How should I evaluate and manage an older adult diagnosed with dementia?

Evaluation and Management of Dementia in Older Adults

Begin with a structured cognitive assessment using validated instruments, implement non-pharmacological interventions as first-line therapy, and consider cholinesterase inhibitors only for confirmed mild-to-moderate Alzheimer disease, while avoiding medications with anticholinergic properties that worsen cognitive function. 1, 2

Initial Diagnostic Evaluation

Cognitive Assessment

• Use the DSM-IV definition of dementia routinely, which requires acquired loss of cognition in multiple domains sufficiently severe to affect social or occupational function 1, 3
• Conduct a thorough mental status examination evaluating specific domains: memory, language, attention, visuospatial cognition (spatial orientation), executive function, and mood 3
• Obtain corroborative history from a close friend or family member regarding cognitive decline and impairment in daily activities 3
• Employ validated screening instruments such as the Mini-Mental State Examination (MMSE, sensitivity 88.3%, specificity 86.2%), Mini-Cog, Clock Drawing Test, or Montreal Cognitive Assessment at initial visit and annually thereafter 2
• If examination findings are normal despite symptoms, proceed to formal neuropsychological testing to determine whether dementia is present 3

Physical and Laboratory Evaluation

• Perform focused physical examination looking for focal neurologic abnormalities suggesting stroke, parkinsonism (increases dementia odds threefold), and signs of reversible causes 1, 3
• Assess gait speed (cut-off <0.8 m/s) coupled with cognitive impairment, as this combination indicates higher dementia risk 1
• Evaluate for frailty as a marker of future dementia risk 1
• Screen for medication toxicity, particularly anticholinergic burden, as this represents the most common cause of potentially reversible cognitive impairment 4
• Order brain neuroimaging (CT or MRI) to identify structural changes including focal atrophy, infarcts, and tumors not apparent on physical examination 3
• Consider cerebrospinal fluid assays or genetic testing only in atypical cases: age <65 years, rapid onset, or impairment in multiple domains without episodic memory involvement 3

Assessment of Contributing Factors

• Take a careful sleep history including sleep duration, insomnia, daytime sleepiness, napping, and REM sleep behavior disorder, as sleep abnormalities facilitate identification of pre-clinical dementia 1
• Assess hearing impairment, as there is strong observational evidence linking it to dementia development 1
• Evaluate for neuropsychiatric symptoms using validated informant-rated scales like the Neuropsychiatric Inventory (NPI-Q) or Mild Behavioural Impairment Checklist (MBI-C) 1
• Screen for depression, as it represents a comorbid factor contributing to cognitive decline 5

Non-Pharmacological Management (First-Line)

Physical Exercise (Strongest Evidence)

• Prescribe group or individual physical exercise as the primary intervention, representing the strongest evidence-based treatment with Level 1B recommendation 1, 2
• Implement individualized multi-component programs combining aerobic exercise (10-20 minutes, 3-7 days/week), resistance training (2-3 days/week), and balance exercises (2-7 days/week), totaling 50-60 minutes daily 2
• Resistance training demonstrates superior effects over other exercise modalities 2

Cognitive Interventions

• Recommend group cognitive stimulation therapy for mild-to-moderate dementia, offering structured activities providing general stimulation for thinking, concentration, and memory in social settings (Level 2B recommendation, 96% consensus) 1
• Propose empirically-supported individual computer-based and group cognitive training when accessible for those at risk or with mild cognitive impairment or mild dementia (Level 1B recommendation, 83% consensus) 1
• Advise patients to increase or maintain engagement in cognitively stimulating activities such as reading, hobbies, volunteering, and lifelong learning, with variety being preferable 1, 2

Lifestyle Modifications

• Recommend adherence to Mediterranean diet with high consumption of mono- and polyunsaturated fatty acids, low saturated fatty acids, and increased fruit and vegetable intake (Level 1B recommendation) 1
• Encourage at least 30 minutes of daily sunlight exposure and 7-8 hours of sleep per night 1, 2
• Promote social engagement through family gatherings and community activities 2

Caregiver Support

• Provide psychosocial and psychoeducational interventions for caregivers, including education, counseling, information regarding services, enhancing care skills, problem-solving, and strategy development (Level 2C recommendation, 96% consensus) 1
• Consider case management to improve coordination and continuity of service delivery (Level 2B recommendation, 93% consensus) 1

Pharmacological Management

Cholinesterase Inhibitors for Alzheimer Disease

• Consider cholinesterase inhibitors (donepezil, rivastigmine) for patients with mild-to-moderate Alzheimer disease (Standard recommendation), though studies demonstrate only small average benefit of 1.9 to 4.9 points on ADAS-cog scale 1, 6, 7
• Recognize that improvements of 1-3 points fall below the 4-point threshold considered clinically significant 2
• For donepezil: start at 5 mg daily; 10 mg daily may provide additional benefit for some patients based on prescriber and patient preference 6
• For rivastigmine: titrate to highest tolerated dose within 6-12 mg/day range given in divided doses 7
• Do NOT prescribe cholinesterase inhibitors for mild cognitive impairment, as evidence does not support their use in this population 2

Memantine

• Use memantine alone or as add-on therapy for moderate-to-severe Alzheimer disease 3

Vitamin E

• Consider vitamin E 1,000 IU orally twice daily to slow progression of Alzheimer disease (Guideline recommendation) 1

Medications to AVOID

• Do NOT prescribe estrogen to treat Alzheimer disease (Standard recommendation) 1
• Minimize exposure to medications with highly anticholinergic properties (Level 1B recommendation, 100% consensus) 1
• Substitute alternative medications for depression, neuropathic pain, and urge-type urinary incontinence when anticholinergics are currently prescribed 1
• Avoid selegiline due to less-favorable risk-benefit ratio compared to vitamin E 1
• Do not use antioxidants, anti-inflammatories, or other putative disease-modifying agents due to risk of significant side effects without demonstrated benefits 1

Medication Review and Optimization

• Conduct multidimensional health assessment including comprehensive medication review to identify reversible or modifiable conditions and rationalize medication use (Level 1B recommendation, 92% consensus) 1
• Review and minimize polypharmacy to reduce adverse drug events 2
• Recognize that medication toxicity represents the most common cause of potentially reversible dementia 4

Management of Behavioral Symptoms

• Implement non-pharmacological approaches as first-line measures, including attention to pain, nutrition, and environmental modifications 5
• For chronic agitation, SSRIs represent first-line pharmacological options 2
• Reserve antipsychotics only for severe, dangerous agitation when behavioral interventions have failed, using lowest effective dose for shortest duration 2

Special Populations

Patients with Intellectual Disabilities

• Recognize that adults with Down syndrome have 50% prevalence of clinical dementia by age 60 years due to genetic link between trisomy 21 and Alzheimer disease 1
• Apply same diagnostic principles but recognize that evaluation and management approaches remain largely undefined in this population 1

Patients with Vascular Risk Factors

• Optimize blood pressure control, as it demonstrates association with reduced dementia risk 2
• Prescribe statin therapy for cholesterol lowering, as it has been associated with reduced risk of incident dementia 2

Common Pitfalls to Avoid

• Do not rely solely on pharmacological approaches, as non-pharmacological interventions demonstrate superior efficacy with minimal risk 1, 2
• Do not ignore shorter symptom duration, less severe dementia, and higher prescription drug use, as these represent risk factors for potentially reversible dementia requiring investigation 4
• Do not overlook comorbid factors including depression, delirium, and polypharmacy that contribute to cognitive decline 5
• Do not prescribe medications lacking support from current clinical practice guidelines from major medical societies 2, 8
• Do not ignore caregiver burden even in mild cognitive impairment; provide educational interventions early 2
• Do not overlook sensory impairments (hearing, vision), which are frequently underdiagnosed yet significantly impact dementia risk 1