Guideline sources The following summarized guidelines for the evaluation and management of dementia are prepared by our editorial team based on guidelines from the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018), the Canadian Task Force on Preventive Health Care (CTFPHC 2016), the American Geriatrics Society (AGS 2015; 2014), the U.S. Preventive Services Task Force (USPSTF 2014), the Canadian Geriatrics Society (CGS 2012), the American Academy of Neurology (AAN 2010), and the American Psychiatric Association (APA 2007). 1 2 3 4 5 6 7 8 9 9 9 10 Definition Dementia is a clinical syndrome characterized by a progressive cognitive decline that interferes with the ability to function independently. 9 Epidemiology Dementia is mostly caused by Alzheimer's disease (60-80%), vascular injury (stroke; 20%), Lewy bodies (5-15%), and frontotemporal impairment (Pick's disease). 9 https://web.pathway.md/diseases/recqgGsIww8nnHUqF 1/9 6/29/23, 10:08 PM Dementia Pathway Disease course Alzheimer's disease, vascular injury, Lewy body deposition, and frontotemporal lobe impairment result in dementia, which causes clinical manifestations of gradual, persistent, and progressive decline in cognition and function. Cognitive deficits may present as memory loss, communication and language impairments, agnosia, apraxia, and impaired executive function (reasoning, judgment, and planning). Dementia progression may lead to behavioral and psychological symptoms including wandering, hoarding, sexual disinhibition, eating inappropriate objects, repetitive behaviors, restlessness, agitation, apathy, aggression, psychosis, hallucinations, and delusions causing considerable distress and safety risk for the patient and their caregivers. 9 Prognosis and risk of recurrence Annual mortality associated with dementia in men and women is 38.3% and 30.5%, respectively. 10 Calculator Calculator Calculat Abbey pain scale for patients wit Abbreviated mental test AMT 10 Abbrev Guidelines 1. Screening and diagnosis Indications for screening: As per CTFPHC 2016 guidelines, avoid screening asymptomatic adults 65 years of age for cognitive impairment. D As per USPSTF 2014 guidelines, insufficient evidence to assess the balance of benefits and harms of screening for cognitive impairment. I Diagnostic criteria: Adopt the criteria for dementia proposed by the National Institute on Aging-Alzheimer's Association working group in 2011. E Adopt the criteria for possible and probable Alzheimer's disease proposed by the National Institute on Aging-Alzheimer's Association working group in 2011. E 2. Diagnostic investigations Indications for head CT: Obtain a CT scan in patients with rapid unexplained decline in cognition or function duration of dementia < 2 years recent and significant head trauma unexplained neurological symptoms such as new onset of severe headache or seizures https://web.pathway.md/diseases/recqgGsIww8nnHUqF 2/9 6/29/23, 10:08 PM Dementia Pathway a history of cancer especially in sites and types that metastasize to the brain a history of anticoagulant use or bleeding disorder a history of urinary incontinence and gait disorder early in the course of dementia any new localizing sign such as hemiparesis or a Babinski reflex unusual or atypical cognitive symptoms or presentation, such as progressive aphasia gait disturbance. E Indications for brain magnetic resonance imaging: obtain MRI of the brain when a radiologist/neuroradiologist and/or a cognitive specialist can interpret patterns of atrophy and other radiological features that may provide added diagnostic and predictive value in the evaluation of patients with dementia. B 18F-fluorodeoxyglucose positron emission tomography and single positron emission computed tomography: obtain a 18F-labeled FDG-positron emission tomography scan in patients with a diagnosis of dementia who have undergone the recommended baseline clinical and structural brain imaging evaluation and have been evaluated by a dementia specialist, but whose underlying pathological process is still unclear, preventing adequate clinical management. B Functional magnetic resonance imaging: avoid functional MRI for the investigation of patients presenting with cognitive complaints. D Positron emission tomography amyloid imaging: avoid the use of amyloid imaging outside of research settings, because even though it represents a promising technique in the evaluation of dementia, there are many unknowns that could impact its diagnostic utility. D Magnetic resonance spectroscopy: avoid magnetic resonance spectroscopy to diagnose dementia or differentiate dementia from mild cognitive impairment. D Other investigations: avoid obtaining imaging biomarkers of neuro-inflammation or tau pathology in dementia patients. D Evaluation of driving risk: Identify patients with dementia at increased risk for unsafe driving by considering the following characteristics: the Clinical Dementia Rating scale A a caregiver's rating of a patient's driving ability as marginal or unsafe B a history of crashes or traffic citations B reduced driving mileage or self-reported situational avoidance B mini-Mental State Examination scores of 24 or less B aggressive or impulsive personality characteristics B 3. Medical management General principles: individualize treatment plans, because patients with dementia display a broad range of cognitive impairments and neuropsychiatric symptoms that can cause significant distress to themselves and caregivers. A Cholinesterase inhibitors: https://web.pathway.md/diseases/recqgGsIww8nnHUqF 3/9 6/29/23, 10:08 PM Dementia Pathway As per CGS 2012 guidelines, offer a trial of a cholinesterase inhibitor for most patients with Alzheimer's dementia. A Show 3 more As per APA 2007 guidelines: Offer cholinesterase inhibitors to patients with mild-to-moderate Alzheimer's disease after a thorough discussion of their potential risks and benefits. B Consider cholinesterase inhibitors in patients with severe Alzheimer's disease. C NMDA antagonists: As per CGS 2012 guidelines, insufficient evidence to recommend for or against combination therapy of a cholinesterase inhibitor and memantine. I As per APA 2007 guidelines, consider memantine, a noncompetitive NMDA antagonist, in patients with moderate and severe Alzheimer's disease. B Antidepressant trial: as per CGS 2012 guidelines, consider a trial of antidepressants in patients with major depressive disorder, severe dysthymia, or severe emotional liability. B Other pharmacological treatments: avoid vitamin E for the treatment of cognitive symptoms of dementia, because of limited evidence for its efficacy as well as safety concerns. D Management of sleep disturbances: manage sleep disturbances in patients with dementia with interventions including maintaining daytime activities and giving careful attention to sleep hygiene. B Show 3 more 4. Nonpharmacologic interventions Long-term care issues: organize care to meet the needs of patients, including those with behavioral problems. A Psychiatric management: Educate patients and families about the illness, its treatment, and sources of additional care and support. A Advise patients and their families of the need for financial and legal planning due to the patient's eventual incapacity. A Psychotherapy: large randomized clinical trials on behavioral approaches have not been performed, but their widespread clinical use is supported by small trials and case studies. B Driving cessation: inform all patients and families that even mild dementia increases the risk of motor vehicle accidents. A 5. Therapeutic procedures Tube feeding: As per Choosing Wisely 2015 guidelines, avoid percutaneous feeding tubes in patients with advanced dementia; offer oral assisted feeding instead. D https://web.pathway.md/diseases/recqgGsIww8nnHUqF 4/9 6/29/23, 10:08 PM Dementia Pathway As per AGS 2014 guidelines, avoid using feeding tubes for older adults with advanced dementia. Offer careful hand feeding; for persons with advanced dementia, hand feeding is at least as good as tube feeding for the outcomes of death, aspiration pneumonia, functional status, and comfort. 6. Specific circumstances Patients with rapidly progressive dementia: define rapidly progressive dementia as a dementia which develops within 12 months after the appearance of first cognitive symptoms. B Show 3 more Patients with early onset dementia: refer all patients with early onset dementia to a memory clinic, preferably one with access to genetic counseling and testing when appropriate. E 7. Preventative measures Management of blood pressure: consider BP lowering to prevent cognitive decline and dementia in adults with hypertension. C 8. Follow-up and surveillance Monitoring for psychiatric symptoms: monitor periodically for the development and evolution of cognitive and non-cognitive psychiatric symptoms, and their response to intervention. A Frequency of follow-up visits: follow-up patients at least every 3-6 months to adjust treatment, enhance safety, and provide timely advice to the patient and family. B Indications for specialist referral: obtain head MRI when a radiologist/neuroradiologist and/or a cognitive specialist can interpret patterns of atrophy and other features that may provide added diagnostic and predictive value. B Discontinuation of cholinesterase inhibitors: Consider discontinuing cholinesterase inhibitors when: the patient and/or their proxy decision-maker decide to stop after a reappraisal of risks and benefits the patient is sufficiently non-adherent with the medication that continued prescription of it would be useless, and it is not possible to establish a system for the administration of the medication to rectify the problem the patient's rate of cognitive, functional, and/or behavioral decline is greater on treatment compared to that prior to being treated the patient experiences intolerable side effects that are definitely or probably related to the cholinesterase inhibitor the comorbidities of the patient make continued use of the agent either unacceptably risky or futile https://web.pathway.md/diseases/recqgGsIww8nnHUqF 5/9 6/29/23, 10:08 PM Dementia Pathway the patient's dementia progresses to a stage where there would be no clinically meaningful benefit from continued therapy. E Clinical findings Patient demographics Symptoms Age > 65 Apathy Being unable to concentrate on tasks Past medical history Confusion Hyperthyroidism Depression Hypothyroidism Dysarthria Medications Loss of ability to do everyday tasks Neurological exam Memory impairment Disorientation Personality or behavioral changes Mood alteration Social history Alcohol consumption Likelihood Ratios Pertinent positives The following findings increase the probability of dementia in adults. 10 Finding LR+ Value Positive 7-Minute Screen 47 (3-730) Positive memory Impairment Screen 33 (15-72) Positive brief Alzheimer Screen 25 (17-35) Positive Mini-Cog 13.0 (9.9-17.0) Show 1 more Pertinent negatives The following findings decrease the probability of dementia in adults. 10 Finding LR- Value Negative brief Alzheimer Screen 0.02 (0.01-0.04) Negative memory Impairment Screen 0.08 (0.02-0.30) Negative 7-Minute Screen 0.09 (0.01-0.59) Negative 6-Item Screen 0.15 (0.04-0.14) Show 1 more Studies https://web.pathway.md/diseases/recqgGsIww8nnHUqF 6/9 6/29/23, 10:08 PM Dementia Pathway 2019 SPRINT-MIND In ambulatory adult patients ( 50 years of age) with hypertension but without diabetes or history of stroke who had an increased cardiovascular risk, intensive BP reduction was not superior to standard BP management with respect to the incidence of adjudicated probable dementia at a median follow-up of 5.11 years. 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