What is the appropriate diagnosis and management for an elderly female patient with progressive altered sensorium, non-conversant behavior, purposeless repetitive activities, and loss of ability to perform Activities of Daily Living (ADLs), with no prior workup?

Diagnosis and Initial Management of Progressive Dementia with Behavioral Disturbances and ADL Loss

Primary Diagnosis

This clinical presentation is most consistent with moderate to severe dementia, likely Alzheimer's disease, given the progressive altered sensorium, purposeless repetitive activities (folding clothes/cleaning), non-conversant behavior, and complete loss of basic ADL independence (bathing, eating). 1

The key diagnostic features include:

• Progressive cognitive decline with altered sensorium indicating more than mild impairment 1
• Loss of basic ADLs (bathing, eating) - this distinguishes dementia from MCI, as MCI primarily affects instrumental ADLs while preserving basic self-care 1
• Purposeless repetitive activities represent behavioral disturbances common in moderate-to-severe dementia 1, 2
• Non-conversant behavior suggests language domain impairment typical of advancing Alzheimer's disease 1

Immediate Diagnostic Workup Required

Perform cognitive assessment using the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA) to objectively document severity - expect scores in the moderate-to-severe range (MMSE ≤14) given the loss of basic ADLs. 1

Obtain collateral history from family/caregiver focusing on:

• Timeline of cognitive decline (weeks vs. months vs. years) - rapid progression (<6 months) raises concern for Creutzfeldt-Jakob disease or other rapidly progressive dementias 3
• Specific functional losses and their sequence 1
• Presence of hallucinations, delusions, or mood changes 1
• Falls history and gait changes 1

Order brain MRI to identify:

• Medial temporal atrophy (hippocampus/amygdala) suggesting Alzheimer's disease 1
• Vascular changes suggesting vascular cognitive impairment 1
• Exclude reversible causes (subdural hematoma, normal pressure hydrocephalus, tumor) 1

Screen for reversible/treatable causes:

• Complete metabolic panel, thyroid function, vitamin B12, folate 1
• Medication review for anticholinergic burden or polypharmacy effects 1
• Depression screening (Cornell Scale for Depression in Dementia) - though less likely given severity of ADL loss 1

Assess hearing and vision - sensory impairments are underdiagnosed dementia risk factors and can worsen functional status 1, 4

Functional Assessment

Use the Disability Assessment in Dementia (DAD) or Functional Activities Questionnaire (FAQ) to systematically document ADL/IADL impairments - these are more clinically practical than research scales like ADCS-ADL. 1

The loss of basic ADLs (bathing, eating) indicates severe functional impairment requiring immediate caregiver support and safety planning. 1, 5

Management of Behavioral Disturbances

For agitation and repetitive behaviors, SSRIs are first-line pharmacologic treatment - they significantly reduce overall neuropsychiatric symptoms and agitation in individuals with vascular cognitive impairment and dementia. 1

Non-pharmacologic interventions should be implemented first:

• Personally tailored interventions based on patient's past life experiences 1
• Structured daily routines to reduce confusion 1
• Massage therapy or animal-assisted interventions for agitation 1

Avoid typical and atypical antipsychotics unless absolutely necessary - they reduce agitation but increase risk of death from cardiac toxicities in dementia patients. 1, 2

Cognitive Enhancement Therapy

If Alzheimer's disease is confirmed, initiate memantine 5 mg once daily, titrating weekly by 5 mg/day to target dose of 20 mg/day (10 mg twice daily) - memantine is FDA-approved for moderate-to-severe Alzheimer's disease and shows beneficial effects on ADL function. 6, 5

Consider adding a cholinesterase inhibitor - these have modest but meaningful beneficial effects on ADL in mild-to-moderate Alzheimer's disease, though efficacy may be limited at this advanced stage. 5

Nutritional Support

Given inability to eat independently, implement oral nutritional supplementation immediately to prevent further decline and maintain nutritional status. 1

Consider percutaneous endoscopic gastrostomy (PEG) tube only if:

• Patient has early or moderate dementia with reversible swallowing dysfunction 1
• Family desires aggressive nutritional support after informed discussion 1

Do NOT place feeding tube if this represents terminal dementia - tube feeding is not recommended in terminal dementia as it does not improve outcomes. 1

Safety and Caregiver Support

Assess fall risk - check orthostatic blood pressure, review medications, and refer for physical therapy evaluation of gait, assistive devices, and balance training. 1

Evaluate caregiver burden using Zarit Burden Interview - caregiver burden is a major determinant of nursing home placement. 1

Arrange home safety evaluation through occupational therapy if patient remains at home. 1

Discuss advance care planning including:

• Health care proxy documentation 1
• Goals of care given poor prognosis 1
• Consideration of hospice/palliative care referral for severe dementia 1

Critical Pitfalls to Avoid

Do not assume this is "normal aging" - the loss of basic ADLs represents pathologic dementia requiring workup. 1

Do not delay brain imaging - reversible causes (subdural hematoma, normal pressure hydrocephalus) must be excluded urgently. 1

Do not use antipsychotics as first-line for behavioral symptoms - they increase mortality risk; try non-pharmacologic interventions and SSRIs first. 1, 2

Do not overlook rapidly progressive dementia - if symptom onset is <6 months, consider Creutzfeldt-Jakob disease and obtain EEG and specialized MRI sequences. 3

Do not neglect sensory impairments - hearing and vision loss worsen cognitive function and should be addressed. 1, 4

Follow-up Plan

Reassess every 6-12 months using the same cognitive and functional scales to track progression. 1

Monitor for complications:

• Aspiration pneumonia risk given eating difficulties 3
• Pressure ulcers if bedbound 1
• Medication side effects, particularly from memantine (dizziness, confusion) 6

Provide ongoing caregiver education about disease progression, behavioral management strategies, and available community resources. 1