How should I assess and treat an older adult with dementia, including workup, medication options, and non‑pharmacologic measures?

Assessment and Management of Dementia in Older Adults

Initial Diagnostic Workup

Obtain a detailed history from both the patient and a reliable informant to establish baseline functioning and document cognitive decline over time, as dementia diagnosis requires evidence of change from previous levels of functioning. 1

Essential History Components

• Document current versus baseline functioning across memory, language, visuospatial skills, executive function, personality changes, and ability to perform instrumental and basic activities of daily living 1
• Assess gait speed using a stopwatch (cut-off <0.8 m/s), as slower gait coupled with cognitive impairment significantly increases dementia risk 1
• Screen for parkinsonism, which increases dementia odds three-fold 1
• Evaluate frailty status as a marker of future dementia risk 1
• Take a careful sleep history including sleep duration, insomnia, daytime sleepiness, napping, and REM sleep behavior disorder 1
• Assess hearing impairment and record as a dementia risk factor 1
• Screen for neuropsychiatric symptoms using validated scales like the Neuropsychiatric Inventory Questionnaire (NPI-Q) or Mild Behavioural Impairment Checklist (MBI-C), particularly for first-episode psychiatric symptoms in later life 1

Cognitive Assessment

• Perform thorough mental status examination evaluating memory, language, attention, visuospatial cognition, executive function, and mood 2
• Use validated screening instruments such as Mini-Mental State Examination (MMSE), Mini-Cog, Clock Drawing Test, or Montreal Cognitive Assessment at initial visit and annually thereafter 3
• Order neuropsychological testing if clinical assessment is inconclusive (symptoms present but normal examination findings) 2

Laboratory and Imaging Evaluation

• Obtain brain neuroimaging (CT or MRI) for most patients to identify structural changes, focal atrophy, infarcts, vascular disease, and potentially reversible surgical pathology 2, 4
• Rule out reversible causes: cardiovascular disease, cerebrovascular disease/stroke, head injury, poorly treated sleep disorders, thyroid disease, vitamin B12 deficiency, metabolic syndrome 1
• Consider CSF analysis in patients with diagnostic uncertainty, onset <65 years, or predominance of language/visuospatial/dysexecutive/behavioral features to rule out Alzheimer's disease pathophysiology 1
• Consider amyloid-PET or CSF biomarkers (low amyloid β1-42, high total-tau or phospho-tau) in atypical cases, though diagnostic usefulness decreases with age 4

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

Physical exercise represents the strongest evidence-based intervention with Level 1B recommendation and should be prescribed for all older adults with cognitive decline. 3

Exercise and Physical Activity

• Prescribe aerobic exercise and/or resistance training of at least moderate intensity, targeting 724 METs-min per week, as this shows superior efficacy compared to pharmacological options 3
• Resistance training shows superior effects over other exercise modalities 3

Cognitive Interventions

• Recommend group cognitive stimulation therapy for mild to moderate dementia, offering structured activities that stimulate thinking, concentration, and memory in social settings 1, 3
• Suggest computer-based and group cognitive training programs when accessible for those at risk or with mild cognitive impairment 1
• Encourage engagement in cognitively stimulating activities including hobbies, volunteering, and lifelong learning, with variety being preferable over any single activity 1

Dietary Modifications

• Recommend adherence to Mediterranean diet to decrease risk of cognitive decline 1
• Advise high consumption of mono- and polyunsaturated fatty acids and low consumption of saturated fatty acids 1
• Increase fruit and vegetable intake 1

Sleep Optimization

• Target 7-8 hours of sleep per night and assess for sleep apnea 3
• Implement morning bright light therapy (2,500-5,000 lux for 1-2 hours) to regulate circadian rhythms, decrease daytime napping, and consolidate nighttime sleep 5

Caregiver Support

• Provide psychoeducational interventions for caregivers including education, counseling, information regarding services, enhancing carer skills, problem solving, and strategy development 1
• Consider case management to improve coordination and continuity of care delivery 1

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Pharmacologic Management

Cholinesterase Inhibitors

For mild to moderate Alzheimer's disease, prescribe donepezil as first-line pharmacologic therapy, recognizing that benefits are modest (1-3 point improvements on ADAS-cog scale, below the 4-point threshold considered clinically significant). 3, 2

• Donepezil for mild to severe Alzheimer's disease 2
• Rivastigmine for symptomatic Parkinson disease dementia 2
• Do NOT prescribe cholinesterase inhibitors for mild cognitive impairment, as evidence does not support their use in this population 3

NMDA Receptor Antagonist

• Memantine (used alone or as add-on therapy) for moderate to severe Alzheimer's disease 2

Medication Optimization

Minimize exposure to medications with highly anticholinergic properties (100% consensus recommendation), substituting alternative medications for depression, neuropathic pain, and urinary incontinence. 1, 3

• Avoid anticholinergic medications including diphenhydramine, hydroxyzine, oxybutynin, and cyclobenzaprine, which worsen confusion and agitation 6
• Conduct multidimensional health assessment including medication review to identify reversible conditions and rationalize medication use 1

Management of Behavioral and Psychological Symptoms

Non-pharmacological interventions must be attempted first and documented as failed before considering antipsychotics for severe, dangerous agitation. 6

When Behavioral Interventions Fail:

• For chronic agitation without psychotic features: SSRIs (citalopram 10-40 mg/day or sertraline 25-200 mg/day) are first-line, with reassessment after 4 weeks 6
• For severe agitation with psychotic features threatening substantial harm: Low-dose risperidone (0.25-0.5 mg/day) is preferred over other antipsychotics, but only after discussing increased mortality risk (1.6-1.7 times higher than placebo) with surrogate decision makers 6, 7
• Use lowest effective dose for shortest duration, with daily evaluation and attempt to taper within 3-6 months 6
• Avoid benzodiazepines except for alcohol/benzodiazepine withdrawal, as they increase delirium, cause paradoxical agitation in 10% of elderly patients, and worsen cognitive function 6

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Special Populations and Considerations

Diabetes Management

• Screen for cognitive impairment annually starting at age 65 3
• Simplify diabetes care plans when cognitive dysfunction is identified 3
• Relax glycemic targets (A1C 8.0-8.5%) to minimize hypoglycemia risk 3

Cardiovascular Risk Reduction

• Optimize blood pressure control to reduce dementia risk 3
• Prescribe statin therapy for cholesterol lowering, as it has been associated with reduced incident dementia 3

Hepatic and Renal Impairment

• For moderate hepatic impairment: Adjust cholinesterase inhibitor dosage 8
• For severe hepatic impairment: Do not use galantamine 8
• For creatinine clearance 9-59 mL/min: Adjust dosage 8
• For creatinine clearance <9 mL/min: Do not use galantamine 8

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Critical Pitfalls to Avoid

• Do not rely solely on pharmacological approaches, as non-pharmacological interventions have demonstrated efficacy with minimal risk while medications show limited benefit 3
• Do not prescribe cholinesterase inhibitors for mild cognitive impairment 3
• Do not ignore caregiver burden even in mild cognitive impairment; provide educational interventions early 3
• Do not overlook sensory impairments (hearing and vision), which are frequently underdiagnosed yet significantly impact dementia risk 3
• Do not continue antipsychotics indefinitely; review need at every visit and taper if no longer indicated 6
• Do not use antipsychotics for mild agitation or behaviors like unfriendliness, poor self-care, repetitive questioning, or wandering 6