Dementia

CME credit available from Harvard Medical School through April 2023.

Published Materials

The goal of this educational program is to help primary care practitioners provide optimal evidence-based care for patients with cognitive impairments related to Alzheimer’s Disease or other types of dementia. The program describes risk factors for dementia, current evidence for both non-pharmacological and pharmacological management of cognitive impairment, best practices for advance care planning, and behavioral and psychological symptoms of dementia (BPSD).

Dementia is a common condition in older adults, with nearly 6 million people being diagnosed with Alzheimer’s disease in the U.S.. Dementia prevalence increases as age advances with one in 10 people age 65 and over having dementia, rising to 1 in 3 for people over age 85.1

New advances in treatments has been slow, prompting a focus on dementia prevention. Few interventions have conclusively proven to reduce dementia incidence but managing common primary care conditions may reduce patient risk such as controlling blood pressure, recommending a Mediterranean diet, identifying and managing depression, and treating hearing loss.2-4

Identification and management of dementia

Patients with signs or symptoms of cognitive impairment should be evaluated for dementia.

A framework for managing patients with Alzheimer’s disease and related dementias

Cholinesterase inhibitors and memantine have a limited role in management. A response to treatment, if it occurs, is time limited and carries a risk of side effects such as nausea, vomiting, bradycardia, hypertension, and dizziness.5 Continuously reassess the benefit and risks of medications, if used.

Given the adverse health outcomes from elder abuse, identifying patients being abused is critical.  A set of nine vulnerability factors may identify those at greatest risk of abuse:

Advance care planning (ACP)

ACP is a continuous, dynamic process of reflection and dialog between a person with dementia, those close to her or him, and their health care providers concerning the patient’s preferences and values in future treatment and care, including end-of-life care.6

Documenting the patient’s wishes allows patients to have more control in care and can avoid unnecessary or unwanted treatments.

As dementia progresses, the goals of care shift along a spectrum. Continuing advance care planning discussions with patients and caregivers can help make these decisions easier with disease progression.

Behavioral and psychological symptoms of dementia are common. These behaviors can be managed with non-drug approaches and medications, if indicated.

Managing behavioral and psychological symptoms of dementia

Unpaid caregivers such as family, friends, and neighbors, provide a majority of the care for community-dwelling older adults with dementia.1 Monitoring caregiver stress and health is crucial to providing patients with dementia the safe, supportive care they need. Situational and emotional coping classes can reduce caregiver anger and depression, while increasing positive coping skills.8


Additional Resources for Providers
Additional Resources for Advance Care Planning
Additional Resources for Driving
Additional Resources for Caregivers

Information current at time of publication, April 2020.

The content of this website is educational in nature and includes general recommendations only; specific clinical decisions should only be made by a treating clinician based on the individual patient’s clinical condition.


References
  1. Alzheimer’s Association. 2019 Alzheimer’s disease facts and figures. Alzheimers Dement. 2019;15(3):321-387.
  2. Sprint Mind Investigators for the SPRINT Research Group. Effect of Intensive vs Standard Blood Pressure Control on Probable Dementia: A Randomized Clinical Trial. JAMA. 2019;321(6):553-561.
  3. Valls-Pedret C, Sala-Vila A, Serra-Mir M, et al. Mediterranean Diet and Age-Related Cognitive Decline: A Randomized Clinical Trial. JAMA Intern Med. 2015;175(7):1094-1103.
  4. Livingston G, Sommerlad A, Orgeta V, et al. Dementia prevention, intervention, and care. Lancet. 2017;390(10113):2673-2734.
  5. Courtney C, Farrell D, Gray R, et al. Long-term donepezil treatment in 565 patients with Alzheimer’s disease (AD2000): randomised double-blind trial. Lancet. 2004;363(9427):2105-2115.
  6. Piers R, Albers G, Gilissen J, et al. Advance care planning in dementia: recommendations for healthcare professionals. BMC Palliat Care. 2018;17(1):88-88.
  7. Mitchell SL. CLINICAL PRACTICE. Advanced Dementia. N Engl J Med. 2015;372(26):2533-2540.
  8. Coon DW, Thompson L, Steffen A, Sorocco K, Gallagher-Thompson D. Anger and depression management: psychoeducational skill training interventions for women caregivers of a relative with dementia. Gerontologist. 2003;43(5):678-689.
BALANCED INFORMATION FOR BETTER CARE