In theClinic

In the Clinic

Dementia
Prevention page ITC2

Screening page ITC3

Diagnosis page ITC4

Treatment page ITC7

Tool Kit page ITC14

Patient Information page ITC15

CME Questions page ITC16

Physician Writer The content of In the Clinic is drawn from the clinical information and education
Peter V. Rabins, MD, MPH resources of the American College of Physicians (ACP), including ACP Smart
David M. Blass, MD Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals
of Internal Medicine editors develop In the Clinic from these primary sources in
Section Editors collaboration with the ACPs Medical Education and Publishing divisions and with
Deborah Cotton, MD, MPH the assistance of science writers and physician writers. Editorial consultants from
Jaya K. Rao, MD, MHS ACP Smart Medicine and MKSAP provide expert review of the content. Readers
Darren Taichman, MD, PhD who are interested in these primary resources for more detail can consult https://
Sankey Williams, MD mksap16.acponline.org/, and other resources referenced in each issue of In the
Clinic.

CME Objective: To review current evidence for prevention, screening, diagnosis,

and treatment of dementia.

The information contained herein should never be used as a substitute for clinical
judgment.

2014 American College of Physicians

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 ementia is defined as a decline in 2 or more cognitive capacities, caus-

D ing impairment in function but not alertness or attention. The decline

in cognition distinguishes it from lifelong intellectual disability (previ-
ously called mental retardation) and single learning disorders, both of which
are present from birth and symptomatic in childhood. That 2 or more cogni-
tive capacities must be impaired distinguishes dementia from amnestic mild
cognitive impairment (MCI), the amnestic syndrome (previously called the
Korsakoff syndrome), and single focal brain lesions. Requiring impairment in
functional activity also distinguishes it from MCI, although this interpretation
is controversial. The requirement for intact attention and alertness distinguish-
es it from delirium. The Diagnostic and Statistical Manual of Mental Disorders,
version 5, has recently proposed replacing the word dementia with the phrase
neurocognitive disorder to destigmatize the syndrome. However, opponents
point out that the term neurocognitive disorder lacks specificity because it in-
cludes other categories of cognitive impairment, such as intellectual disability,
learning disabilities, and delirium.

Dementia is a syndrome rather than a specific illness; the most common

types are Alzheimer disease (AD), vascular dementia, Lewy body dementia,
and frontotemporal dementia. One or 2% of these patients presenting with
dementia has a potentially reversible disorder, such as normal pressure hydro-
cephalus, medication-induced cognitive impairment, hypothyroidism, or ma-
jor depression.

Although it can begin at any age after childhood, dementia is predominantly

a syndrome of later life, with the prevalence in persons older than 65 years
estimated to be 9%13%. The annual incidence rate is 0.25% at age 65 and
doubles every 5 years, reaching approximately 15% at age 95 (1).
Caring for patients with dementia is a heavy emotional and financial burden
for families and society as a whole. Patients can be cared for initially in the
1. Brookmeyer R, Gray S, home, but institutionalization is ultimately required for many patients67%
Kawas C. Projections
of Alzheimers dis-
die in nursing homes (2). Depending on the methods used to value informal
ease in the United care, the yearly per-person cost attributable to dementia ranged between
States and the public
health impact of de-
$41 689 and $56 290 in 2010 (3).
laying disease onset.
Am J Public Health.
1998;88:1337-42.
Although most forms of dementia currently have no cure, research findings
[PMID: 9736873] and accumulated clinical experience support a set of practices that maximizes
2. Mitchell SL, Teno JM,
Miller SC, Mor V. A na-
the function and well-being of patients with dementia and their families. This
tional study of the lo- approach incorporates a broad range of practices, including comprehensive di-
cation of death for
older persons with agnostic assessment, optimization of treatment for general medical conditions,
dementia. J Am Geri-
atr Soc. 2005;53:299-
attention to patient comfort and quality of life, pharmacotherapy, control of
305. psychiatric symptoms, and education and support of the patients family.
[PMID: 15673356]
3. Hurd MD, Martorell P,
Delavande A, Mullen
KJ, Langa KM. Mone-
tary costs of demen-
tia in the United
Prevention
States. N Engl J Med.
2013;368:1326-34.
What medical interventions or A 2011 meta-analysis identified 7 potential-
[PMID: 23550670] health behaviors can help patients ly modifiable risk factors for AD and calcu-
doi:10.1056/NEJM-
sa1204629 prevent dementia or cognitive lated a population attributable risk (PAR)
4. Barnes DE, Yaffe K.
decline? and CI for each in the United States: physical
The projected effect
inactivity (PAR = 21% [95% CI, 5.836.6]),
of risk factor reduc- Although the different types of
tion on Alzheimers depression (PAR = 14.7% [CI, 9.620.3]),
disease prevalence. dementia have several risk factors, smoking (PAR = 10.8% [CI, 3.019.8]), midlife
Lancet Neurol.
2011;10:819-28.
data supporting the effectiveness hypertension (PAR = 8.0% [CI, 2.215.1]),
[PMID: 21775213] of specific preventive measures to midlife obesity (PAR = 7.3% [CI, 4.310.8]) ,
doi:10.1016/S1474-
4422(11)70072-2 address them are limited. cognitive inactivity or low educational

2014 American College of Physicians ITC2 In the Clinic Annals of Internal Medicine 5 August 2014

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 attainment (PAR = 7.3% [CI, 4.410.3]), and sedative-hypnotics. Several studies
diabetes mellitus (PAR = 3.3% [CI, 1.55.4]) (4). have shown that elderly patients
taking benzodiazepines or other
However, the National Institutes of
sedative-hypnotics perform more
Health sponsored a panel report
poorly on cognitive tests than those 5. Daviglus ML, Plass-
published in the same year conclud- man BL, Pirzada A,
not taking these medications (6). Bell CC, Bowen PE,
ing that Currently, insufficient Burke JR, et al. Risk
evidence exists to draw firm conclu- Significant epidemiologic evidence factors and preven-
tive interventions for
sions on the association of any mod- links mid-life estrogen use to a Alzheimer disease:
ifiable factors with the risk of AD lower incidence of dementia later in
state of the science.
Arch Neurol.
(5). Because avoiding or ameliorat- life (7). However, in prospective 2011;68:1185-90.
[PMID: 21555601]
ing the risk factors for dementia pro- prevention trials, including the doi:10.1001/archneu-
vides other health benefits, it seems rol.2011.100
large Womens Health Initiative 6. Larson EB, Kukull WA,
prudent to advise patients to address Buchner D, Reifler BV.
Memory Study (WHIMS), use of Adverse drug reac-
these risk factors for the potential
estrogen plus progestin for preven- tions associated with
benefit of lowering the risk for AD. global cognitive im-
tion of dementia was associated pairment in elderly
Patients should also be advised to persons. Ann Intern
with an increased incidence of de- Med. 1987;107:169-
minimize risk for head trauma by
using seat belts in automobiles and mentia and other medical compli- 73. [PMID: 2886086]
7. Zandi PP, Carlson MC,
helmets for contact sports and riding cations (8). Plassman BL, Welsh-
Bohmer KA, Mayer LS,
a bicycle or motorcycle. The WHIMS was a placebo-controlled, ran-
Steffens DC, et al;
Cache County Mem-
domized, controlled trial of estrogen plus ory Study Investiga-
What medications can be used in tors. Hormone re-
progestin (n = 2229) versus placebo (n = placement therapy
patients presenting with signs of 2303) for prevention of dementia in and incidence of
dementia? Alzheimer disease in
women aged 65 years and older. Use of es- older women: the
Clinicians should regularly review trogen for a mean of 4 years was associat- Cache County Study.
JAMA. 2002;288:2123-
the medications of elderly patients ed with a relative risk of 2.05 (CI, 1.213.48) 9. [PMID: 12413371]
and minimize use of those that can for dementia during the study period. 8. Shumaker SA, Legault
C, Rapp SR, Thal L,
cause cognitive impairment, partic- Wallace RB, Ockene
JK, et al; WHIMS In-
ularly benzodiazepines, anticholin- Ginkgo biloba did not prevent de- vestigators. Estrogen
ergics, barbiturates, and other mentia in one prospective trial (9). plus progestin and
the incidence of de-
mentia and mild cog-
nitive impairment in
postmenopausal
Screening women: the Womens
Health Initiative
Should clinicians screen for As a result, the clinician should Memory Study: a ran-
domized controlled
dementia? consider dementia in the differen- trial. JAMA.
2003;289:2651-62.
Universal screening for dementia is tial diagnosis of adult patients of [PMID: 12771112]
not recommended (10), but the dis- any age with symptoms of memory 9. DeKosky ST,
Williamson JD, Fitz-
order is prevalent and often goes difficulty interfering with daily patrick AL, Kronmal

undetected in the primary care function, unexplained functional RA, Ives DG, Saxton
JA, et al; Ginkgo Eval-
setting (11). decline, deterioration in hygiene, uation of Memory
(GEM) Study Investi-
questionable adherence to medica- gators. Ginkgo biloba
In a study reviewing the primary care tion regimens, or new-onset psy- for prevention of de-
mentia: a random-
records of 297 patients, dementia in 65% chiatric symptoms. ized controlled trial.
of patients meeting the criteria was not JAMA. 2008;300:2253-
62. [PMID: 19017911]
noted on the patients chart, including What methods should clinicians doi:10.1001/jama.200
20% of those with advanced dementia use when looking for dementia? 8.683
10. U.S. Preventive Serv-
(11). In a retrospective review of 1489 pa- When elderly patients are being ices Task Force.
evaluated for dementia, clinicians Screening for cogni-
tients referred to a memory disorders pro- tive impairment in
gram, those referred from a dementia should use a standardized screen- older adults.
Rockville, MD:
screening program had a mean Mini- ing instrument together with a Agency for Health-
Mental Status Examination (MMSE) score brief history from the patient and care Research and
Quality; 2014. Ac-
of 20.8 5.7 compared with those re- a knowledgeable informant. The cessed at www.us-
preventiveservices-
ferred from their physicians (18.8 6.6), screening instrument should be taskforce.org/uspstf1
from families (16.8 6.6), or from other easy to use, highly sensitive, 4/dementia/demen-
tiasumm.htm on 5
sources (15.3 7.1) (11). widely available, and supported by May 2014.

5 August 2014 Annals of Internal Medicine In the Clinic ITC3 2014 American College of Physicians

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 population data relevant to the pa-
tient in question. The MMSE (12)
has been widely used but is now
copyrighted. Alternatives include
the Mini-Cog (13), the St. Louis
University Mental Status Exam
(SLUMS) (14), and the Montreal
Cognitive Assessment (MoCA)
(15). The Mini-Cog has the bene-
fit of brevity, the SLUMS is most
similar to the MMSE (16), and
the MoCA has the best sensitivity
but lower specificity (17). An
alternative instrument is the In-
formant Questionnaire on Cogni-
tive Decline in the Elderly (IQ
CODE), which can be filled out
by a family member or other in-
formant who knows the patient
well (18).

Prevention and Screening... Use of benzodiazepines, anticholinergics, barbiturates,

and other sedative-hypnotics must be minimized in elderly patients. Screening for
dementia in the elderly population is not recommended, but in selected patients a
brief history from the patient and a knowledgeable informant together with a stan-
dardized instrument, such as the MMSE, the Mini-Cog, the SLUMS, or the MoCA, can
be used to decide whether a more extensive evaluation is necessary.

CLINICAL BOTTOM LINE

Diagnosis
What elements of the history are are dominated by difficulties with
especially important in evaluating short-term memory, subtle lan-
patients with suspected dementia? guage and visuospatial perceptual
Clinicians should use the patients problems, and changes in executive
11. Valcour VG, Masaki
KH, Curb JD, history to characterize the cognitive function. Significant reductions in
Blanchette PL. The
detection of demen-
deficits, generate a differential di- efficiency and organizational abili-
tia in the primary agnosis, and determine the cause of ties that the patient may or may
care setting. Arch In-
tern Med. the dementia. This goal is best ac- not recognize could also occur.
2000;160:2964-8.
[PMID: 11041904]
complished by identifying medical, Symptoms begin insidiously and
12. Folstein MF, Folstein neurologic, and psychiatric signs are slowly progressive. The overall
SE, McHugh PR.
Mini-Mental State. and symptoms that may be clues to level of alertness remains unim-
A practical method the cause of the cognitive problems paired. Patients or families may not
for grading the cog-
nitive state of pa- and establishing their order of ap- label these difficulties as memory
tients for the clini-
cian. J Psychiatr Res.
pearance, severity, and associated problems but may instead report
1975;12:189-98. features. In the case of cognitive conversations when the patient has
[PMID: 1202204]
13. Borson S, Scanlan J, difficulties, it is most important to no recollection of previous discus-
Brush M, Vitaliano P,
Dokmak A. The Mini-
try to obtain collateral information sions, increased forgetfulness that
Cog: a cognitive vi- from a knowledgeable informant,
tal signs measure for causes the patient to lose objects or
dementia screening because cognitive dysfunction can
become confused while shopping,
in multi-lingual eld- impair the patients ability to report
erly. Int J Geriatr Psy- or simply increased disorganization
chiatry. accurately. It is often easier to col-
2000;15:1021-7. and decreased efficiency. Symptoms
[PMID: 11113982]
lect this information without the
are often first noticed or reported
14. Saint Louis Universi- patient present.
ty School of Medi- at the time of a life change, such as
cine. Saint Louis Uni-
versity Mental Status In taking the history, the physician the death of a spouse, a move into a
Examination. St.
Louis: Saint Louis must be knowledgeable about the new residence, or being in an unfa-
University School of differential diagnosis and natural miliar place on vacation. Table 1
Medicine. Accessed
at http://aging history of the most common types describes the diagnostic criteria of
.slu.edu/index.php
?page=saint-louis
of dementia (Appendix Table, avail- the National Institute of Neurolog-
-university-mental able at www.annals.org). For exam- ical and Communicative Diseases
-status-slums-exam
on 7 May 2014. ple, in classic AD, early symptoms and StrokeAlzheimers Disease

2014 American College of Physicians ITC4 In the Clinic Annals of Internal Medicine 5 August 2014

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 Table 1. Diagnostic Criteria for Different Kinds of Alzheimer Disease*
Probable Alzheimer disease is defined by:
Dementia established by clinical examination and documented by an instrument, such as the MoCA, SLUMS or Mini- 15. Nasreddine Z. Mon-
Mental Status Examination treal Cognitive As-
Deficits in 2 or more areas of cognition, one of which is usually memory sessment. Greenfield
Park, Qubec, Cana-
Progressive decline da: Center for Diag-
nosis & Research on
No disturbance of consciousness Alzheimers Disease;
Onset between age 4090 years 2014. Accessed at
www.mocatest.org
Absence of other disorders that could account for the deficits on 7 May 2014.
Possible Alzheimer disease is defined by: 16. Tariq SH, Tumosa N,
Chibnall JT, Perry MH
Dementia established by clinical examination and documented by an instrument, such as the Mini-Mental Status 3rd, Morley JE. Com-
Examination parison of the Saint
Louis University
Absence of other conditions that would cause dementia Mental Status Exami-
nation and the Mini-
Variations in the clinical course from the typical course of Alzheimer disease; when another condition is present that Mental State Exami-
could cause dementia but is not felt to be the primary cause; or when there is a single, severe, progressive cognitive nation for detecting
deficit without an identifiable cause dementia and mild
neurocognitive dis-
Definite Alzheimer disease is defined by: ordera pilot study.
The presence of clinical criteria for probable Alzheimer disease combined with biopsy- or autopsy-confirmed histopathology. Am J Geriatr Psychia-
try. 2006;14:900-10.
The diagnosis of probable Alzheimer disease is supported by the presence of: [PMID: 17068312]
17. Roalf DR, Moberg PJ,
Specific cognitive deficits, such as executive dysfunction, aphasia, agnosia, and apraxia Xie SX, Wolk DA,
Impaired activities of daily living Moelter ST, Arnold
SE. Comparative ac-
Positive family history curacies of two
Supportive laboratory tests, such as normal lumbar puncture, normal electroencephalography, and cerebral atrophy on common screening
instruments for clas-
neuroimaging sification of
The diagnosis of Alzheimer disease is unlikely when: Alzheimers disease,
mild cognitive im-
The onset is acute pairment, and
Focal neurologic findings are present healthy aging.
Alzheimers Dement.
Seizure or gait disturbance is present early in the disease course 2013;9:529-37.
[PMID: 23260866]
doi:10.1016/j.jalz.201
*Adapted from reference 25. 2.10.001
18. Jorm AF. The Inform-
ant Questionnaire
on Cognitive De-
cline in the Elderly
(IQCODE): a review.
and Related Disorders Association Confusion Assessment Method, Int Psychogeriatr.
2004;16:275-93.
Work Group (19, 20). increases identification of delirium [PMID: 15559753]
19. McKhann G, Drach-
in high-risk settings, such as the man D, Folstein M,
Clinicians evaluating a patient intensive care unit (21). It is im- Katzman R, Price D,
with a change in cognition or portant to remember that many
Stadlan EM. Clinical
diagnosis of
overall function must consider elderly patients report minor cog- Alzheimers disease:
report of the
delirium. Delirium is characterized nitive problems, such as mild for- NINCDS-ADRDA
by cognitive impairment and an getfulness, difficulty remembering Work Group under
the auspices of De-
impaired level of alertness/attention/ names, and reduced concentration. partment of Health
and Human Services
consciousness. In contrast to de- These problems are typically spo- Task Force on
mentia, the onset of delirium is radic, do not worsen significantly Alzheimers Disease.
Neurology.
usually abrupt, and fluctuations over time, are easily compensated 1984;34:939-44.
[PMID: 6610841]
over minutes or hours are promi- for, do not affect function, and are 20. McKhann GM, Knop-
nent. Although some patients may often judged to be worse by the man DS, Chertkow
H, Hyman BT, Jack
be agitated and manifest psychotic patient than by others. In contrast, CR Jr, Kawas CH, et
al. The diagnosis of
symptoms, others are slow and early dementia insidiously be- dementia due to
drowsy and appear mildly de- comes a pattern; worsens over Alzheimers disease:
recommendations
pressed or withdrawn. Prompt time; is difficult to offset; eventu- from the National In-
stitute on Aging-
diagnosis of delirium is critical ally interferes with routine activi- Alzheimers Associa-
because it usually reflects an un- ties, such as bill paying and meal tion workgroups on
diagnostic guide-
derlying systemic condition, such preparation; and is often judged to lines for Alzheimers
disease. Alzheimers
as infection, metabolic derange- be worse by others than by the Dement. 2011;7:263-
ment, medication effect, or cancer. patient. Patients with memory 9. [PMID: 21514250]
doi:10.1016/j.jalz.201
Use of an instrument, such as the problems should be screened for 1.03.005

5 August 2014 Annals of Internal Medicine In the Clinic ITC5 2014 American College of Physicians

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 dementia, but a complete evaluation having the patient interpret pro-
Laboratory Studies for Patients
should be reserved for those with verbs or similes. Asking the patient
Being Evaluated for Cognitive
Problems*
measurable impairment in memory to draw a clock and put the hands
or other aspects of cognition. at 10 minutes past 11 is a quick
Comprehensive metabolic profile
Complete blood count
test of visual-spatial perception,
How should clinicians evaluate praxis, and planning ability. Also,
Thyroid-stimulating hormone level
the physical, mental, and cogni- the patient should be evaluated for
Vitamin B12 level
tive status of patients with corticosensory deficits, such as
In addition, patients may need to
undergo additional tests, suspected dementia? neglect or leftright confusion.
including the following: During the physical examination,
Rapid plasma reagin (fluores- the clinician should look for condi- What laboratory tests are helpful
cent treponemal antibody can tions that can cause or worsen cog- in the evaluation of any patient
be checked in cases where con-
cern for neurosyphilis is higher) nitive symptoms (Appendix Table, with cognitive dysfunction?
HIV test www.annals.org), with an emphasis According to guidelines from the
Toxicology screen on vascular and neurologic disease. American Academy of Neurology,
Erythrocyte sedimentation rate The examination should include a
Heavy metal screen
patients who are evaluated for cog-
Thiamine level mental status evaluation that begins nitive problems should have a labo-
Paraneoplastic panel with an assessment of the patients ratory evaluation for common
Chest radiograph or computed level of alertness, general appear- medical disorders, with selected
tomography of the chest
Urinalysis ance, and cooperation, which can additional studies depending on the
provide clues to delirium, depres- specific clinical situation (see the
*Adapted from references 22 and 23. sion, or nutritional deficiencies. Box: Laboratory Studies for Pa-
Speech should be evaluated for its tients Being Evaluated for Cogni-
content (grammatical or semantic tive Problems).
errors) and form (rate, fluency, and
volume); the patients mood and af- When should clinicians order
fect should be assessed for depres- imaging studies and other, more
sion, anxiety or mania, and the risk specialized laboratory studies?
for suicide; and thought content and Patients with cognitive difficulties
perception should be examined for less than 3 years in duration should
delusions or hallucinations and ob- have a neuroimaging study of the
21. Ely EW, Inouye SK,
Bernard GR, Gordon sessions or compulsions. head using computed tomography
S, Francis J, May L, et
al. Delirium in me-
or magnetic resonance imaging to
chanically ventilated The cognitive examination should exclude cerebrovascular disease,
patients: validity and
reliability of the Con-
include a standard instrument, hemorrhage, tumor, abscess,
fusion Assessment such as the SLUMS, which takes Creutzfeldt-Jakob disease, and hy-
Method for the In-
tensive Care Unit 5 minutes to administer, or the drocephalus. The yield is higher in
(CAM-ICU). JAMA. MOCA, which can take 10 min- patients with early age of onset;
2001;286:2703-10.
[PMID: 11730446] utes. Both tests have strengths and rapid progression; focal neurologic
22. Knopman DS,
DeKosky ST, Cum-
limitations. The MOCA empha- deficits; risk factors for cerebrovas-
mings JL, Chui H, sizes executive function and is cular disease; recent falls; central
Corey-Bloom J,
Relkin N, et al. Prac- more sensitive; the SLUMS evalu- nervous system (CNS) infection;
tice parameter: diag-
nosis of dementia
ates orientation, immediate recall, unexplained fluctuation of con-
(an evidence-based concentration, naming, language sciousness; or symptoms atypical of
review). Report of
the Quality Stan- function, praxis, and visualspatial AD, such as early and marked per-
dards Subcommittee
of the American
perception. Naming and praxis can sonality change. Routine use of glu-
Academy of Neurol- be further tested by asking the pa- cose or amyloid positron emission
ogy. Neurology.
2001;56:1143-53. tient to name a series of common tomography scanning is not recom-
[PMID: 11342678]
23. Massoud F, Devi G,
and uncommon objects and by ask- mended, although these tests may
Moroney JT, Stern Y, ing them to demonstrate tasks, be useful in certain cases, such as
Lawton A, Bell K, et
al. The role of rou- such as brushing hair or teeth or differentiating frontotemporal de-
tine laboratory stud- slicing bread. Abstract reasoning mentia from AD and in assessing
ies and neuroimag-
ing in the diagnosis and judgment should be tested by for early-onset dementia (24, 25).
of dementia: a clini-
copathological
asking for solutions to real-life
study. J Am Geriatr problems, such as what to do if one Genetic studies are not indicated
Soc. 2000;48:1204-
10. [PMID: 11037005] smells smoke in the house, or by in the evaluation of dementia

2014 American College of Physicians ITC6 In the Clinic Annals of Internal Medicine 5 August 2014

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 unless there is a specific concern syndrome, CNS cancer, or im-
about Huntington disease. Cur- munosuppression is possible. Neu-
rent evidence does not support ropsychological testing provides
routine testing for the ApoE4 the most comprehensive assess-
allele (26). Testing for the autoso- ment of cognitive function and is
mal dominant gene mutations particularly useful if the diagnosis
found in patients with familial of dementia is uncertain (27) or a
AD or fronto-temporal dementia precise characterization of the pa-
should be considered only if mul- tients cognitive impairment is
tiple family members are affected, necessary. 24. Foster NL, Heide-
brink JL, Clark CM,
the clinical picture and workup Jagust WJ, Arnold SE,
support one of these disorders, What other disorders should Barbas NR, et al.
FDG-PET improves
and the patient is younger than clinicians consider in the accuracy in distin-
60 years at onset. Genetic coun- assessment of cognitive guishing frontotem-
poral dementia and
seling is recommended before ge- dysfunction? Alzheimers disease.
Brain.
netic testing (26). During assessment of patients 2007;130:2616-35.
with cognitive disturbances, they [PMID: 17704526]
25. Johnson KA, Mi-
Other tests should be reserved for should be evaluated for not only noshima S, Bohnen
NI, Donohoe KJ, Fos-
specific situations. Electroen- the most common disorders that ter NL, Herscovitch P,
cephalography may be useful if cause dementia but also medica- et al; Amyloid Imag-
ing Task Force of the
there is a question of delirium, tions, depression, and MCI. Pa- Alzheimers Associa-
tion and Society for
seizures, encephalitis, or tients with MCI (28) have cogni- Nuclear Medicine
CreutzfeldtJakob disease. Lumbar tive decline without impaired and Molecular Imag-
ing. Update on ap-
puncture may be indicated in pa- function and should be followed propriate use criteria
tients younger than 55 years and closely, because 7% to 15% con- for amyloid PET im-
aging: dementia ex-
in those with rapidly progressive vert each year and meet the crite- perts, mild cognitive
impairment, and ed-
dementia; a positive rapid plasma ria for dementia; after 5 years, ucation. Amyloid Im-
reagin; and if acute or chronic nearly 50% of patients with MCI aging Task Force of
the Alzheimers As-
CNS infection, the paraneoplastic meet dementia criteria (28). sociation and Socie-
ty for Nuclear Medi-
cine and Molecular
Imaging. Alzheimers
Dement.
2013;9:e106-9.
Diagnosis... Patients who report cognitive and functional decline should be evalu- [PMID: 23809369]
ated through a detailed history of medical, neurologic, and psychiatric symptoms doi:10.1016/j.jalz.201
from the patient and a knowledgeable informant. They should also be given a 3.06.001
26. Loy CT, Schofield PR,
thorough physical and mental status evaluation and a cognitive examination. Turner AM, Kwok JB.
Whether to obtain basic laboratory studies and additional studies, including Genetics of demen-
tia. Lancet.
structural neuroimaging, is dictated by the clinical presentation. 2014;383:828-40.
[PMID: 23927914]
doi:10.1016/S0140-
6736(13)60630-3
CLINICAL BOTTOM LINE 27. Schmand B, Rienstra
A, Tamminga H,
Richard E, van Gool
WA, Caan MW, et al.
Responsiveness of
magnetic resonance
Treatment imaging and neu-
ropsychological as-
sessment in memory
What should clinicians advise patients may be unable to identify clinic patients. J
Alzheimers Dis.
patients and caregivers about symptoms, such as constipation, 2014;40:409-18.
general health and hygiene? dysuria, tooth pain, or diminished [PMID: 24473187]
doi:10.3233/JAD-
In the early stages of dementia, visual or auditory acuity, and the 131484
patients may have difficulty com- clinician should proactively look 28. Gauthier S, Reisberg
B, Zaudig M, Pe-
prehending the details of their for these problems. tersen RC, Ritchie K,
Broich K, et al; Inter-
medical care, organizing care, and national Psychogeri-
keeping track of appointments and It is important to attend to general atric Association Ex-
pert Conference on
medications. The clinician should medical and preventive care as mild cognitive im-
be alert to these limitations and conscientiously as in patients pairment. Mild cog-
nitive impairment.
prepare a care plan that compen- without dementia. A stroke or Lancet.
2006;367:1262-70.
sates for them. Later in the illness, heart attack due to uncontrolled [PMID: 16631882]

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 hypertension is likely to impair a patient continues to drive, the his-
patients function and quality of tory should be updated regularly
life as much as the dementia itself, to determine whether the capacity
at least in the early and middle to drive has deteriorated. State
stages of the disease. Thus, caring laws differ in regard to reporting
for patients with dementia in- patients with a diagnosis of de-
cludes careful attention to basic mentia to local MVAs, and the
general health practices, including clinician should be familiar with
good control of hypertension, dia- the applicable regulations. The
betes, and cholesterol; antiplatelet American Academy of Neurology
therapy where appropriate; and Evidence-Based Practice Parame-
vaccinations. For patients with ter outlines an approach to assess-
more advanced dementia, it be- ing driving in patients with
comes increasingly important to dementia (29).
pay attention to nutrition, skin
care (particularly of the perineum), In a prospective, casecontrol study using
the Washington University Road Test,
toileting schedules, and dental
which has an off-road and on-road com-
care. ponent, only 3% of controls failed the test,
19% of patients with very mild AD failed,
What should clinicians advise
and 41% with mild AD failed (P< 0.001).
29. Iverson DJ, Gronseth about safety issues, such as Previous driving experience did not protect
GS, Reger MA, driving, cooking, and other
Classen S, Dubinsky against failure (30).
RM, Rizzo M; Quality activities that may require
Standards Subcomit-
tee of the American supervision? A physician-directed recommen-
Academy of Neurol-
ogy. Practice param-
Patients with progressive dementia dation can have beneficial and
eter update: evalua- ultimately lose the ability to drive, adverse outcomes. For example, a
tion and
management of but predicting when an individual Canadian study of what happened
driving risk in de- patient should stop driving is diffi- when physicians recommended
mentia: report of the
Quality Standards cult, particularly if the restriction that patients discontinue driving
Subcommittee of
the American Acad- significantly burdens the patient or for a variety of disorders reported
emy of Neurology. family members. Nonetheless, ad- a 45% reduction in road crashes
Neurology.
2010;74:1316-24. dressing the issue is imperative, as (4.76 vs. 2.73) (P<0.001), a
[PMID: 20385882]
doi:10.1212/WNL.0b
numerous studies have shown that decrease in return visits to the
013e3181da3b0f driving ability becomes impaired physician, and an increase in visits
30. Hunt LA, Murphy CF,
Carr D, Duchek JM, in early stages of the disease. to emergency departments for
Buckles V, Morris JC.
Reliability of the
depression (31).
Washington Univer- The patient should be asked about
sity Road Test. A per- recent motor vehicle accidents, Clinicians should assess other
formance-based as-
sessment for drivers near misses, and changes in driv- safety issues with the patient and
with dementia of
the Alzheimer type.
ing ability. These inquiries should family on an ongoing basis. Pa-
Arch Neurol. be made in a setting that facilitates tients with progressive dementia
1997;54:707-12.
[PMID: 9193205] an open exchange of information eventually are unable to administer
31. Redelmeier DA,
Yarnell CJ, Thiruchel-
and may necessitate meeting with medications; cook; or use power
vam D, Tibshirani RJ. an informant without the patient tools, lawnmowers, or firearms.
Physicians warnings
for unfit drivers and present. Patients with early de- Home-safety assessments by home
the risk of trauma
from road crashes. N
mentia whose driving ability has therapists can determine which
Engl J Med. already deteriorated should be activities are still safe and which
2012;367:1228-36.
[PMID: 23013074] instructed to stop driving immedi- need to be limited or supervised.
32. Lyketsos CG, Stein-
berg M, Tschanz JT,
ately. Those with early dementia An activity can often be modified
Norton MC, Steffens who have no history of driving to allow ongoing participation in a
DC, Breitner JC.
Mental and behav- problems should undergo a driving safe fashion, such as cooking or
ioral disturbances in evaluation through the local motor gardening together with a family
dementia: findings
from the Cache vehicle administration (MVA) or member or friend. Wandering
County Study on
Memory in Aging.
an occupational therapy program from home is fairly common, pres-
Am J Psychiatry. at a local hospital. If no impair- ents significant safety concerns,
2000;157:708-14.
[PMID: 10784462] ment in driving is evident and the and must be assessed regularly.

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 What should clinicians advise about pressure to perform, in pain, or
nonpharmacologic approaches to lonely. Common examples in the in-
sleep problems, behavioral stitutional setting include agitation
problems, and psychiatric when personal care is being provid-
manifestations of dementia? ed, during shift changes, and in the
Psychiatric symptoms, such as de- presence of specific staff members. 33. Brodaty H, Arasarat-
pression, anxiety, sleep problems, When patterns are recognized, tar- nam C. Meta-analy-
sis of nonpharmaco-
agitation, hallucinations, and delu- geted interventions can be devel- logical interventions
sions, are common and often require oped, implemented, and refined. for neuropsychiatric
symptoms of de-
intervention (32). Various nonphar- Approaching behavioral distur- mentia. Am J Psychi-
atry. 2012;169:946-
macologic approaches are effective bances this way can often preclude 53. [PMID: 22952073]
and should be tried first unless the the use of psychotropic medications. doi:10.1176/appi.ajp.
2012.11101529
symptoms are causing immediate 34. Rabins PV, Lyketsos
danger or marked distress (33). Nonpharmacologic interventions were ef- CG, Steele CD. Practi-
cal Dementia Care.
These approaches emphasize the fective in reducing behavioral and psycho- 2nd ed. New York:
logical symptoms (overall effect size, 0.34 Oxford Univ Pr; 2006.
notion that many emotional and 35. Kales HC, Gitlin LN,
[CI, 0.200.48]; P=0.01) and improving care-
behavioral disturbances can be de- giver reactions to these behaviors (overall
Lyketsos CG; Detroit
Expert Panel on As-
coded or understood in terms of in- effect size, 0.15 [CI, 0.040.26]; P=0.006) (33). sessment and Man-
agement of Neu-
ternal or environmental factors that ropsychiatric
make them more or less likely to When should clinicians prescribe Symptoms of De-
mentia. Manage-
occur. This decoding process should acetylcholinesterase inhibitors and ment of neuropsy-
chiatric symptoms of
be done using systematic approach- memantine to slow cognitive dementia in clinical
es, such as 4-D or DICE (34, 35) decline? settings: recommen-
dations from a mul-
(Table 2). Decoding involves de- Acetylcholinesterase inhibitors, such tidisciplinary expert
scribing the behavior in detail and as donepezil, galantamine, or rivas- panel. J Am Geriatr
Soc. 2014;62:762-9.
noting its characteristics, including tigmine, can be prescribed to delay [PMID: 24635665]
doi:10.1111/jgs.12730
the time of day, location, antecedent cognitive decline in patients with 36. Howard R, McShane
factors, people present and absent, mild, moderate, or advanced AD. R, Lindesay J, Ritchie
C, Baldwin A, Barber
proximity to eating or other key ac- These drugs are better tolerated if R, et al. Donepezil
and memantine for
tivities, and the consequences of the they are slowly titrated to reach the moderate-to-severe
behavior. Common examples of en- target dose. Memantine is approved Alzheimers disease.
N Engl J Med.
vironmentally driven behavioral dis- for use in moderate-to-advanced 2012;366:893-903.
turbances include agitation when AD and can be used in conjunction [PMID: 22397651]
doi:10.1056/NEJ-
the patient is hungry, tired, under with acetylcholinesterase inhibitors. Moa1106668

Table 2. Approach for Assessing and Treating Behavioral and Psychiatric Disturbances*
Define/Describe Decode (What Causes
the Problem)
What occurs and Cognitive impairment,
under what psychiatric symptoms,
circumstances? medical condition,
environment?
Persistent yelling What is being said Forgetfulness, fear
and when is it said? perhaps from psychotic
What consequences symptoms, pain, shift
result from the changes, noise/other
yelling (to the bothersome stimuli,
patient and others)? presence/absence of
particular individuals
Depressed mood Describe patients Frustration with forget-
mood. What time of fulness, delirium, major
day is it exhibited? depression, medications,
In what environment? general medical conditions,
Around which people? environment (recent move,
Are there clear pre- departure of a caregiver,
cipitating events? some trigger in the milieu)
Devise a Treatment Plan
Treat psychiatric or medical
conditions, alter environment
or patient placement within
it, alter environment or
patient placement within it,
redirect, reassure, medicate
Provide reassurance or distraction,
treat depressionmedications/
electroconvulsive therapy, treat
general medical conditions,
adjust medications, improve
patient activity regimen,
adjust milieu
Determine Whether the
Treatment Has Worked
Monitor frequency of yelling
following the interventions
Monitor/document patients
mood after intervention;
monitor/document side
effects; identify barriers to
implementation of the
treatment plan

*Adapted from reference 35.

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 When the benefit is unclear, the of these drugs in patients with vas-
drug may be stopped but should be cular dementia is not recommended.
restarted if acute cognitive deteriora- Vitamin E has been shown to have
tion occurs. Patients and families modest benefit on function but not
may need help in developing realistic cognition in 2 well-designed trials of
expectations for these agents. Side patients with dementia, and con-
effects of cholinesterase inhibitors cerns about increased mortality were
include nausea, diarrhea, bradyar- not substantiated (40, 41).
37. Emre M, Aarsland D,
rhythmia, syncope, weight loss, and
Albanese A, Byrne ataxia. Which pharmacologic agents are
EJ, Deuschl G, De
Deyn PP, et al. Ri-
ineffective in treating specific
vastigmine for de- One study followed 295 community-living types of dementia and should be
mentia associated patients who had been receiving donepezil avoided?
with Parkinsons dis-
for at least 3 months (36) and assessed
ease. N Engl J Med. The herbal supplement ginkgo
2004;351:2509-18. outcomes at the end of 1 year. The primary
[PMID: 15590953]
outcome included standard measures of biloba does not slow progression of
38. McKeith I, Del Ser T,
Spano P, Emre M, cognitive ability as determined by the dementia (42). Also, nonsteroidal
Wesnes K, Anand R,
et al. Efficacy of ri- Standardized MMSE and the ability to per- anti-inflammatory drugs, estrogen,
vastigmine in de- form activities of daily living as measured and ergoid mesylates should not be
mentia with Lewy
bodies: a ran- by the Bristol Activities of Daily Living Scale prescribed for cognitive decline.
domised, double- (BADLS). Patients assigned to continue Data on whether the widely used
blind, placebo-con-
trolled international donepezil, compared with those assigned food supplements coconut oil and
study. Lancet. to discontinue the drug, had a score on the Axona can be recommended are
2000;356:2031-6.
Standardized MMSE that was higher (indi-
[PMID: 11145488] inadequate.
39. Beversdorf DQ, cating better cognitive ability) by 1.9 points
Warner JL, Davis RA,
Sharma UK, Nagaraja
(1.4 points is the minimum clinically im- When should clinicians prescribe
HN, Scharre DW. portant difference) (CI, 1.32.5) and a score
Donepezil in the antidepressants in patients with
treatment of de-
on the BADLS that was lower (indicating
mentia with Lewy less impairment) by 3.0 points (3.5 points is dementia?
bodies [Letter]. Am J
the minimum clinically important differ- Nearly one third of patients with
Geriatr Psychiatry.
2004;12:542-4. ence) (CI, 1.84.3). Patients assigned to re- dementia develop an episode of
[PMID: 15353396]
40. Sano M, Ernesto C,
ceive memantine instead of placebo had a major depression after the onset of
Thomas RG, Klauber score on the Standardizes MMSE that was dementia (43), but evidence for the
MR, Schafer K,
Grundman M, et al.
1.2 points higher (CI, 0.61.8; P<0.001) and efficacy of antidepressant medica-
A controlled trial of a score on the BADLS that was 1.5 points tions is mixed (44). One explana-
selegiline, alpha-to- lower (CI, 0.32.8; P<0.02). The differences
copherol, or both as tion is that some symptoms of
treatment for between donepezil and memantine were
Alzheimers disease. major depression, such as weight
not statistically significant, and adding
The Alzheimers Dis-
memantine to donepezil was not better loss and disturbed sleep, may be
ease Cooperative
Study. N Engl J Med. than either drug alone. produced by dementia alone and
1997;336:1216-22.
[PMID: 9110909]
complicate the diagnosis. Clinicians
41. Dysken MW, Sano M, Which other pharmacologic therefore need to have a high index
Asthana S, Vertrees
JE, Pallaki M, agents are helpful in treating of suspicion for major depression.
Llorente M, et al. Ef-
fect of vitamin E and
specific types of dementia, and in
memantine on func- what situations should clinicians When should clinicians prescribe
tional decline in antipsychotic agents to treat
Alzheimer disease: consider prescribing these agents?
the TEAM-AD VA co- The acetylcholinesterase inhibitor behavioral disturbances or psycho-
operative random-
ized trial. JAMA. rivastigmine has been shown to be tic symptoms, and what are their
2014;311:33-44.
[PMID: 24381967] effective in improving cognitive per- side effects?
doi:10.1001/jama.20 formance in patients with mild-to- Absent a significant risk for harm,
13.282834
42. Schneider LS, moderate Parkinson disease in doses psychotic symptoms, such as halluci-
DeKosky ST, Farlow similar to those used in AD, and it nations, delusions, and agitated be-
MR, Tariot PN, Hoerr
R, Kieser M. A ran- is believed that this benefit occurs havior, should first be treated non-
domized, double-
blind, placebo-con- with the other acetylcholinesterase pharmacologically (33) because all
trolled trial of two inhibitors (37). Several trials have drugs in this class carry a risk for el-
doses of Ginkgo
biloba extract in de- also shown the benefits of acetyl- evated mortality (1.62.0 in the sub-
mentia of the
Alzheimers type.
cholinesterase inhibitor treatment sequent 1252 weeks) (45-48).
Curr Alzheimer Res. for cognition in dementia with Pharmacotherapy is indicated if
2005;2:541-51.
[PMID: 16375657] Lewy bodies (38, 39). However, use symptoms are causing significant

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 distress for the patient or creating a antipsychotic medications is associat-
dangerous situation. The second- ed with the metabolic syndrome,
43. Zubenko GS,
generation antipsychotic agents are weight gain, hyperlipidemia, and dia- Zubenko WN,
McPherson S, Spoor
usually recommended instead of betes mellitus. Recent evidence sup- E, Marin DB, Farlow
first-generation agents because of a ports the effectiveness and relative MR, et al. A collabo-
rative study of the
lower risk for tardive dyskinesia. safety of nonpharmacologic interven- emergence and clin-
Overall, the efficacy of these agents ical features of the
tions for neuropsychiatric and major depressive
is modest (46). Although more evi- behavioral symptoms (33), which re- syndrome of
Alzheimers disease.
dence supports the use of risperi- inforces the recommendations to use Am J Psychiatry.
done and olanzapine, similar drugs drugs sparingly for these symptoms. 2003;160:857-66.
[PMID: 12727688]
also are used. These drugs should be However, head-to-head trials of 44. Brodaty H. Antide-
pressant treatment
prescribed at the lowest possible pharmacologic and nonpharmacolog- in Alzheimers dis-
dose and for the shortest possible ic interventions have not been done. ease. Lancet.
2011;378:375-6.
time. Ongoing use should be moni- [PMID: 21764117]
doi:10.1016/S0140-
tored regularly, and attempts should Which drugs should clinicians use 6736(11)61031-3
be made to decrease the dose and to treat sleep problems? 45. Schneider LS, Dager-
man KS, Insel P. Risk
discontinue the drug within 3 Clinicians should try nonpharma- of death with atypi-
cal antipsychotic
months of starting. They should not cologic methods before using med- drug treatment for
be routinely used only for sleep due ications in patients with dementia dementia: meta-
analysis of random-
to toxicity (Table 3). The U.S. Food who have insomnia because of the ized placebo-con-
trolled trials. JAMA.
and Drug Administration requires potential risks associated with 2005;294:1934-43.
black-box warnings for second- sedative-hypnotics in this popula- [PMID: 16234500]
46. Schneider LS, Dager-
generation antipsychotics because tion. Careful attention should be man K, Insel PS. Effi-
cacy and adverse ef-
of increased rates of death and cere- paid to sleep environment, caffeine fects of atypical
brovascular events. The reasons for consumption, daytime sleeping, af- antipsychotics for
dementia: meta-
these bad outcomes are unclear, but ternoon and evening medications, analysis of random-
ized, placebo-con-
falls, infections, and cardiovascular and other elements of basic sleep hy- trolled trials. Am J
and cerebrovascular events may con- giene. Meta-analyses do not support Geriatr Psychiatry.
2006;14:191-210.
tribute. In addition, treatment with the efficacy of any pharmacologic [PMID: 16505124]

Table 3. Cognitive Agents for Alzheimer Disease*

Agent Mechanism of Dosage Benefits Side Effects Notes
Action
Donepezil Acetylcholin- Begin 5 mg/d; if Delayed symptom Nausea, vomiting, The higher end of the dosing
esterase tolerated, increase progression in mild, diarrhea, anorexia, range may be harder for
inhibition to target dose of moderate, and advanced syncope patients to tolerate; dose higher
10 mg/d after 1 month Alzheimer disease than 10mg not recommended
Galantamine Acetylcholin- Start 4 mg twice daily; Delayed symptom Nausea, vomiting, Routine liver function testing
esterase target dose total 24 mg/d; progression in mild, diarrhea, anorexia, is unnecessary; the higher end
inhibition increase by 4 mg twice moderate, and advanced syncope of the dosing range may be
daily every 1 month until Alzheimer disease; harder for patients to tolerate;
in target range improvement in caregiver begin extended-release (once
rated quality of life was daily) galantamine at 8 mg/d;
observed increase by 8 mg/d every
1 month to the target dose of
24 mg/d; higher dose not
recommended
Rivastigmine Acetylcholin- Start 1.5 mg twice daily; Delayed symptom Nausea, vomiting, Higher end of the dose range
esterase target range is 612 mg/d; progression in mild, diarrhea, anorexia, may be less tolerable tolerate;
inhibition increase by 1.5 mg twice moderate, and advanced syncope also available as a transdermal
daily every 1 month until Alzheimer disease patch
in target range
Memantine NMDA- Begin 5 mg/d, increase by Less functional decline, Dizziness, confusion, Generic available; branded
receptor 5 mg/d every 1 month until improved cognition, and headache, constipation drug only available in sustained-
antagonism target of 10 mg twice daily reduced demands on care- release form; available in tablets
givers in moderate-to- or solution; avoid concomitant
advanced Alzheimer disease use with amantadine

*NMDA = N-methyl-d-aspartic acid.

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 intervention. If necessary, 2550 preserved capacities would benefit
mg of trazodone can be used with the patient.
cautious monitoring (49).
Treatment of dementia requires a
What other steps should clinicians broad clinical approach that ideally
take to maximize quality of life? includes preventive medicine, psy-
Clinicians should proactively ad- choeducation, behavioral therapy,
dress issues that have the potential safety evaluation, and pharmaco-
to significantly affect quality of therapy. The clinician should expect
life. Examples include the working to interact with a broad range of
order of sensory aids, such as professionals, including occupation-
glasses and hearing aids; dental al therapists, social workers, physi-
care; noise, lighting, and tempera- cal therapists, and speech and
ture; sufficient social and cognitive language pathologists, to provide
stimuli; cleanliness; pain levels; optimal care.
and constipation.
47. Wang PS, When should clinicians recom-
Schneeweiss S,
Avorn J, Fischer MA, Advance directives have the poten- mend hospitalization?
Mogun H, Solomon tial to benefit all patients. Since full During the assessment of cognitive
DH, et al. Risk of
death in elderly incapacitation is inevitable for impairment, hospitalization should
users of convention-
al vs. atypical an-
every person with progressive de- be considered for patients who can-
tipsychotic medica- mentia who lives long enough to not be evaluated safely or compre-
tions. N Engl J Med.
2005;353:2335-41. experience the full course of the hensively as outpatients because of
[PMID: 16319382]
48. Gill SS, Bronskill SE,
disease, early advance directives dangerous behavior, unsafe living
Normand SL, Ander- maximize the likelihood that the conditions, compromised nutrition,
son GM, Sykora K,
Lam K, et al. Antipsy- persons wishes for end-of-life care neglected medical conditions, or
chotic drug use and will be carried out. lack of cooperation. In addition to
mortality in older
adults with demen- safety issues, hospitalization can fa-
tia. Ann Intern Med. When should clinicians consult a cilitate thorough history-taking,
2007;146:775-86.
[PMID: 17548409] neurologist, psychiatrist, or other neuroimaging, other diagnostic
49. Camargos EF, Louza-
da LL, Quintas JL, professional? studies, neuropsychological evalua-
Naves JO, Louzada Clinicians should consider consult- tion, safety evaluation by occupa-
FM, Nbrega OT. Tra-
zodone improves ing a geriatric psychiatrist, neurolo- tional therapists, and future care
sleep parameters in
Alzheimer disease
gist, geriatrician, or dementia planning.
patients: a random- specialist in patients with atypical
ized, double-blind,
and placebo-con- features of dementia, such as early Psychiatric hospitalization is some-
trolled study. Am J
Geriatr Psychiatry.
onset, early noncognitive neurolog- times required because of the severi-
2014. ic symptoms, rapid progression, ty of psychiatric symptoms. For ex-
[PMID: 24495406]
doi:10.1016/j.jagp.20 early personality changes, or unusu- ample, hospitalization should be
13.12.174 al symptom patterns. Consulting a considered for depressed patients
50. Yaffe K, Fox P, New-
comer R, Sands L, geriatric psychiatrist or dementia who exhibit suicidality, decreased
Lindquist K, Dane K,
et al. Patient and specialist should also be considered food and fluid intake, delusions, de-
caregiver character-
istics and nursing
for evaluation or management of pression, immobility, inability to at-
home placement in difficult-to-treat neuropsychiatric tend to medical conditions, or need
patients with de-
mentia. JAMA. symptoms, such as depression, psy- for electroconvulsive therapy. Pa-
2002;287:2090-7.
[PMID: 11966383]
chosis, or behavioral disturbances. tients with behavioral disturbances
51. Chan DC, Kasper JD, These symptoms can create dan- who are dangerous to themselves or
Black BS, Rabins PV.
Presence of behav- gerous situations for the patient who cannot be treated safely or suc-
ioral and psychologi- and others and reduce quality of cessfully as an outpatient because of
cal symptoms pre-
dicts nursing home life. Consulting a specialist should wandering, violence, calling out, hy-
placement in com-
munity-dwelling also be considered if patients re- perphagia, or a severely disordered
elders with cognitive quire physical retraint. Referral to a sleepwake cycle, should also be
impairment in uni-
variate but not mul- neuropsychologist may be necessary hospitalized. Patients with psychotic
tivariate analysis. J
Gerontol A Biol Sci
if it is unclear whether dementia hallucinations and delusions may re-
Med Sci. is present and when in-depth quire hospitalization if they do not
2003;58:548-54.
[PMID: 12807927] documentation of impaired and respond to outpatient treatment,

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 require the addition of multiple med- physically and emotionally, and in-
ications, are in distress or having quiring about caregiver well-being
behavioral disturbances, or present a is a critical component of dementia
risk to others. Involuntary commit- care. Common caregiver symptoms
ment may be required in any of include guilt, anger, grief, fatigue,
these situations. loneliness, demoralization, and de-
pression. The patients symptoms
How can clinicians help families and the demands on the caregiver
decide to move a patient with change over time, so the well-being
dementia into a long-term care of the caregiver must be assessed at
facility? every visit.
As dementia progresses, moving to
an environment that can adequately Most caregivers benefit from a range
address the progressive needs of of interventions (33) that focus on
the patient with dementia is often education about dementia, skills
necessary, either to an assisted-living training, and the caregivers own well-
facility or to a nursing home (50). being. Many pamphlets, books, and 52. Teri L, Logsdon RG,
Some patients may need to move educational Web sites are available. Uomoto J, McCurry
SM. Behavioral treat-
because of inadequate support at Patient and caregiver safety must be ment of depression
in dementia pa-
home. Generally, a move into a nurs- evaluated at each follow-up visit, and tients: a controlled
ing home is prompted by develop- caregivers need to be informed about clinical trial. J Geron-
tol B Psychol Sci Soc
ment of physical and cognitive local respite programs and supported Sci. 1997;52:P159-66.
[PMID: 9224439]
limitations that cannot be managed in long-term planning. 53. Haupt M, Karger A,
at home, such as the need for full as- Jnner M. Improve-
ment of agitation
sistance with transferring, ambula- Caregivers should also be informed and anxiety in de-
tion, toileting, or feeding. Other of the potential benefits of psychoed- mented patients af-
ter psychoeducative
patients have to move because of un- ucational and other support groups, group intervention
with their caregivers.
manageable psychiatric symptoms or which are available in most areas. Int J Geriatr Psychia-
high caregiver burden (51). Several large, well-conducted trials try. 2000;15:1125-9.
[PMID: 11180469]
have shown that groups with a focus 54. Mittelman MS, Haley
WE, Clay OJ, Roth
Families with ample financial re- on problem-solving, communication, DL. Improving care-
sources may be able to provide many management of behavioral distur- giver well-being de-
lays nursing home
services at home that usually are pro- bances, and emotional support were placement of pa-
tients with
vided in a facility. Periods of respite effective in delaying nursing home Alzheimer disease.
care may help families delay place- placement for up to 1 year, diminish- Neurology.
2006;67:1592-9.
ment. Families should be supported ing caregiver and patient depression, [PMID: 17101889]
and guided through the difficult and and reducing patient agitation and 55. Bekelman DB, Black
BS, Shore AD, Kasper
painful decision-making process. anxiety (52-54). JD, Rabins PV. Hos-
pice care in a cohort
Families may be advised to proac- of elders with de-
tively investigate facilities in their re- What are the options for end-of- mentia and mild
cognitive impair-
gion so a good decision can be made life care? ment. J Pain Symp-
quicklyfor example, because of a Hospice criteria for persons with de- tom Manage.
2005;30:208-14.
sudden change in functional ability mentia are specific to dementia. [PMID: 16183004]
56. Rabins PV, Hicks KL,
after a medical illness or accident. Therapy for pain, neuropsychiatric Black BS. Medical de-
symptoms, and supportive medical cisions made by sur-
rogates for persons
What caregiver needs should be care are paramount. Consider dis- with advanced de-
mentia within weeks
addressed by the clinician? continuation of medications that or months of death.
Caregiving for a patient with de- have no short-term benefit, such as AJOB Prim Res.
2011;2:61-65.
mentia is extremely taxing, both cholesterol-lowering agents (55, 56). [PMID: 24818042]

5 August 2014 Annals of Internal Medicine In the Clinic ITC13 2014 American College of Physicians

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 Treatment... A broad approach that addresses comfort and quality of life, cognitive
enhancement, stabilization of psychiatric symptoms, and caregiver well-being needs
to be adopted. Patients with AD can be treated with acetylcholinesterase inhibitors,
and memantine can be added for patients with moderate-to-severe AD. It is impor-
tant to identify and treat psychiatric symptoms, such as depression, psychosis, anxi-
ety, and behavioral disturbances with both behavioral and pharmacologic treatment
to minimize risk factors for cerebrovascular disease and to treat any other condi-
tions that could reduce cognition. Attending to safety issues, regular monitoring of
the caregivers well-being, and suggesting referral to support groups and other psy-
choeducational activities are also important.

CLINICAL BOTTOM LINE

In the Clinic ACP Smart Medicine Module

In the Clinic
http://smartmedicine.acponline.org/content.aspx?gbosID=164

Tool Kit
Access the American College of Physicians Smart Medicine module
on dementia.

Patient Information
http://psychiatryonline.org/pdfaccess.ashx?ResourceID=243205&PDF
Source=6
American Psychiatric Association practice guideline for the treatment
Dementia of patients with Alzheimer disease and other types of dementia.
www.alz.org
www.alz.org/care/overview.asp
Information from the Alzheimers Association
www.caregiver.org
Help for caregivers from the National Caregiver Alliance.
www.nia.nih.gov/Alzheimers/
Alzheimers Disease Education and Referral Center (ADEAR)
(1-800-438-4380)
Clinical Guidelines
www.guideline.gov/summary/summary.aspx?doc_id=3690
2014 guideline from the U.S. Preventive Services Task Force guideline
on screening for cognitive decline in older adults.
https://www.aan.com/Guidelines/Home/ByTopic?topicId=15
American Academy of Neurology guidelines on diagnosing
Creutzfeldt-Jakob disease, assessing driving risk in patients with
dementia, early detection of dementia and mild cognitive
impairment, and diagnosis of dementia.

2014 American College of Physicians ITC14 In the Clinic Annals of Internal Medicine 5 August 2014

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 WHAT YOU SHOULD In the Clinic
Annals of Internal Medicine
KNOW ABOUT DEMENTIA

What is dementia?
Dementia is a group of symptoms related to impaired
memory and thinking skills. People with dementia
begin to forget things and can have problems with
everyday tasks. There are different types of
dementia. Dementia symptoms usually start slowly
and get worse over time.

What are the symptoms?

Forgetting things more and more often
Trouble with familiar activities, like making a meal
or a phone call
Having trouble finding the right words
Poor judgment, such as leaving the house with no
coat in the winter
Misplacing things or putting things in unusual
places, such as keys in the refrigerator
Personality changes, such as becoming very con-
fused, suspicious, fearful, or dependent
Unable to follow instructions, such as taking
medications
Unexplained weight loss
New onset of depression or anxiety

How is it diagnosed?
There is no one specific test for dementia. If a doctor
thinks a patient may have dementia, they will
review symptoms and ask about medical history.
Some other tests a doctor may perform are:
How is it treated?
There are treatments that may help to manage
different symptoms of dementia. These may help

Memory testto check memory and concentration
Neurologic examinationto check for problems that
may indicate a brain disorder. A doctor will test
things like speech, reflexes, and coordination.
Brain scanslike MRI or CT scans.
Laboratory blood testswhich can rule out problems
that may cause symptoms similar to dementia.
Patient Information
people with dementia think better and slow down
the worsening of symptoms. Behavior changes can
be treated in ways that promote comfort for the
patient. For example, creating a calm environment
and making sure people with dementia have enough
rest can help to manage behavior symptoms.
Medicines also may help these and other symptoms.
Talk with a doctor for the best treatment options.

For More Information

www.acponline.org/patients_families/products/health_tips/dem_en.pdf
American College of Physicians

www.alz.org/what-is-dementia.asp
Alzheimers Association

https://caregiver.org/node/92
Family Caregiver Alliance

www.nlm.nih.gov/medlineplus/dementia.html
Medline Plus

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 CME Questions
1. A 79-year-old man is evaluated for a
1-year history of forgetfulness and not
being able to remember names. He is a
retired attorney. He reports no problems
with performing activities of daily living,
planning his day, or managing his
finances. He is frustrated but not
depressed and is still able to enjoy life.
He has hypertension and hyperlipidemia
controlled with hydrochlorothiazide and
simvastatin.
On physical examination, he is afebrile,
blood pressure is 140/82 mm Hg, and
pulse rate is 78/min. Mini-Mental State
Examination score is 25. His lungs are
clear. The heart is without murmur.
Neurologic, motor, and sensory
examinations are normal.
Which of the following is the most likely
diagnosis?
A. Alzheimer disease
B. Mild cognitive impairment
C. Pseudodementia
D. Vascular dementia
2. A 77-year-old woman is evaluated in the
emergency department for a 1-week
history of progressive agitation and
confusion. She has no history of fever or
falling episodes. The patient lives in a
nursing home, has advanced dementia,
and is dependent on others for all
activities of daily living. She can indicate
when she needs to void and generally is
not incontinent. She can ambulate with a
cane but must be accompanied because of
a tendency to wander. Although she
enjoys being around others and can make
simple conversation with family members
and nursing home personnel, she does not
recognize anyone by name or remember
what was said. She has a history of osteo-
arthritis, hypertension, atrial fibrillation,
anxiety, and depression. There have been
no recent additions or changes to her
medications, which are hydro-
chlorothiazide, warfarin, amitriptyline,
alprazolam, and oxybutynin.
Questions are largely from the ACPs Medical Knowledge Self-Assessment Program (MKSAP, accessed at
http://www.acponline.org/products_services/mksap/15/?pr31). Go to www.annals.org/intheclinic/
to complete the quiz and earn up to 1.5 CME credits, or to purchase the complete MKSAP program.
2014 American College of Physicians
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Physical examination is noncontributory.
Results of a complete blood count,
comprehensive metabolic profile, and
urinalysis are normal. A chest radiograph
reveals no evidence of infection or heart
failure.
Which of the following is most
appropriate as an initial step in
management?
A. Add donepezil
B. Add risperidone
C. Discontinue anticholinergic and
sedative medications
D. Obtain an electroencephalogram
3. A 66-year-old man is evaluated for a
2-month history of odd behavior. He is a
retired high school principal and has a
5-year history of Parkinson disease.
According to his wife, his lifelong interest
in repairing household items has lately
escalated out of control. Increasingly,
the patient starts new tasks he never
completes; stays up all night taking apart
appliances and furniture but never fixes or
reassembles them, and leaves parts strewn
throughout the house. The patient insists
that he is making necessary repairs and will
soon put everything back together. His
Parkinson symptoms remain well controlled
with ropinirole and levodopa-carbidopa. His
motor function is generally good, and he is
able to function independently.
On physical examination, temperature is
36.7C (98.1F), blood pressure is 126/80
mm Hg sitting and standing, pulse rate is
72/min, and respiration rate is 16/min;
BMI is 27.
Which of the following is the most likely
cause of this patients symptoms?
A. Dementia with Lewy bodies
B. Dopamine agonist medication
C. Frontotemporal dementia
D. Progression of Parkinson disease
ITC16 In the Clinic
4. A 73-year-old woman is evaluated for
short-term memory loss. She has trouble
remembering names, where she placed
certain items such as her keys, and
occasionally what she did earlier in the
day. She avoids some social situations
and has lower self-esteem because of
memory problems and decreased social
contact, but notes no depression, low
energy, or sleep disturbance. She still
enjoys playing cards with her husband.
She does not need help with eating,
dressing, or bathing. Her hypertension is
well controlled with hydrochlorothiazide.
She has no history of stroke. She is
concerned about her condition and wants
to know if anything can be done about it.
On physical examination, temperature is
37.2C (98.9F), blood pressure is 135/84
mm Hg, and pulse rate is 72/min. She is
conversant with a normal range of affect.
Neurologic examination is without focal
deficit. The remainder of the physical
examination is normal. Mini-Mental
State Examination score is 26.
Which of the following is the most
appropriate management of this patient?
A. Anticholinesterase inhibitor
B. Cognitive rehabilitation
C. Positron-emission tomography scan
D. Reassurance that progression to
dementia is unlikely
Disclosures: Drs. Rabins and Blass, ACP
Contributing Authors, have disclosed
the following conflict of interest:
Payment for manuscript preparation:
American College of Physicians.
Disclosures can also be viewed at
www.acponline.org/authors/icmje/
ConflictOfInterestForms.do?msNum
=M14-1345.
Annals of Internal Medicine 5 August 2014