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Dementia

Brief Overview: According to UpToDate, “Dementia is an acquired disorder that is characterized by a decline in cognition involving one or more cognitive domains (learning and memory, language, executive function, complex attention, perceptual-motor, social cognition) [3,4]. While traditional definitions of dementia required a decline in at least two cognitive domains, the definition of major neurocognitive disorder as outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM) only requires a substantial decline in a single cognitive area [3]. The deficits must represent a decline from previous level of function and be severe enough to interfere with daily function and independence. The most common form of dementia in older adults is Alzheimer disease (AD), accounting for 60 to 80 percent of cases.”

Dementia is not a single disease, but an umbrella term that includes conditions such as Alzheimer’s disease, vascular dementia, Lewy body dementia, and frontotemporal dementia.
Management focuses on maintaining function and safety, managing behavioral symptoms, supporting caregivers, and planning for progressive care needs.

Types of Dementia: According to Cleveland Clinic: “There are three types. They differ based on the cause:

  • Primary: A brain disease is the main cause of dementia. There aren’t any other causes. Examples include: Alzheimer’s disease, frontotemporal dementia, Lewy body dementia, vascular dementiaand mixed dementia (two or more types combined).
  • Secondary: This type happens from another medical condition that causes changes in your body. The brain dysfunction is a secondary consequence. Examples include infections or alcohol related.
  • Reversible: Some secondary causes of dementia could be reversible from treatable issues like vitamin deficiency or medication side effects.”

Prevalence: According to Cleveland Clinic, “An estimated 6.7 million U.S. adults age 65 or older have dementia.”

Etiology: According to alzheimers.gov, “Dementia is the result of changes in certain brain regions that cause neurons (nerve cells) and their connections to stop working properly. Researchers have connected changes in the brain to certain forms of dementia, but, in most cases, the underlying causes are unknown. For a small number of people, rare genetic variants that cause dementia have been identified.”

Risk Factors:

  • Advanced age (strongest risk factor)
  • Family history of dementia
  • Cardiovascular disease (hypertension, diabetes, hyperlipidemia)
  • History of stroke or transient ischemic attack
  • Traumatic brain injury
  • Low educational attainment
  • Depression and social isolation
  • Smoking and sedentary lifestyle

Commonly Associated Conditions:

  • Alzheimer’s disease (most common cause)
  • Vascular disease and prior stroke
  • Depression and anxiety
  • Sleep disorders
  • Delirium (especially during illness or hospitalization)
  • Frailty and falls
  • Urinary incontinence
  • Malnutrition and weight loss

Common Medications:

Medications do not cure dementia but may help stabilize cognitive symptoms or manage behavioral disturbances.

  • Cognitive symptom management:
    • Cholinesterase inhibitors:
      • Donepezil, rivastigmine, galantamine
    • NMDA receptor antagonist:
      • Memantine (moderate to severe dementia)
    • Behavioral and psychological symptoms (used cautiously):
      • SSRIs for depression or anxiety
      • Antipsychotics for severe agitation or psychosis only when non-drug measures fail (increased risk in dementia patients)
    • Important note:
      • Avoid medications with anticholinergic effects when possible, as they can worsen cognition.

Common Labs, Imaging, and Tests:

  • Mental status exam
  • Depression screening
  • Lab tests: serum vitamin B12, TSH, CMP, CBC
  • Neuroimaging – CT, MRI
  • Neuropsychological testing

Common Symptoms:

  • Memory loss affecting daily activities
  • Difficulty with language or word-finding
  • Impaired judgment or decision-making
  • Disorientation to time or place
  • Personality or behavior changes
  • Difficulty performing familiar tasks
  • Progressive loss of independence
  • Later stages: difficulty swallowing, walking, or communicating

Common Treatments:

  • Medication management (as directed by healthcare provider)
  • Non-pharmacologic strategies for behavior (routine, reassurance, redirection)
  • Cognitive stimulation and structured activities
  • Caregiver education and support
  • Home safety modifications
  • Advance care planning and legal preparation
  • Coordination with neurology, geriatrics, social work, and community resources

Physical Findings:

  • Often normal early in disease
  • Gait instability and falls in later stages
  • Weight loss and frailty
  • Poor hygiene or self-care as disease progresses
  • Neurologic deficits depending on dementia subtype

Potential Complications and Contraindications:

  • Potential complications:
    • Falls and fractures
    • Wandering and safety risks
    • Aspiration pneumonia
    • Malnutrition and dehydration
    • Behavioral disturbances
    • Caregiver burnout
    • Increased hospitalizations and delirium risk
  • Contraindications / cautions:
    • Antipsychotics increase risk of stroke and mortality in dementia
    • Benzodiazepines and sedatives increase confusion and fall risk
    • Anticholinergic medications worsen cognition

General Health and Lifestyle Guidance:

  • Maintain consistent routines and familiar environments
  • Encourage physical activity and social engagement as tolerated and approved by healthcare provider
  • Ensure adequate nutrition and hydration
  • Optimize sleep hygiene
  • Use calendars, labels, and visual cues
  • Simplify tasks and choices
  • Assess home safety (falls, cooking, driving, wandering)
  • Provide caregiver support and respite resources

Suggested Questions to Ask Patients:

  1. What cognitive or behavior changes have you noticed recently?
  2. Are there any safety concerns (falls, wandering, driving)?
  3. Is the patient able to manage medications and daily tasks?
  4. Have there been changes in mood, sleep, or appetite?
  5. Any recent illness, infection, or hospitalization?
  6. How is the caregiver coping? Do they have support?
  7. Are advance directives or care plans in place?

Suggested Talking Points:

  • Dementia is a syndrome with many causes; care focuses on safety and quality of life.
  • Medications may help symptoms but do not stop progression.
  • Routine and environment are powerful tools in managing behaviors.
  • Caregiver support is essential and available.
  • Planning ahead helps ensure the patient’s wishes are respected.

Sources:

This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.