Dementia Management

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Core management
  • Exclude delirum and investigate for treatable causes.
  • The aim of treatment is supportive as there is no cure for primary dementias (e.g. Alzheimer’s Disease.)
  • However, depression, psychosis etc affecting someone with dementia should be recognised and treated.
  • Involving carers in the management plan is crucial as dementia is lifelong and will worsen progressively. Use information leaflet.
Red Flags
  • If there is a sudden increase in confusion in known cases of dementia this may be due to acute infection, reaction to medication, acute psychosis, misuse of alcohol or drugs.
  • Manage risks such as wandering, fires, exploitation by relatives.

Physical Exam and Investigations

  • Always do a physical exam to rule out comorbid illnesses which can complicate dementia.
  • Assess for depression which can cause confusion in the elderly.
  • Look for possible causes – HIV, syphilis, TFTs, high cholesterol, high BP, poor diabetic control, alcohol use, vitamin deficiencies (B12 and folate).

Psychosocial

  • Reassure, as they may be feeling frightened.
  • Remind them of who they are, where they are, what the time is and what has happened to them repeatedly.
  • Encourage good diet and exercise and teach family how to assist with personal hygiene.
  • Encourage patient to use remaining abilities as much as possible to maintain independence.
  • Use written or visual reminders to help memory
  • Engage community and neighbours if person wanders and gets lost e.g. keep their address in their pocket
  • If distressed, talk about fond memories from their past, with photos if available
  • They may become angry with their family for restricting or stopping unsafe behaviour – this can be verbal or physical.

If the person becomes depressed or anxious, consider using an antidepressant. If the person is agitated with symptoms of psychosis (delusions or hallucinations) after doing these things, you may have to give them some medicine such as low-dose haloperidol to treat psychosis.

Medication

For severe behavioural disturbances or aggression consider short course of low dose of antipsychotic medications. Use of these medications in the elderly increases risk of falls etc. Therefore, always try psychosocial interventions first.

  • 1st line: Haloperidol25 PO od/bd for 7 days or until agitation resolves or
  • 2nd line: Risperidone5 – 1mg PO od/bd until agitation resolves.
  • If the psychotic symptoms persist/return after stopping the above medication – refer for consideration of long-term antipsychotic use.
  • If antipsychotics are unavailable, you can consider Diazepam 2mg PO od/bd, but be aware that it can worsen confusion.

Referral or Admission

  • If underlying condition and behavioural disturbance cannot be managed at home or health facility.
  • If sudden deterioration, maybe need admission for investigation of cause (see box)

Follow-Up

  • If antipsychotics have been started, consider reviewing the patient once a week until stable.
  • Once stable, review once every three to six months.
  • Monitor for depression.
  • Remember that new symptoms will emerge over time as the condition worsens.
  • Always do a physical to rule out comorbid illnesses which can complicate dementia.
  • Assess risk for committing suicide.
  • Consider stopping antipsychotics if symptoms resolve.
  • Consider continuing with low-dose antipsychotic if psychotic symptoms persist.
  • Assess for carers stress and try to offer education about the illness.