What is the best approach to diagnose and treat a geriatric patient with dementia?

Diagnosis and Management of Dementia in Geriatric Patients

Begin with validated cognitive screening using the Mini-Cog test in primary care settings, followed by comprehensive assessment of functional status, behavioral symptoms, and caregiver burden, with brain MRI (preferred over CT) to identify reversible causes and guide treatment planning. 1

Initial Diagnostic Approach: Distinguish Delirium from Dementia First

Critical first step: Rule out delirium before attributing symptoms to dementia alone. Delirium is a medical emergency with twice the mortality if missed, and up to 31% of geriatric patients may have delirium at admission. 2, 3

Two-Step Delirium Screening Process

• Apply the Delirium Triage Screen (highly sensitive) followed by the Brief Confusion Assessment Method (highly specific) to all geriatric patients with cognitive changes 1, 3
• Repeat screening regularly as mental status fluctuates 1, 2
• Key distinguishing features: delirium has acute onset, fluctuating course, disordered attention/consciousness; dementia has insidious onset, constant course, generally preserved attention (until advanced stages) 1, 3

Immediate Evaluation for Reversible Causes of Delirium

• Discontinue anticholinergic medications (antihistamines, muscle relaxants) and benzodiazepines immediately unless treating withdrawal 2, 3
• Evaluate for urinary tract infection and pneumonia (account for >80% of infection-related delirium) 2, 3
• Assess for dehydration, electrolyte disturbances, hypercalcemia, and medication toxicity (especially opioids in renal impairment) 2, 3
• Perform thorough physical examination for pain, constipation, urinary retention, and pressure ulcers 2, 3
• Ensure patients use glasses and hearing aids, as sensory impairments significantly contribute to delirium 2, 3

Cognitive Assessment for Dementia Diagnosis

Primary Care Screening

Use the Mini-Cog test as the first-line screening tool (sensitivity 76%, specificity 89%), validated in heterogeneous populations and endorsed by the Alzheimer's Association for Medicare annual wellness visits. 1

• Alternative validated tools include Memory Impairment Screen, Picture-based Memory Impairment Screen, or AD8 informant interview 1
• For more detailed assessment (10-15 minutes), consider Montreal Cognitive Assessment (MoCA) or Saint Louis University Mental Status Examination 1

When to Refer for Neuropsychological Testing

Neuropsychological evaluation is indicated when: 1

• Symptoms are mild, unusual, or presentation is complex
• Patient has very limited or extensive education
• Language or cultural considerations affect assessment
• Comorbidities present (sensory/motor impairments, stroke, brain injury, depression, anxiety, polypharmacy, substance abuse)

Comprehensive Assessment Beyond Cognition

Functional Status Assessment

Assess activities of daily living using validated, familiar tools rather than research-specific instruments: 1

• Disability Assessment in Dementia (DAD)
• Functional Activities Questionnaire (FAQ)
• Barthel Index Score
• Functional Assessment Staging Scale (FAST)

Behavioral and Neuropsychiatric Symptoms

Use simple, validated tools for behavioral assessment: 1

• NPI-Q (brief Neuropsychiatric Inventory)
• Patient Health Questionnaire-9 (PHQ-9) for depression
• Cornell Scale for Depression in Dementia
• Geriatric Depression Scale (GDS) (note: less sensitive in advanced dementia)

Caregiver Burden Assessment

Regularly assess caregiver burden using the Zarit Burden Interview, as this is a major determinant of hospitalization and nursing home placement. 1

Global Assessment with Informant Input

Use tools that integrate caregiver perspective: 1

• Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)
• HABC-Monitor

Neuroimaging: Essential for Diagnosis

When to Order Brain Imaging

Anatomical neuroimaging is recommended in most situations, particularly with: 1

• Cognitive symptom onset within past 2 years (regardless of progression rate)
• Unexplained decline in known dementia patient
• Recent significant head trauma
• Unexplained neurological signs (severe headache, seizures, Babinski sign, gait disturbances)
• History of cancer (risk for brain metastases)
• Risk for intracranial bleeding
• Symptoms suggesting normal pressure hydrocephalus
• Significant vascular risk factors

MRI vs. CT

MRI is strongly preferred over CT due to higher sensitivity for vascular lesions and dementia subtypes. 1

If MRI is performed, obtain these sequences: 1

• 3D T1 volumetric sequence with coronal reformations (for hippocampal volume assessment)
• Fluid-attenuated inversion recovery (FLAIR)
• T2 or susceptibility-weighted imaging (SWI)
• Diffusion-weighted imaging (DWI)
• Use 3T MRI over 1.5T when available

If CT is performed: 1

• Non-contrast CT with coronal reformations to assess hippocampal atrophy

Imaging Interpretation

Use semi-quantitative scales for routine interpretation: 1

• Medial temporal lobe atrophy (MTA) scale
• Fazekas scale for white matter changes
• Global cortical atrophy (GCA) scale

Treatment Approach

Non-Pharmacologic Interventions (First-Line)

Prioritize cognitively engaging activities, physical exercise, and socialization: 4

• Cognitively engaging activities (reading, puzzles)
• Physical exercise (walking, structured programs)
• Social engagement (family gatherings, group activities)

Pharmacologic Treatment for Alzheimer Disease

For mild to severe Alzheimer disease: 4

• Acetylcholinesterase inhibitor (donepezil) provides modest symptomatic relief

For moderate to severe Alzheimer disease: 4

• Memantine (alone or added to acetylcholinesterase inhibitor)

For Parkinson disease dementia: 4

• Rivastigmine for symptomatic treatment

Management of Agitated Delirium (When Present)

Minimize chemical and physical restraints—use only when absolutely necessary for safety. 1

When pharmacologic intervention is required for severe agitation: 3

• Haloperidol 0.5-1 mg (oral, IM, or subcutaneous) is first-line
• Avoid benzodiazepines as first-line due to increased delirium duration and respiratory depression risk

Critical Pitfalls to Avoid

• Never assume confusion is "just dementia"—always screen for delirium as it indicates acute medical illness 3
• Never treat asymptomatic bacteriuria in elderly patients, as time-limited antibiotic trials worsen functional recovery and increase Clostridium difficile risk 3
• Never use physical restraints to manage behavioral symptoms, as this worsens delirium 2, 3
• Never rely on cognitive screening alone to rule in dementia—these tools are better at ruling out cognitive impairment 1
• Review total "anticholinergic burden" from polypharmacy, as multiple sedating agents compound cognitive impairment 3

Specialty Referral Considerations

Refer to dementia subspecialist when: 1

• Diagnostic uncertainty persists after initial evaluation
• Age of onset <65 years
• Rapid symptom onset
• Atypical presentation (impairment in multiple domains but not episodic memory)
• Prominent neuropsychiatric or sensorimotor dysfunction at presentation
• Complex care needs requiring interdisciplinary team approach