What is the optimal dementia care plan for a Medicare beneficiary (≥65 years) covering comprehensive geriatric assessment, pharmacologic therapy (cholinesterase inhibitors, memantine), advance care planning, home safety, and Medicare (Parts A, B, C, D) coverage?

Dementia Care Planning for Medicare Patients

Comprehensive Geriatric Assessment and Cognitive Screening

Begin with the Mini-Cog as your cognitive screening tool—it takes only 2-4 minutes, has 76% sensitivity and 89% specificity, and is endorsed by the Alzheimer's Association for Medicare Annual Wellness Visits. 1 If the Mini-Cog is positive, proceed to comprehensive cognitive testing with the Montreal Cognitive Assessment (MoCA), which takes 10-15 minutes and has 90% sensitivity for detecting mild cognitive impairment. 1

Your comprehensive assessment must systematically evaluate:

• Functional status: Use Activities of Daily Living (ADL) and Instrumental ADL scales to measure independence 2
• Neuropsychiatric symptoms: Apply the Neuropsychiatric Inventory (NPI) or Cohen-Mansfield Agitation Inventory to quantify behavioral disturbances 2
• Comorbidities: Document all medical conditions using standardized tools like the Cumulative Illness Rating Scale 3
• Medication review: Identify and eliminate anticholinergic medications (diphenhydramine, oxybutynin, cyclobenzaprine) that worsen cognition 4, 5
• Safety assessment: Evaluate fall risk with the "get up and go test," assess driving capacity, and review medication management ability 2, 1

Pharmacologic Therapy for Cognitive Symptoms

For mild-to-moderate Alzheimer's disease, initiate donepezil 5 mg daily, increasing to 10 mg after 4-6 weeks—this is the most studied cholinesterase inhibitor with once-daily dosing and minimal hepatotoxicity. 2, 4 The American College of Physicians and American Academy of Family Physicians guidelines establish that cholinesterase inhibitors provide modest benefit, with approximately 20-35% of patients showing a 4-point improvement on the ADAS-cog scale (equivalent to delaying decline by one year). 2

Alternative cholinesterase inhibitors include:

• Rivastigmine: Start 1.5 mg twice daily, titrate to 3-6 mg twice daily; also licensed for Parkinson's disease dementia 2, 6
• Galantamine: Start 4 mg twice daily, titrate to 8-12 mg twice daily 2, 6

For moderate-to-severe dementia (MMSE <15), add memantine 5 mg daily, titrating to 10 mg twice daily over 4 weeks—memantine can be combined with cholinesterase inhibitors for additive benefit. 4, 3 The MEMAGE study demonstrated that combined therapy significantly improved MMSE scores and prevented agitation/aggression in elderly patients. 3

When to Continue or Discontinue Cognitive Medications

Continue cholinesterase inhibitors and memantine throughout the disease course unless there is no meaningful benefit after an adequate trial or the patient reaches end-stage dementia. 4, 7 Cochrane review evidence shows that discontinuing cholinesterase inhibitors results in worse cognitive function (mean difference -2.09 SMMSE points at 12 months) and greater functional impairment (mean difference -3.38 BADLS points). 7

Management of Behavioral and Psychological Symptoms

Exhaust non-pharmacological interventions before any psychotropic medication—this is the cornerstone of dementia care planning. 5, 4 The American Geriatrics Society requires documented failure of behavioral approaches before considering medications. 5

Non-Pharmacological Interventions (First-Line)

Implement these systematically:

• Environmental modifications: Ensure adequate lighting, reduce excessive noise, simplify the environment with clear labels and color-coded storage 5, 4
• Communication strategies: Use calm tones, simple one-step commands, allow adequate processing time, apply the "three R's" (Repeat, Reassure, Redirect) 2, 5, 4
• Structured routines: Establish predictable daily schedules for meals, exercise, and bedtime 5, 4
• Safety measures: Install grab bars, remove hazardous objects, ensure adequate supervision 2, 5
• Activity-based interventions: Provide at least 30 minutes of sunlight exposure daily, increase supervised mobility, tailor activities to individual abilities 5

Pharmacological Treatment for Behavioral Symptoms

For chronic agitation without psychotic features, initiate citalopram 10 mg daily (maximum 40 mg) or sertraline 25-50 mg daily (maximum 200 mg)—SSRIs are first-line pharmacological treatment. 5, 4 The Canadian Stroke Best Practice Recommendations explicitly designate SSRIs as first-line for agitation in vascular dementia, with evidence showing significant improvement in overall neuropsychiatric symptoms. 5

Evaluate response after 4 weeks using quantitative measures (NPI or Cohen-Mansfield Agitation Inventory). 5 If no clinically significant response, taper and discontinue. 5

Reserve antipsychotics only for severe agitation with psychotic features or imminent risk of harm to self or others after behavioral interventions have failed. 5, 4 If absolutely necessary:

• Risperidone: Start 0.25 mg at bedtime, target 0.5-1.25 mg daily (extrapyramidal symptoms increase above 2 mg/day) 5
• Quetiapine: Start 12.5 mg twice daily, maximum 200 mg twice daily (more sedating, risk of orthostatic hypotension) 5
• Olanzapine: Start 2.5 mg at bedtime, maximum 10 mg daily (less effective in patients >75 years) 5

Critical Safety Requirements for Antipsychotics

Before initiating any antipsychotic, you must:

1. Discuss with patient/surrogate: Increased mortality risk (1.6-1.7 times higher than placebo), cardiovascular effects, cerebrovascular adverse events, falls risk, metabolic changes 5, 4
2. Use lowest effective dose for shortest duration: Daily in-person evaluation required 5
3. Attempt taper within 3-6 months: Approximately 47% of patients continue antipsychotics without clear indication 5
4. Monitor for adverse effects: Extrapyramidal symptoms, falls, sedation, QT prolongation, cognitive worsening 5

Avoid benzodiazepines for routine agitation management (except alcohol/benzodiazepine withdrawal)—they increase delirium incidence and duration, cause paradoxical agitation in 10% of elderly patients, and risk respiratory depression. 5, 4

Advance Care Planning

Initiate advance care planning discussions immediately after diagnosis while the patient retains decision-making capacity. 2 The CMS Cognitive Assessment and Care Plan benefit (introduced 2017) requires participation of an independent historian (family care partner) and mandates psychosocial components. 2

Address these specific elements:

• Healthcare proxy and advance directives: Document preferences for future medical decisions 2
• Goals of care: Discuss realistic expectations for disease progression, treatment limitations, and end-of-life preferences 2
• Financial and legal planning: Recommend durable power of attorney, will preparation, long-term care insurance review 2
• Driving cessation planning: Establish timeline and alternative transportation arrangements 1
• Future placement decisions: Discuss criteria for considering assisted living or nursing home placement 2

Home Safety Assessment and Modifications

Conduct a systematic home safety evaluation addressing:

• Fall prevention: Install handrails, remove throw rugs, improve lighting, install grab bars in bathroom 2, 5
• Wandering prevention: Consider door locks, gate locks, identification bracelets 5
• Medication safety: Implement supervised medication administration, use pill organizers 1
• Kitchen safety: Remove access to stove if appropriate, simplify appliances 5
• Environmental simplification: Reduce clutter, use clear labels, provide structured layouts 5

Medicare Coverage for Dementia Care

Medicare Part B Coverage

Medicare Part B covers the Annual Wellness Visit (AWV) with cognitive impairment detection, introduced in 2011. 2 This includes a comprehensive health risk assessment and personalized prevention plan. 2

Medicare Part B covers the Cognitive Assessment and Care Plan Services (CPT codes 99483), introduced in 2017. 2 This benefit reimburses for:

• Comprehensive cognitive assessment
• Care planning with patient and care partner participation
• Advance care planning discussions
• Coordination with community resources 2

Medicare Part D Coverage

Medicare Part D covers FDA-approved dementia medications:

• Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) 2
• Memantine 2
• Antidepressants for behavioral symptoms 5

Medicare Advantage (Part C) Additional Benefits

Medicare Advantage plans receive dementia risk-adjusted additional payments (authorized 2020) to compensate for higher costs of complex care. 2 These plans may offer supplemental benefits not covered by traditional Medicare, including:

• Care coordination services
• Home safety assessments
• Caregiver support programs
• Adult day care services 2

Caregiver Support and Community Resources

Link families to the Alzheimer's Association and local Geriatric Workforce Enhancement Programs (GWEPs)—48 programs exist nationwide providing dementia education and support. 2 The Health Resources and Services Administration launched GWEPs in 2015 specifically to enhance geriatric clinical capacity. 2

Provide caregiver education on:

• Understanding that behaviors are symptoms of dementia, not intentional actions 5
• Implementing non-pharmacological interventions 5
• Recognizing signs of caregiver burnout 2
• Accessing respite care services 2

Common Pitfalls to Avoid

1. Do not add psychotropic medications without first treating reversible medical causes: Systematically investigate pain, urinary tract infections, pneumonia, constipation, urinary retention, dehydration, and metabolic disturbances 2, 5
2. Do not continue antipsychotics indefinitely: Review need at every visit, attempt taper within 3-6 months 5, 4
3. Do not use antipsychotics for mild agitation or behaviors unlikely to respond: Unfriendliness, poor self-care, repetitive questioning, and wandering do not warrant antipsychotics 5
4. Do not prescribe anticholinergic medications: Diphenhydramine, hydroxyzine, oxybutynin, and cyclobenzaprine worsen confusion and agitation 5, 4
5. Do not discontinue cholinesterase inhibitors without clear rationale: Evidence shows worsening cognitive and functional outcomes after discontinuation 7