What is the recommended management plan for patients with dementia?

Management of Dementia

Dementia management should prioritize non-pharmacological interventions first, with pharmacological therapy reserved for specific cognitive and behavioral symptoms that respond to medication, using cholinesterase inhibitors for mild-to-moderate disease and memantine for moderate-to-severe disease. 1

Initial Assessment and Workup

Before initiating any treatment, identify and address reversible or modifiable contributors to cognitive decline:

• Correct sensory impairments: vision correction, cerumen disimpaction, hearing amplification 1
• Evaluate and treat depression with antidepressants if indicated 1
• Review and optimize all medications: eliminate or reduce problematic medications, especially those with anticholinergic properties 1
• Address sleep disorders: initiate continuous positive airway pressure or other interventions 1
• Investigate and treat underlying pain, discomfort, and mobility difficulties 1
• Optimize thyroid supplementation if hypothyroidism present 1
• Conduct multidimensional health assessment to identify all reversible conditions 1

Non-Pharmacological Management (First-Line Approach)

Individual-Level Interventions

Exercise is strongly recommended for all patients with dementia (group or individual physical exercise, though specific duration and intensity cannot be specified) 1

Group cognitive stimulation therapy should be considered for mild-to-moderate dementia, offering enjoyable activities providing general stimulation for thinking, concentration, and memory in a social setting 1

Cognitive training activities including reading, playing chess, music therapy, art therapy, and reminiscence therapy may have positive impact on cognition 1

Dietary recommendations: Mediterranean diet rich in nuts, berries, green leafy vegetables, and fish 1

Behavioral and Psychological Symptoms Management (DICE Approach)

The American Geriatrics Society endorses a structured four-step approach for managing neuropsychiatric symptoms 1:

DESCRIBE step: Characterize specific behaviors by asking caregivers to detail the antecedents, behaviors, and consequences "as if in a movie" 1, 2

INVESTIGATE step: Examine for underlying causes including:

• Undiagnosed medical conditions (infections, cardiovascular disease) 1, 2
• Unrecognized or undertreated pain 1, 2
• Medication side effects or drug toxicity 1, 2
• Environmental triggers (excessive noise, crowding, poor lighting) 1, 2
• Delirium or other acute medical problems 1

CREATE step: Develop personalized interventions addressing patient, caregiver, and environmental factors 1, 2

EVALUATE step: Assess effectiveness of interventions within 30 days and adjust as needed 1, 2

Caregiver Support

Psychosocial and psychoeducational interventions for caregivers are strongly recommended, including education, counseling, information regarding services, enhancing carer skills, problem-solving, and strategy development 1

Case management should be considered to improve coordination and continuity of service delivery including social aspects of care 1

Dementia-friendly organizations/communities should be developed to promote inclusion of people with dementia and their caregivers in decisions and discussions 1

Pharmacological Management

Cognitive Symptoms

For mild-to-moderate Alzheimer's disease, Parkinson's disease dementia, Lewy body dementia, or vascular dementia:

Cholinesterase inhibitors are recommended 1:

• Donepezil: Start 5 mg once daily, may increase to 10 mg daily after 4-6 weeks 3
• Rivastigmine: Initiate 1.5 mg twice daily, increase by 1.5 mg twice daily every 4 weeks as tolerated, maximum 6 mg twice daily 1, 4
• Galantamine: Start 4 mg twice daily with meals, increase to 8 mg twice daily after 4 weeks, may increase to 12 mg twice daily based on tolerability 3

For moderate-to-severe Alzheimer's disease, Parkinson's disease dementia, Lewy body dementia, or vascular dementia:

Memantine is recommended alone or in combination with a cholinesterase inhibitor 1:

• Start 5 mg once daily, increase weekly by 5 mg/day in divided doses to 20 mg/day (10 mg twice daily) 5
• Combination therapy with donepezil provides cumulative, additive benefits over monotherapy 3, 5

Behavioral and Psychological Symptoms

Non-pharmacological approaches should be attempted first before considering psychotropic medications 1, 2

Psychotropics are unlikely to impact: unfriendliness, poor self-care, memory problems, inattention, repetitive verbalizations/questioning, rejection of care, shadowing, or wandering 1

When psychotropics are considered, they should target only specific symptoms that respond to medication (such as severe agitation, aggression, or psychosis) after ruling out underlying medical causes 1, 2

Deprescribing Considerations

Discontinuation of cholinesterase inhibitors should be considered if (after >12 months of treatment) 1:

• Clinically meaningful worsening over past 6 months without other contributing factors 1
• No clinically meaningful benefit observed at any time during treatment 1
• Severe or end-stage dementia (dependence in most basic activities of daily living) 1
• Development of intolerable side effects (severe nausea, vomiting, weight loss, anorexia, falls) 1
• Poor medication adherence precluding safe ongoing use 1

Cholinesterase inhibitors should be discontinued if prescribed for indications other than AD, PDD, DLB, or VD (such as frontotemporal dementia) 1

Similar criteria apply for memantine discontinuation after >12 months of treatment 1

All deprescribing decisions should involve patient preferences (if capable), prior expressed wishes, and collaboration with family or substitute decision makers 1

Follow-Up and Monitoring

Reassess every 6 months for drug toxicity, new medical or psychiatric problems, environmental changes, and emergence of new behaviors 2

At first follow-up visit, assess adherence to and tolerance of medications 1

Response to medication is judged primarily on subjective and objective findings during interview and follow-up memory testing, as there is no formal consensus framework for judging treatment response 1

Provide stage-specific education (early, middle, or late stage) to caregivers 1:

• Early stage: Communication strategies, modification of expectations, safety concerns, behavior changes, adapting supervision for short-term memory loss 1
• Midstage anticipatory guidance: Prepare for dysphagia, mobility impairments, urinary incontinence, seizures 1
• Late stage: Proactive discussions about advance directives and goals of care 1

End-of-Life Care

Palliative care focused on improving quality of life, maintaining function, and maximizing comfort should be provided when prolonging life is no longer meaningful 1

Address nutrition, feeding difficulties, bowel and urinary disorders, mobility problems, and pressure ulcerations in late-stage disease 2

Critical Pitfalls to Avoid

Do not rush to pharmacological interventions before adequately trying non-pharmacological approaches 1, 2

Do not fail to identify underlying medical conditions or pain that may be causing or exacerbating behavioral symptoms 1, 2

Do not misinterpret symptoms: "agitation" may encompass anxiety, repetitive questions, aggression, or wandering—each requiring different interventions 1, 2

Avoid medications with anticholinergic properties that worsen cognitive symptoms 1, 2

Do not overlook caregiver stress and depression that may inadvertently exacerbate patient behaviors 2

Do not rely solely on pharmacological approaches without implementing environmental and behavioral strategies, as non-pharmacological interventions have demonstrated efficacy with minimal risk 2

Recognize that all symptomatic therapies do not alter the underlying disease process, and patients continue to experience decline over time despite treatment 3