At a glance
- For patients with dementia, schedule routine follow-up visits at least every three to six months.
- Family members are likely to play an active role in maintaining pharmacotherapy and other treatment.
- Unless danger to the patient or others is acute, try nonpharmacologic interventions before medication.
- Half of patients with dementia experience sleep problems.
Although Alzheimer’s disease (AD) and other dementias are considered neurologic or psychiatric disorders, their day-to-day management—both at home and in long-term care facilities—is ordinarily the province of primary care.
“Almost everyone with dementia has a combination of medical, psychosocial, and emotional needs requiring skills that primary-care practitioners [PCPs] utilize in caring for all their patients,” says Peter V. Rabins, MD, professor of psychiatry at Johns Hopkins School of Medicine in Baltimore and chair of the American Psychiatric Association work group that produced Practice Guideline for the Treatment of Patients With Alzheimer’s Disease and Other Dementias.
Given the progressive nature of these conditions, “longitudinal care is crucial, and PCPs naturally bring this to the treatment setting,” points out Dr. Rabins. Clinicians should schedule routine follow-up visits at least every three to six months.
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Focus on the family
“In most cases, the family is as much a target of treatment as the patient,” Dr. Rabins advises. Family members may provide information about symptoms and difficulties that patients themselves cannot and are likely to play an active role in maintaining pharmacotherapy and other treatment.
Family education about the disease should be thorough and should include counseling about such sources of support as the Alzheimer’s Foundation. The safety of the patient and others is a paramount concern; advise family members on removing hazards from the environment and dealing with such potentially dangerous behaviors as wandering.
Because even relatively mild dementia increases the risk of motor vehicle accidents, questions surrounding the patient’s fitness to drive must be addressed.
[The guideline suggests that an American Medical Association pamphlet, Physician’s Guide to Counseling and Assessing Older Drivers, may be helpful in this regard].
Keep in mind that a caregiver may be emotionally overwhelmed by the situation. “If that person is also a patient, the PCP should address his or her needs in the setting of dementia and also separately,” instructs Dr. Rabins.
Medical management
The interplay between dementia and medical conditions is complex and demanding. Initial and subsequent evaluations should include thorough physical examination and appropriate lab testing, with particular attention paid to medications and medical problems that can adversely affect cognition, such as diabetes mellitus and thyroid dysfunction.
Consider how dementia complicates general medical assessment and treatment, take steps to compensate for patients’ difficulties describing symptoms and cooperating with physical examinations, and attend to problems with medication adherence.
The guideline notes that patients with dementia are frequently more prone to adverse drug responses (e.g., anticholinergic effects, orthostasis, and sedation).
Treating cognitive symptoms
Medications approved by the FDA for mild to moderate Alzheimer’s disease include the cholinesterase inhibitors donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne); donepezil is also approved for severe cases.
Only rivastigmine carries approval for mild-to-moderate dementia associated with Parkinson’s disease, “but there is no reason to believe the benefit is specific to this cholinesterase inhibitor,” the guideline states. These drugs might also be considered for dementia with Lewy bodies.
The FDA has also approved the N-methyl-D-aspartate antagonist memantine (Namenda) for moderate-to-severe AD; its side-effect profile may be superior to that of cholinesterase inhibitors for some patients.
Whichever drug is prescribed, “It is important to emphasize that benefits are modest, and there is no good evidence that they affect disease progression,” says Dr. Rabins. “At the level of biology, they do not change what is happening.”
