Clinical Module on Alzheimer's Disease & Related Dementias

CME credit available from Harvard Medical School through May 2026.

Published Materials

• Summary Brochure
• Evidence Document
• Lecanemab referral sheet
• Patient Brochure – Advance care planning
• Patient Brochure – Amyloid
• Patient Brochure – BPSD
• Tear Off – Caregiver resources

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, behavioral and psychological symptoms of dementia (BPSD), and best practices for advance care planning.

Dementia is a common condition in older adults, with over 6 million people being diagnosed with Alzheimer’s disease in the U.S.¹

While many factors have been associated with the development of dementia, few interventions have conclusively proven to reduce dementia incidence. Two interventions that may reduce patient risk are controlling blood pressure and recommending a Mediterranean diet.^2,3

Identification and management of dementia

Patients with signs or symptoms of cognitive impairment should be evaluated for dementia with a validated tool. A comprehensive physical exam, relevant history, and attempts to evaluate for reversible causes should be completed before making the diagnosis. Additional testing may be recommended.⁴

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

Older medications

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.

Newer medications

After years of research and development, monoclonal antibodies to reduce amyloid deposits in the brain have shown potential benefit. Lecanemab (Leqembi) slowed cognitive decline compared to placebo over 18 months in patients with mild cognitive impairment or mild Alzheimer’s disease.⁶

On an 18 point scale, lecanemab slowed decline by 0.45 points compared to placebo⁶

It is not clear whether such a small change would be noticed by many patients, families, or clinicians.⁷

Unlike older medications, lecanemab is an intravenous (IV) infusion given every two weeks in an infusion center. Patients should be tested for elevated brain amyloid prior to treatment and then be monitored with magnetic resonance imaging (MRI) throughout treatment.

Infusion related reactions, such as flushing, fever, body aches, and rashes, occurred in 1 of every 4 patients, although premedication can prevent these reactions. Cerebral edema, effusion, and hemorrhage occurred in 27% of patients given lecanemab compared to 9% given placebo.⁶ The magnitude of bleeding risk is unknown with lecanemab. A small number of patients taking lecanemab and anticoagulants or tPA (tissue plasminogen activator) had major bleeds resulting in stroke and death.⁸

The decision to use lecanemab should be based on a clear discussion of the risks and expected benefit from treatment. It will not stop or reverse cognitive decline.

Changes in patient behavior may appear as cognitive status declines. Non-drug interventions can help address the underlying causes of these changes. When the behaviors are dangerous or distressing, medication options may be required.

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.⁹

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.¹⁰

Documenting the patient’s wishes allows patients to have more control in care and can avoid unnecessary or unwanted treatments. Numerous resources (noted further down this page) can assist patients and families in having discussions and documenting key decisions.

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.

Additional Resources for Providers

• Alzheimer’s Association
• POLST form
• Billing tips for ACP

Additional Resources for Advance Care Planning

• The Conversation Project
• Alzheimer’s Association
• National Institute on Aging
• HealthInAging.org

Additional Resources for Driving

• AAA Senior Driving
• Alzheimer’s Association
• Eldercare transportation locator
• Pennsylvania Transportation Services
• Pennsylvania Department of Aging – Transportation

Additional Resources for Caregivers

• Alzheimer’s Association caregiver support
• Alzheimer’s Association safety
• DementiaFriendsPA.org
• Respite care options
• Pennsylvania Adult Day Centers
• Local Area Agency on Aging

Information current at time of publication, May 2023.

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. 2022 Alzheimer’s disease facts and figures. Alzheimers Dement. 2022 Apr;18(4):700-789.
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. van Dyck CH, Swanson CJ, Aisen P, et al. Lecanemab in early Alzheimer’s Disease. N Engl J Med. 2022;388(1):9-21.
7. Andrews JS, Desai U, Kirson NY, et al. Disease severity and minimal clinically important differences in clinical outcome assessments for Alzheimer’s disease clinical trials. Alzheimers Dement (N Y). 2019;5:354-363.
8. Piller C. Second death linked to potential antibody treatment for Alzheimer’s disease. 2022; www.science.org/content/article/second-death-linked-potential-antibody-treatment-alzheimer-s-disease. Accessed March 24, 2023.
9. 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.
10. 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.