What is the recommended treatment approach for patients with dementia?

Treatment Approach for Dementia

The treatment of dementia should prioritize non-pharmacological interventions as the foundation of care, with pharmacological therapy reserved for specific indications: cholinesterase inhibitors or memantine for cognitive symptoms in Alzheimer disease, and antipsychotics only for severe, dangerous agitation or psychosis after non-pharmacological approaches have been attempted. 1

Initial Assessment Framework

Before initiating any treatment, conduct a comprehensive evaluation to identify reversible contributors to cognitive decline 1:

• Assess and correct modifiable factors including vision impairment, hearing deficits (cerumen disimpaction, amplification), thyroid dysfunction, vitamin B12/folate deficiency, depression, sleep disorders, and problematic medications 1
• Evaluate for pain, discomfort, and mobility difficulties as these commonly exacerbate behavioral symptoms 1
• Document symptom patterns including type, frequency, severity, and timing of cognitive and behavioral symptoms using quantitative measures 1

Non-Pharmacological Interventions (Primary Treatment)

Most of the treatment approach should be non-pharmacological 1. The evidence strongly supports these interventions as first-line therapy 1:

Core Behavioral Strategies

• Implement structured daily routines with predictable activities, cognitive training (reading, music therapy, reminiscence therapy), and physical exercise programs 1, 2
• Modify the environment using communication strategies (calmer tones, simple single-step commands), behavioral modifications, and adapting supervision levels to account for memory loss 1
• Provide caregiver education and support including respite services, as caregiver stress directly impacts patient outcomes 1

Evidence-Based Non-Pharmacological Interventions

Recent evidence demonstrates that multifactorial non-pharmacological interventions improve depression, sleep disturbances, daily functioning, and quality of life 3. These include physical activity, cognitive training, and social engagement 1, 3.

Pharmacological Management

For Cognitive Symptoms

Base the decision to initiate pharmacological therapy on individualized risk-benefit assessment 1:

• Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) for mild to moderate Alzheimer disease 1, 4, 5, 6
• Memantine for moderate to severe Alzheimer disease, used alone or as add-on therapy to cholinesterase inhibitors 1, 4, 6
• Rivastigmine specifically for Parkinson disease dementia 5, 6

Important caveats: Start at low doses and titrate to the minimum effective dose as tolerated 1. The evidence for these medications shows only modest symptomatic benefit, with limited data in some populations (particularly intellectual disabilities) 1. Choice should be based on tolerability, adverse effect profile, ease of use, and cost, as evidence is insufficient to compare effectiveness between agents 1.

For Behavioral and Psychological Symptoms

Antipsychotics should only be used when symptoms are severe, dangerous, or cause significant patient distress 1:

• Review non-pharmacological interventions first before initiating antipsychotics in non-emergency situations 1
• Discuss risks and benefits with the patient (if feasible) and surrogate decision-maker, including increased mortality risk 1
• Start low, go slow: Initiate at low dose and titrate to minimum effective dose 1
• Reassess at 4 weeks: If no clinically significant response after 4-week trial at adequate dose, taper and withdraw the medication 1
• Consider tapering after symptom stabilization: Even with positive response, discuss potential tapering with patient/family 1

Deprescribing Considerations

Cognitive enhancers should be discontinued in specific situations 1:

• Mild cognitive impairment: Cholinesterase inhibitors and memantine should be deprescribed 1
• Lack of response or adverse effects: Taper and discontinue if clinically significant side effects occur or no benefit is observed 1

Follow-Up and Monitoring

• Schedule follow-up visits to review laboratory results, assess medication adherence and tolerance, and evaluate response using objective measures 1
• Reassess every 6 months for drug toxicity, new medical/psychiatric problems, and environmental issues as behaviors evolve 7
• Provide stage-specific education: Early-stage counseling on communication strategies and safety; mid-stage anticipatory guidance on dysphagia, mobility impairments, incontinence; late-stage discussions on advance directives and goals of care 1

Critical Pitfalls to Avoid

• Do not rush to pharmacological interventions before adequately trying non-pharmacological approaches 1, 7
• Do not overlook underlying medical conditions or pain that may cause or exacerbate symptoms 1
• Avoid medications with anticholinergic properties that worsen cognitive symptoms 7
• Do not neglect caregiver stress and depression which can inadvertently exacerbate patient behaviors 7