

Deprescribing Anti-Dementia Drugs

Decisions about deprescribing cognitive enhancers must consider patient preferences (if capable), prior expressed wishes, and collaboration with family or substitute decision makers. 1

When to Consider Discontinuing Cholinesterase Inhibitors

For patients taking cholinesterase inhibitors for >12 months, discontinuation should be considered if:

• Clinically meaningful worsening of dementia (cognition, functioning, or global assessment) over past 6 months without other medical conditions (delirium, significant illness) or environmental factors (recent residence transition) explaining the decline 1

• No clinically meaningful benefit was observed at any time during treatment (no improvement, stabilization, or decreased rate of decline) 1

• Severe or end-stage dementia (dependence in most basic activities of daily living, inability to respond to environment, or limited life expectancy) 1

• Intolerable side effects develop (severe nausea, vomiting, weight loss, anorexia, falls) 1

• Poor medication adherence precludes safe ongoing use or ability to assess effectiveness 1

Inappropriate Cholinesterase Inhibitor Use

• Discontinue cholinesterase inhibitors prescribed for indications other than AD, PDD, DLB, or VD (e.g., frontotemporal dementia, other neurodegenerative conditions) 1

When to Consider Discontinuing Memantine

For patients taking memantine for >12 months, apply the same discontinuation criteria as for cholinesterase inhibitors listed above 1

Common Pitfalls to Avoid

• Avoid initiating pharmacological treatment before ruling out reversible causes including infections, metabolic disturbances, stroke, depression, and anticholinergic medication effects 1, 2

• Avoid using medications with anticholinergic properties that worsen cognitive symptoms 1

• Avoid fixed-dose escalation protocols that ignore tolerability, as this leads to high dropout rates (particularly with higher doses like rivastigmine 9 mg/day) 4

• Avoid continuing cholinesterase inhibitors in frontotemporal dementia or other non-approved indications where they provide no benefit 1

• Avoid neglecting caregiver burden and support needs, as this impacts both patient and caregiver outcomes 1