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An estimated 5.3 million people have Alzheimer's disease in 2009. The prevalence of Alzheimer's disease and other dementias will continue to increase with the rapid growth of our older population. Managing these complex conditions can be a challenge for busy healthcare professionals. The American Geriatrics Society (AGS) is pleased to make this online Guide to Dementia Diagnosis and Treatment available for healthcare providers and trainees who care for older adults.

You can use this guide online or click here to print out a convenient, pocket-sized version of the guide to carry with you. We are also developing a PDA version that will be available in the 3rd quarter of 2009.

The information in this card is based on two acclaimed AGS publications. Geriatrics At Your Fingertips^TM is a portable, pocket-sized guide to the evaluation and management of diseases and disorders that most commonly affect older people. The Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine is a comprehensive text for those who wish to expand and update their knowledge in the field.

The AGS is a nationwide, non-profit association of healthcare professionals dedicated to improving the health, independence, and quality of life for all older people. The AGS has a diverse, multidisciplinary membership of healthcare professionals, researchers, educators, administrators, and students. For more information on the AGS, its publications, and membership benefits, please go to www.americangeriatrics.org or call 800-247-4779.

• Signs and Symptoms/Progression of Alzheimer's Disease
• Evaluation
• Treatment
• Caregiver Issues and Resources
• References

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DEMENTIA SYNDROME
Chronic acquired decline in memory and in at least one other cognitive function (eg, language, visual-spatial, executive) sufficient to affect daily life.

• Report by patient or caregiver of memory loss
• Objective signs of memory impairment
• Mild construction, language, or executive dysfunction
• No functional impairment
• 6%-15% annual conversion rate to dementia syndrome
• Some cases of mild cognitive impairment may not progress to AD

• Disoriented to date
• Naming difficulties (anomia)
• Mild difficulty copying figures
• Problems managing finances
• Recent recall problems
• Decreased insight
• Irritability, mood change
• Social withdrawal

• Disordered to date, place
• Comprehension difficulties (aphasia)
• Impaired calculating skills
• Impaired new learning
• Getting lost in familiar places
• Problems with dressing, grooming
• Not cooking, shopping, banking
• Restless, anxious, depressed
• Delusions, agitation, aggression

• Remote memory gone
• Nearly unintelligible verbal output
• Unable to copy or write
• No longer grooming or dressing
• Incontinent
• Motor or verbal agitation

Note: The MMSE is not as accurate in individuals with less than an 8th-grade education, or in those from varied cultural backgrounds or whose primary language is not English (higher rates of false positives). It is also not sensitive in highly educated individuals, although a score of 30 can still indicate cognitive impairment. The Mini-Cog may be more appropriate to use in these instances.

* MMSE = Mini-Mental State Examination; CDR = Clinical Dementia Rating Scale;
FAST = Reisberg Functional Assessment Staging Scale; MoCA = Montreal Cognitive Assessment

NEUROPSYCHIATRIC SYMPTOMS
Consider superimposed delirium or pain as precipitating factor.

• Seen in about 20% of AD patients
• Delusions may be paranoid (eg, people stealing things, spouse unfaithful)
• Hallucinations (~11% of patients) are more commonly visual

• Seen in up to 40% of AD patients; may precede onset of AD
• May cause acceleration or decline if untreated; suspect if patient stops eating or withdraws
• Sadness
• Loss of interest in usual activities
• Anxiety and irritability

• Seen in up to 80% of patients with AD
• A leading cause of nursing-home admission

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History: Always obtain from family or other caregiver: time symptoms first noted, family history of dementia, head injury, falls, alcohol and other substance exposure, history of depression, focal weakness, gait disturbance, complete medications review (NOTE: Although completely reversible dementia [eg, drug toxicity] is rare, identifying and treating general medical conditions may improve function.).
Comprehensive physical and neurologic examination: Check esp. for focal weakness, gait impairment, language impairment, extrapyramidal signs (rigidity, tremor, bradykinesia).
Assess functional status: Ask about bathing, dressing, toileting, transferring, as well as intermediate activities (eg, managing finances, medications, cooking, shopping).
Evaluate mental status for attention, immediate and delayed recall, remote memory, executive function, depression. Useful screening tests are the Mini-Cog, number of animals named in 1 minute, MMSE, Geriatric Depression Scale, PHQ-9.

Clinical Features Distinguishing AD and Other Dementias
AD: Memory, language, visual-spatial disturbances, indifference, delusions, agitation
Frontotemporal dementia: Relative preservation of memory and visual-spatial skills, personality change, executive dysfunction, excessive eating and drinking
Lewy body dementia: visual hallucinations, delusions, extrapyramidal symptoms, fluctuating mental status, sensitivity to antipsychotic medications
Vascular dementia: abrupt onset, stepwise deterioration, executive dysfunction, gait changes

Reference standard for the presence of dementia or mild cognitive impairment:

• Especially helpful in mild, early disease and atypical presentations
• Quantifies and establishes the type of cognitive deficits
• Establishes baseline for comparison

• Complete blood cell count, thyroid-stimulating hormone, B12, folate, serum calcium, liver and kidney function tests, electrolytes
• Serologic test for syphilis (selectively)
• Glucose and HIV for patients at risk

The likelihood of detecting structural lesions is increased with:

• Onset age <60 years
• Focal (unexplained) neurologic signs or symptoms
• Abrupt onset or rapid decline (weeks to months)
• Predisposing conditions (eg, metastatic cancer or anticoagulants)

Neuroimaging may detect the 5% of patients with clinically significant structural lesions that would otherwise be missed.

MINI-COG^TM SCREEN FOR DEMENTIA
The Mini-Cog^TM screen combines an uncued 3-item recall test with a clock-drawing test (CDT) that serves as a recall distractor. The Mini-Cog can be administered in about 3 min, requires no special equipment, and is less influenced by level of education or language differences.

1. Make sure you have the patient's attention. Instruct the patient to listen carefully to, repeat back to you, and remember (now and later) 3 unrelated words.
2. Instruct the patient to draw the face of a clock, either on a blank sheet of paper, or on a sheet with the clock circle already drawn on the page. After the patient puts the numbers on the clock face, ask him or her to draw the hands of the clock to read a specific time (11:10 or 8:20 are most commonly used and more sensitive than some others). These instructions can be repeated, but no additional instructions should be given. If the patient cannot complete the CDT in 3 min or less, move on to the next step.
3. Ask the patient to repeat the 3 previously presented words.

Scoring
Give 1 point for each recalled word after the CDT distractor. Score 0-3 for recall.
Give 2 points for a normal CDT, and 0 points for an abnormal CDT. The CDT is considered normal if all numbers are depicted, once each, in the correct sequence and position, and the hands readably display the requested time. Do not count equal hand length as an error. Add the recall and CDT scores together to get the Mini-Cog score:

• 0-2 positive screen for dementia
• 3-5 negative screen for dementia

Source: Adapted from 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, and Borson S, Scanlan JM, Watanabe J, Tu SP, Lessig M. Improving identification of cognitive impairment in primary care. Int J Geriatr Psychiatry 2006; 21(4):349-355. Reprinted with permission of S. Borson.
Mini-Cog^TM Copyright 2000, 2004, 2006, 2009. All rights reserved. Licensed for print distribution by S. Borson, MD, solely use as a clinical aid. Any other use is strictly prohibited. To obtain information on the Mini-Cog^TM contact Dr. Borson at soob@u.washington.edu.

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Primary goals are to improve quality of life and maximize functional performance by enhancing cognition and addressing mood and behavior.

• Identify and treat comorbid physical illnesses (eg, hypertension, diabetes mellitus).
• Institute stroke prophylaxis for vascular and mixed dementias.
• Avoid anticholinergic medications, eg, benztropine, diphenhydramine, hydroxyzine, oxybutynin, tricyclic antidepressants, clozapine, thioridazine.
• Limit prn psychotropic medication use.
• Promote brain health by exercise, balanced diet, stress reduction.
• Maximize activities of daily living (ADLs) and exercise (eg, walking).
• Set realistic goals.
• Specify and quantify target behaviors.
• Assess and monitor cognition, mood, and behavior.
• Intervene to decrease hazards of wandering.
• Monitor physical environment for safety (eg, stairs).
• Establish and maintain relationship with patient and family.
• Advise patient and family about driving, sources of support, financial and legal issues, and advance directives, including establishing surrogate decision maker.
• Consider referral to hospice (FAST=7).

Advise caregiver(s) to:

• Use scheduled toileting and prompted toileting for incontinence.
• Offer graded assistance (as little help as possible to perform ADLs), role modeling, cueing, and positive reinforcement to increase independence.
• Avoid adversarial debates; try to redirect conversation instead.
• Use services of caregiver support groups.

Pharmacologic Treatment of Cognitive Dysfunction
Patients with mild or moderate Alzheimer's disease (AD) should receive a cognitive enhancer (Table 1). Because the effects of treatment cannot be fairly evaluated until the patient has been on a cognitive enhancer for some time, caregivers should commit to a trial treatment period of at least 3 months before the medication is started. In controlled trials, modest symptomatic benefit for cognition, mood, behavioral symptoms, and daily function was seen in patients with AD treated for 1 year with cholinesterase inhibitors versus placebo; open trials demonstrated benefit for 3 yr. Only 10%-25% of patients taking cholinesterase inhibitors may show modest global improvement, but more patients may have less rapid cognitive decline. Initial studies have shown benefits of these medications for patients with dementia associated with Parkinson's disease, Lewy body dementia, and vascular dementia. These drugs may attenuate noncognitive symptoms and delay nursing-home placement. Memantine (Namenda) demonstrated modest efficacy compared with placebo in moderate to severe AD as monotherapy and when combined with donepezil (Aricept). D/C cognitive enhancers when FAST=7. Vitamin E @1000 IU q12h found to delay functional decline in AD (caution in those with cardiovascular disease because ≥400 IU may increase mortality).

Table 1. Cognitive Enhancers

^a Cholinesterase inhibitors. FDA labeling for AD is as follows: donepezil-mild, moderate, severe; galantamine-mild, moderate; rivastigmine-mild, moderate. Continue if patient improves or stabilizes; stopping medication can lead to rapid decline. Adverse events increase with higher dosage. Possible adverse events include nausea, vomiting, diarrhea, dyspepsia, anorexia, weight loss, leg cramps, bradycardia, syncope, insomnia, and agitation.
^b Approved by FDA for moderate to severe AD. Possible adverse events include dizziness, headache, somnolence. NMDA = N-methyl-d-aspartate.
^c Increased mortality found in controlled studies of mild cognitive impairment.

• Elicit caregiver observations of patient's cognitive function and behavior (alertness, initiative) and follow functional status (ADLs and instrumental ADLs).
• Follow cognitive status (eg, improved or stabilized) by caregiver's report or serial ratings of cognition (eg, Mini-Cog, MMSE).

• First, identify and examine context of behavior (is it harmful to patient or others?), environmental triggers (eg, overstimulation, unfamiliar surroundings, frustrating interactions).
• Are delusions or hallucinations interfering with function?
• Exclude underlying physical discomfort (eg, illnesses or medications).
• Consider nonpharmacologic strategies.
• Select pharmacologic agent on the basis of symptoms (Table 2).
  
  • Cognitive enhancers may slow deterioration, and agitation may worsen if they are discontinued.
  • Low dosages of antipsychotic medications have a limited role but may be necessary at times. Note: this use is "off label"; use in AD patients has a BLACK BOX warning because the risk of death was higher with drug treatment than with placebo in clinical trials. Risk-benefit must be discussed with both patients and caregivers before starting treatment. In the CATIE-AD trial (NEJM 2006;355:1525-1538), modest treatment with atypical antipsychotics showed no significant benefit (p=0.22). Olanzapine, risperidone, and quetiapine had marginally higher response rates (32%, 29%, and 26%, respectively) than placebo (21%). Response was mitigated by greater extrapyramidal symptoms, sedation, and confusion in the treated groups. Weight gain was reported, particularly in women treated with olanzapine and quetiapine. Olanzapine was also associated with decreased HDL cholesterol.

Table 2. Guidelines for Pharmacologic Treatment of Agitation

^a Greater mortality and cerebrovascular events than placebo; use with particular caution in patients with cerebrovascular disease or hypovolemia.
^b Higher dosages may be needed in emergency situations; use for only short periods of time.
^c Small divided daytime dosage and larger bedtime dosage; watch for sedation and orthostasis.
^d Can be given q12h; allow 2-4 wk for adequate trial.
^e Can monitor serum levels; usually well tolerated; check complete blood count (CBC), platelets for agranulocytosis, thrombocytopenia risk.
^f Monitor serum levels; periodic CBCs, platelet counts secondary to agranulocytosis risk. Beware of drug-drug interactions.

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Maintaining the health and well-being of caregivers is essential for effective treatment of dementia patients. Over 50% of caregivers develop depression. Physical illness, isolation, anxiety, and burnout are common. Intensive education and support of caregivers may delay institutionalization of patients with dementia. Adult day care for patients and respite services for caregivers may help.

• Alzheimer's Association (www.alz.org) offers support and education; chapters are located in major cities throughout the US.
• Alzheimer's Disease Education and Referral Center (www.nia.nih.gov/Alzheimers/) operated by the National Institute on Aging, ADEAR provides information for people with AD, their families, and the public. Publications include a caregiver guide.
• Alzheimer's Foundation of America (www.alzfdn.org) offers information and telephone support services for caregivers.
• American Geriatrics Society Foundation for Health in Aging (www.healthinaging.org) offers Eldercare at Home, a comprehensive online guide for family caregivers.
• Family Caregiver Alliance (www.caregiver.org) offers support, education, and information for caregivers.
• National Alliance for Caregiving (www.caregiving.org) is dedicated to providing support to family caregivers and the professionals who help them and to increasing public awareness of issues facing family caregivers.
• National Family Caregivers Association (www.thefamilycaregiver.org) educates, supports, empowers and speaks up for the more than 50 million Americans who care for loved ones with a chronic illness or disability or the frailties of old age.

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Barton C, Small GW, Yaffe K. Dementia. In: Pompei P, Murphy JB, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine. 6th ed. New York: American Geriatrics Society; 2006:221-230.

Blennow K, deLeon MJ, Zetterberg H. Alzheimer's disease. Lancet 2006;368(9533):387-403.

Lantz MS, Lyketsos CG. Behavioral problems in dementia. In: Pompei P, Murphy JB, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine. 6th ed. New York: American Geriatrics Society; 2006:231-238.

Reuben DB, Herr KA, Pacala JT, Pollock BG, Potter JF, Semla TP. Dementia. In: Geriatrics At Your Fingertips: 2009.11th ed. New York: The American Geriatrics Society; 2009:54-59.

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