How to manage dementia in a geriatric patient?

Managing Dementia in Geriatric Patients

For geriatric patients with dementia, prioritize non-pharmacological interventions first—including environmental modifications, structured routines, and caregiver education—while reserving cholinesterase inhibitors (donepezil) for mild-to-severe Alzheimer's disease and memantine for moderate-to-severe disease, with antipsychotics used only as a last resort for severe, dangerous agitation after behavioral approaches have failed. 1, 2

Initial Assessment and Diagnosis

Cognitive Evaluation

• Obtain a detailed history from both the patient and a close family member or friend to document cognitive decline and impairment in daily activities 2
• Conduct a thorough mental status examination evaluating memory, language, attention, visuospatial cognition (spatial orientation), executive function, and mood 2
• Use brief cognitive screening questionnaires to initiate and organize the assessment, but if findings are inconclusive (symptoms present but normal examination), order neuropsychological testing 2

Physical and Laboratory Workup

• Perform a focused physical examination looking for focal neurologic abnormalities suggesting stroke, extrapyramidal signs suggesting Lewy body dementia, or other findings that identify dementia etiology 2
• Order brain neuroimaging (CT or MRI) to identify structural changes including focal atrophy, infarcts, or tumors not apparent on physical examination 2
• Consider cerebrospinal fluid assays or genetic testing only in atypical cases: age of onset younger than 65 years, rapid symptom onset, or impairment in multiple cognitive domains but preserved episodic memory 2

Non-Pharmacological Management (First-Line for All Patients)

Environmental and Behavioral Interventions

• Establish a predictable daily routine with regular physical exercise, consistent meal times, and a structured sleep schedule 1, 3
• Ensure adequate task lighting, use clear labels on doors and drawers, create a safe environment with grab bars and bath mats, and establish way-finding aids to reduce confusion 1, 3
• Implement cognitively engaging activities tailored to the patient's current abilities and previous interests, such as reading, puzzles appropriate to their level, or group cognitive stimulation therapy for mild-to-moderate dementia 3, 2
• Encourage regular physical exercise such as walking, which has evidence for delaying cognitive deterioration 4, 2
• Promote socialization through family gatherings and day care programs for patients with Alzheimer's disease 4, 2

Communication Strategies

• Use a calm, gentle tone with simple one-step commands rather than complex multi-step instructions 1, 3
• Avoid open-ended questions and yelling; instead use gentle touch for soothing when appropriate 1, 3
• Allow adequate time for the patient to process information before expecting a response 1

Safety Measures

• Register patients at risk for wandering in the Alzheimer's Association Safe Return Program 4
• Install locked doors and gates as appropriate to prevent unsafe wandering 4
• Remove hazardous items from the environment and install handrails 4

Pharmacological Management for Cognitive Symptoms

Alzheimer's Disease Treatment

For Mild to Severe Alzheimer's Disease:

• Initiate donepezil starting at 5 mg once daily, which can be increased to 10 mg once daily after 4-6 weeks 5, 2
• Donepezil provides modest symptomatic relief and is the preferred acetylcholinesterase inhibitor for all stages of Alzheimer's disease 2
• The 23 mg dose may be considered for moderate-to-severe disease but is associated with more nausea, vomiting, and weight loss, particularly in patients weighing less than 55 kg 5

For Moderate to Severe Alzheimer's Disease:

• Add memantine 5 mg once daily, increasing weekly by 5 mg/day in divided doses to a target of 20 mg/day (10 mg twice daily) 6, 2
• Memantine can be used alone or as add-on therapy to donepezil, with combination therapy showing statistically significant benefits on activities of daily living and cognition compared to donepezil monotherapy 6

Other Dementia Types

• For Parkinson disease dementia, use rivastigmine to treat symptomatic cognitive decline 2
• For vascular dementia with agitation, SSRIs (citalopram 10-40 mg/day or sertraline 25-200 mg/day) are first-line pharmacological treatment, as they significantly improve overall neuropsychiatric symptoms, agitation, and depression 1

Managing Behavioral and Psychological Symptoms

Systematic Investigation of Underlying Causes (Always First)

• Aggressively search for and treat reversible medical triggers: pain (a major contributor in patients who cannot verbally communicate discomfort), urinary tract infections, pneumonia, constipation, urinary retention, dehydration, and medication side effects 1, 3
• Review all medications to identify and discontinue anticholinergic agents (diphenhydramine, hydroxyzine, oxybutynin, cyclobenzaprine) that worsen confusion and agitation 1
• Address sensory impairments (hearing aids, glasses) that increase confusion and fear 1

Non-Pharmacological Interventions for Behavioral Symptoms

• Use the DICE approach (Describe, Investigate, Create, Evaluate) with behavioral and environmental modifications as first-line management 3
• Have caregivers maintain ABC (antecedent-behavior-consequence) charting to identify triggers of behavioral symptoms 1
• Implement the "three R's" approach: repeat instructions as needed, reassure the patient, and redirect to another activity to divert attention from problematic situations 4
• Use scheduled toileting or prompted voiding to reduce urinary incontinence 4

Pharmacological Treatment for Behavioral Symptoms (Only After Non-Pharmacological Approaches Fail)

For Chronic Agitation Without Psychotic Features:

• Initiate an SSRI as first-line: citalopram 10 mg/day (maximum 40 mg/day) or sertraline 25-50 mg/day (maximum 200 mg/day) 1
• SSRIs are well-tolerated with minimal anticholinergic side effects and effectively treat depression superimposed on dementia 4, 1
• Assess response using quantitative measures (Cohen-Mansfield Agitation Inventory or NPI-Q) within 4 weeks; if no clinically significant response, taper and withdraw 1

For Severe Agitation With Psychotic Features or Imminent Risk of Harm:

• Reserve antipsychotics only when the patient is severely agitated, threatening substantial harm to self or others, and behavioral interventions have failed 1
• Before initiating, discuss with the patient (if feasible) and surrogate decision maker the increased mortality risk (1.6-1.7 times higher than placebo), cardiovascular effects, cerebrovascular adverse reactions, falls, and metabolic changes 1
• Use risperidone 0.25 mg once daily at bedtime, titrating to 0.5-1.25 mg daily (maximum 2-3 mg/day), with extrapyramidal symptoms occurring at doses above 2 mg/day 1
• Alternative: quetiapine 12.5 mg twice daily (maximum 200 mg twice daily), which is more sedating with risk of orthostatic hypotension 1
• Use the lowest effective dose for the shortest possible duration with daily in-person examination to evaluate ongoing need 1
• Evaluate response within 30 days; if minimal improvement, refer to a mental health specialist, and consider gradual dose reduction after 6 months of symptom stabilization 3

For Acute Severe Agitation in Emergency Settings:

• Use haloperidol 0.5-1 mg orally or subcutaneously (maximum 5 mg daily in elderly patients) only after non-pharmacological interventions have failed and there is imminent risk of harm 1
• Monitor for extrapyramidal symptoms and QTc prolongation with ECG 1

What NOT to Use:

• Avoid typical antipsychotics (haloperidol, fluphenazine, thiothixene) as first-line therapy due to 50% risk of tardive dyskinesia after 2 years of continuous use in elderly patients 1
• Avoid benzodiazepines for routine use due to risk of tolerance, addiction, depression, cognitive impairment, increased delirium incidence and duration, and paradoxical agitation in 10% of elderly patients 4, 1
• Do not newly prescribe cholinesterase inhibitors to prevent or treat delirium or agitation, as they have been associated with increased mortality 1

Medication Management and Safety

Medication Review

• Bring in all medication bottles to compile a complete list and assess for drug interactions, anticholinergic effects, and medications contributing to behavioral symptoms 7
• Partner with the patient's pharmacist to optimize medication management, determine appropriate dosages, identify potential interactions, and eliminate unnecessary or dangerous medications 7
• Simplify medication schedules by consolidating dosing times and reducing complexity 7

Ongoing Monitoring

• Schedule medication reviews at least every 3-6 months to evaluate ongoing necessity and identify opportunities for deprescribing 7
• Review the need for antipsychotics at every visit and taper if no longer indicated, as approximately 47% of patients continue receiving antipsychotics after discharge without clear indication 1, 7
• Implement time-limited medication trials with clear endpoints to determine if medications are actually needed 7

Caregiver Support and Education

Essential Caregiver Education

• Educate caregivers that behaviors are symptoms of dementia, not intentional actions, to promote empathy and understanding 1
• Teach effective communication techniques: calm tones, simple commands, allowing adequate processing time 1, 7
• Provide targeted education about high-risk medications (antipsychotics, benzodiazepines, opioids) that require immediate medical attention if side effects occur 7
• Teach caregivers to recognize medication side effects warranting immediate contact: sudden confusion, falls, difficulty breathing 7

Support Systems

• Establish regular telephone follow-up calls with caregivers to respond to questions, review medication concerns, and assess for side effects 7
• Engage visiting nurses, social workers, or home health aides to conduct in-home medication reviews and provide hands-on support 7
• Refer to social work and chaplaincy services for additional support 4

Advance Care Planning

• After diagnosis, meet with the patient and family to answer questions and provide information about diagnosis, prognosis, future care needs, treatment options, and potential research participation 4
• Facilitate important discussions regarding personal and financial planning while the patient retains decision-making capacity 8

Critical Pitfalls to Avoid

• Never use exclusively pharmacological interventions without first applying and documenting failure of non-pharmacological strategies 3
• Do not use antipsychotics for mild agitation; reserve them for severe symptoms that are dangerous or cause significant distress 1
• Avoid continuing antipsychotics indefinitely without reassessment; inadvertent chronic use should be avoided 1
• Do not underestimate pain and discomfort as causes of behavioral disturbances 3
• Never assume caregivers understand medication side effects without explicit education and written documentation 7
• Avoid prescribing new medications without ensuring the caregiver has a clear plan for administration and monitoring 7
• Patients over 75 years respond less well to antipsychotics, particularly olanzapine, requiring consideration of alternative treatments 1