Quick Summary
Dementia is a clinical syndrome causing functional decline across cognitive domains. Source pages incomplete or inaccessible — please provide valid URLs: 5 (follow-up).
- Dangerous aggression or risk of harm needs urgent attention.
- Violent behavior often requires pharmacologic intervention.
- Sudden decline or new symptoms require prompt evaluation.
Initial assessment
- Cognitive decline impairs work and social functioning.
- Consciousness is usually preserved early.
- Obtain comprehensive medical and psychiatric history.
- Include caregiver report of symptoms and behaviors.
- Perform neuropsychological and neuropsychiatric assessment.
- Consider memory clinic referral for multidisciplinary care.
Diagnosis
- Use DSM‑5 to diagnose dementia subtypes.
- Diagnosis is based on clinical assessment.
- Alzheimer’s disease is a clinical degenerative syndrome.
- MRI supportive with hippocampal or global cortical atrophy.
- DLB shows minimal medial temporal atrophy on MRI.
- Vascular dementia requires clinical history and imaging evidence.
Diagnostics (Lab Test and Imaging)
- Baseline labs include CBC, electrolytes, LFTs, renal, glucose, thyroid, B12, folate.
- Screens for syphilis when clinically suspected.
- EEG in suspected CJD, seizures, or delirium.
- Obtain structural brain imaging in all patients.
- MRI preferred. CT if MRI unavailable or contraindicated.
- FDG‑PET may aid when diagnosis remains uncertain.
Pharmacological management
- Cholinesterase inhibitors
- Indication: all stages of Alzheimer’s disease.
- Benefits: improve cognition, behavior, function.
- Use in DLB and Parkinson’s disease dementia.
- Not for frontotemporal dementia or MCI.
- Memantine
- Indication: moderate to severe Alzheimer’s disease.
- Monotherapy if cholinesterase inhibitor not tolerated.
- Combination may delay symptom progression.
- Anti‑amyloid monoclonal antibodies
- Donanemab for early Alzheimer’s with confirmed amyloid.
- Lecanemab for MCI due to Alzheimer’s or mild Alzheimer’s.
- Reduce amyloid plaques in early disease.
- Antipsychotics for agitation or psychosis
- Reserve for severe distress or dangerous aggression.
- Use lowest effective dose for shortest time.
- Reassess at least every six weeks.
- Consider taper within sixteen weeks when possible.
- Benzodiazepines
- Use only when necessary for anxiety or procedures.
- Start low and titrate cautiously.
- Prefer short‑acting or non‑metabolized agents.
- Antidepressants
- SSRIs are preferred for depression in Alzheimer’s.
- Consider venlafaxine or mirtazapine.
- Start low and increase carefully.
Follow up / Monitoring
- Assess disease severity before starting medications.
- Monitor cognitive, behavioral, and functional outcomes.
- Titrate or switch therapy based on response.
- Reassess antipsychotics at least every six weeks.
- Taper antipsychotics within sixteen weeks when feasible.
- Educate patients and caregivers on routine follow‑up.
Special situations
- Early‑onset familial Alzheimer’s due to APP, PSEN1, PSEN2.
- Down syndrome increases risk of irreversible dementia.
- DLB features parkinsonism and visual hallucinations.
- DLB has neuroleptic sensitivity risk.
- PDD shows dementia years after motor symptoms.
- FTD presents with early behavioral and language change.
Overview
Dementia and Alzheimer’s Disease are terms that are usually
interchanged. In the Introduction
section, this will be clarified.
There are millions of people affected by Alzheimer’s disease
regionally and worldwide. Details on the number of individuals affected are in
the Epidemiology section.
There are many causes of Alzheimer’s disease. The Etiology section enumerated these causes.
The complex and multifactorial pathophysiology of Alzheimer’s disease is
discussed in the Pathophysiology section.
The modifiable and non-modifiable risk factors of
Alzheimer’s disease are enumerated in the Risk
Factors section, while the different types of Alzheimer’s
disease are discussed in the Classification
section.
History and Physical Examination
The Clinical Presentation and History sections detail the cognitive and other manifestations of Alzheimer's disease. The Physical Examination section mentions the neurologic assessment needed to rule out treatable causes of the disease.
Diagnosis
Diagnostic criteria in diagnosing Alzheimer's disease are in
the Diagnosis or Diagnostic Criteria section.
The Screening, Laboratory
Tests and Ancillaries and Imaging sections enumerate the tests
that can be performed in assessing and evaluating the effect of the disease on the
patient.
Other diseases to be considered which present
similarly are in the Differential Diagnosis
section.
Management
There are several drugs that can be considered in the
management of cognitive and neuropsychiatric symptoms of Alzheimer’s disease
and they are enumerated and discussed in the Pharmacological
Therapy section.
Several supportive measures and psychotherapies can be given
to patients with Alzheimer’s disease and the Nonpharmacological
section explains each one.
The Prevention
section enumerates the ways to prevent the disease through the modifiable risk factors
identified.
