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
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
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.
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
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.
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
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.
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.