Alzheimer’s Disease and Related Disorders
CME credit available from Harvard Medical School through August 2017.
Evaluation and management of Alzheimer’s Disease and related disorders
The primary goal of the educational program is to help practitioners better manage patients with dementia in order to optimize quality of life and minimize stress to the patient and caregiver. Alzheimer’s disease (AD), the most common form of dementia, currently affects approximately 5 million individuals over age 65 in the United States, with the percentage of those affected rising significantly with age, from about 3% of those between ages 65 and 74, to about 32% of those age 85 and older.1 Mild cognitive impairment (MCI) is more common than dementia in community-dwelling older adults.2 Estimates of prevalence vary widely though, from between 2%-10% at age 65 to between 5%-25% by age 85.3 Primary care providers need to be adept at screening, diagnosis, and managing patients with dementia and also know when to refer to a specialist.
A framework for managing dementia
Who to screen for cognitive impairment?
The U.S. Preventative Services Task Force does not recommend universal screening for cognitive impairment. It suggests testing those over 65 years of age who present with:4
complaints of cognitive deficit by patient or family
mood or anxiety symptoms
increased risk of safety problems
What screening tool to use?
A short screening tool such as the Mini-Cog5 or AD8 identifies patients who need a more detailed evaluation.
Principles of managing a patient with dementia
Across each stage of dementia, it is important to:
Focus on managing overall health.
Establish and reinforce daily routines surrounding eating, exercise, stimulating cognitive/social activities and sleep.
Review the patient’s medication profile for drugs that can worsen cognition.
The Alzheimer’s Association can provide counseling, support groups, and caregiver liaisons at all stages
For an overview of education and counseling for patient and caregivers, treatment options and referrals at each stage of dementia, please see ‘A roadmap for managing dementia’ in Appendix 3 of the Evidence document.
Pharmacologic management of cognitive decline
Cholinesterase inhibitors and memantine may slow the rate of cognitive decline, but the clinical significance of these modest changes is unclear and these drugs rarely improve cognition. If a response does occur, it will do so within three months of starting treatment. However, most patients will return to baseline or below within six to twelve months of therapy. Treatment with a cholinesterase inhibitor or memantine is not recommended for MCI. If a cholinesterase inhibitor or memantine is prescribed:
Start at a low dose and titrate slowly.
Monitor carefully for side effects (nausea, vomiting, diarrhea, anorexia, dizziness, etc).
Reassess at 3-6 months to determine if the risk-benefit relationship warrants continued treatment.
Some studies have shown that the combination of a cholinesterase inhibitor and memantine provides a modest reduction in the rate of decline only in patients with moderate to severe Alzheimer’s Disease.6 However other studies have found no benefits of combination therapy.7
Managing behavioral and psychological symptoms of dementia
Behavioral and psychological symptoms of dementia (BPSD) are common, and can manifest as yelling, physical aggression, apathy, hostility, sexual disinhibition, defiance, wandering, psychotic symptoms, emotional lability and paranoid behaviors.8-9 The prevalence of “clinically significant” BPSD in community–dwelling patients with dementia is estimated at 60%, with higher rates (50% – 80%) among residents of care facilities.10,11 Distinguishing between acute and non-acute BPSD can guide management. Acute BPSD includes symptoms such as aggression or delusions that are severely disruptive, dangerous, or distressing to the patient.
Managing behavioral problems in patient with cognitive impairment12-14
Because of the increased risk of death and other serious side effects in the use of antipsychotic medications in elderly patients; their use should be strictly restricted to dangerous or disturbing BPSD. More information on the management of BPSD can be found in the in the module ‘Preventing overuse of antipsychotic drugs in nursing home care: Safer alternatives.’
Information current at time of publication, August 2014.
The content of this website is educational in nature and includes general recommendations only; specific clinical decisions should only be made by a treating physician based on the individual patient’s clinical condition.
- Hebert, L.E., et al., Alzheimer disease in the US population: prevalence estimates using the 2000 census. Arch Neurol, 2003. 60(8): p. 1119-22.
- Graham, J.E., et al., Prevalence and severity of cognitive impairment with and without dementia in an elderly population. Lancet, 1997. 349(9068): p. 1793-6.
- American Psychiatric Association, DSM-5, Diagnostic and Statistical Manual of Mental Disorders: Fifth ed2013, Washington DC: American Psychiatric Association.
- Lin, J.S., et al., Screening for cognitive impairment in older adults: A systematic review for the U.S. Preventive Services Task Force. Ann Intern Med, 2013. 159(9): p. 601-12.
- Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15(11):1021-1027.
- Tariot, P.N., et al., Memantine treatment in patients with moderate to severe Alzheimer disease already receiving donepezil: a randomized controlled trial. JAMA, 2004. 291(3): p. 317-24.
- Howard R, McShane R, Lindesay J, et al. Donepezil and memantine for moderate-to-severe Alzheimer’s disease. N Engl J Med. Mar 8 2012;366(10):893-903.
- Kales, H.C., et al., Risk of mortality among individual antipsychotics in patients with dementia. Am J Psychiatry, 2012. 169(1): p. 71-9.
- Huybrechts, K.F., et al., Risk of death and hospital admission for major medical events after initiation of psychotropic medications in older adults admitted to nursing homes. CMAJ,
- Lyketsos CG, Lopez O, Jones B, Fitzpatrick AL, Breitner J, DeKosky S. Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: results from the Cardiovascular Health Study. JAMA. 2002;288(12):1475-1483.
- Magaziner J, German P, Zimmerman SI, et al. The prevalence of dementia in a statewide sample of new nursing home admissions aged 65 and older: diagnosis by expert panel. Epidemiology of Dementia in Nursing Homes Research Group. The Gerontologist. Dec 2000;40(6):663-672.
- Kapusta P RL, Bareham J, Jensen B. Behavior management in dementia. Can Fam Physician. 2011;57(12):1420-1422.
- Centres for Medicare and Medicaid Services. State Operations Manual, Appendix PP-Guidance to Surveyors for Long Term Care Facilities. www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf.
- The Royal Australian and New Zealand College of Psychiatrists Faculty of Psychiatry of Old Age. The Use of Antipsychotics in Residential Aged Care, Clinical Recommendations. www.bpac.org.nz/a4d/resources/docs/RANZCP_Clinical_recommendations.pdf. 2011.