What are the diagnostic and treatment approaches for dementia?

Dementia: Diagnostic and Treatment Approaches

Diagnostic Evaluation

For any patient with suspected dementia, begin by obtaining corroborative history from a reliable informant using structured tools (AD8, IQCODE, or Quick Dementia Rating System), followed by objective cognitive testing with the Montreal Cognitive Assessment (MoCA) for suspected mild impairment or Mini-Mental State Examination (MMSE) for moderate dementia, combined with mandatory laboratory workup and neuroimaging in most cases. 1, 2

When to Suspect Dementia

Do not screen asymptomatic individuals routinely. 3 Instead, actively evaluate patients who present with:

• Missed appointments or appearing at incorrect times 3, 4
• Difficulty remembering or following medication instructions 3, 4
• Unexplained decline in instrumental activities of daily living 3, 4
• Decrease in self-care abilities 3, 4
• New-onset depression or anxiety in later life 3, 4

High-Risk Populations Requiring Active Inquiry

Proactively ask about cognitive concerns in patients with: 3, 2, 4

• History of stroke or transient ischemic attack
• Late-onset depressive disorder or lifetime history of major depression
• Untreated sleep apnea
• Recent delirium episode
• Parkinson's disease
• Recent head injury
• First major psychiatric episode at advanced age

Cognitive Assessment Tools

For rapid screening (5-10 minutes): Use Memory Impairment Screen + Clock Drawing Test, Mini-Cog, AD8, or four-item MoCA (Clock-drawing, Tap-at-letter-A, Orientation, Delayed-recall). 3, 4

For comprehensive screening when mild cognitive impairment is suspected: Use the MoCA, which is more sensitive than MMSE for detecting early dementia. 3, 2, 4 The MMSE remains acceptable for moderate dementia but lacks sensitivity for mild impairment. 3

Mandatory Laboratory Workup

Order the following core tests in all patients: 1, 2, 4

• Complete blood count
• Comprehensive metabolic panel
• Thyroid function tests (TSH, free T4)
• Vitamin B12 and folate levels
• Liver function tests
• HIV testing if risk factors present 4

Neuroimaging Requirements

Obtain MRI (preferred over CT) in most situations, especially when: 1, 2, 4

• Cognitive symptoms began within past 2 years
• Unexpected decline in cognition or function
• Recent significant head trauma
• Unexplained neurological manifestations
• Significant vascular risk factors present

MRI is superior for detecting vascular lesions. 1, 2, 4

Functional Assessment

Systematically assess impact on instrumental activities of daily living using structured tools (Pfeffer Functional Activities Questionnaire or Disability Assessment for Dementia): 2

• Ability to manage finances
• Medication management
• Transportation abilities
• Household management
• Cooking and shopping abilities

Additional Assessments

Routinely evaluate: 4

• Gait speed and parkinsonism
• Hearing impairment (treat with audiologic rehabilitation as it may improve cognition) 1
• Sleep disorders, particularly sleep apnea 1, 4
• Neuropsychiatric symptoms using NPI-Q or MBI-C 2

Common Pitfall: Relying solely on patient self-report without informant corroboration leads to missed diagnoses due to lack of insight. 2 Always obtain collateral history.

Treatment Approaches

Pharmacological Management

For mild to moderate Alzheimer's disease dementia: Initiate a cholinesterase inhibitor—donepezil, rivastigmine, or galantamine. 1, 4, 5 These provide modest symptomatic relief. 5

For moderate to severe dementia: Add memantine (FDA-approved for moderate to severe Alzheimer's dementia), either alone or combined with a cholinesterase inhibitor. 1, 4, 6, 5

For Parkinson's disease dementia: Use rivastigmine, which demonstrated statistically significant improvement in ADAS-cog scores (3.8 points vs placebo at 24 weeks) in patients with mild-to-moderate Parkinson's disease dementia. 7

Medication Review: Minimize or avoid medications with anticholinergic properties, using alternative medications when possible. 1 Conduct regular medication reviews to identify potentially inappropriate medications. 1

Non-Pharmacological Interventions

Physical Activity: Prescribe aerobic exercise and/or resistance training of at least moderate intensity. 1, 4 Exercise is recommended for all people living with dementia, though specific duration and intensity cannot be precisely specified. 1

Dietary Recommendations: Advise adherence to Mediterranean diet with high consumption of mono- and polyunsaturated fatty acids and low consumption of saturated fatty acids. 1, 4

Cognitive and Social Engagement: 1

• Encourage cognitively stimulating activities (reading, puzzles)
• Consider group cognitive stimulation therapy for mild to moderate dementia
• Support social engagement opportunities throughout the life course

Follow-Up and Monitoring

Schedule follow-up visits every 6-12 months using a multi-dimensional approach that assesses: 1, 2, 4

• Cognitive function (using MMSE or MoCA)
• Functional autonomy
• Behavioral symptoms
• Caregiver burden

More frequent assessment (every 3-6 months) is indicated for patients with behavioral symptoms. 1, 2

Special Considerations

For subjective cognitive decline with normal testing: Conduct comprehensive diagnostic workup to identify reversible causes and arrange annual follow-ups if corroborative history is positive. 1, 2

For end-of-life care: Focus on improving quality of life and maximizing comfort, considering palliative care for terminal stages. 1