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DEMENTIA
• Dementia is NOT a normal part of aging

• Symptoms of dementia can be caused by different diseases
• Some symptoms of dementia may include:
1. Memory loss – The individual may repeat questions or statements, misplace

things or lose items, forget names of others, forget appointments or to take
medications/pay bills. The person may begin to forget recent events with
progression to forgetting events/people/history from longer ago. The individual
may show increasing forgetfulness and disorientation (person, place, time).
Learning new ideas/tasks and remembering new information is often difficult.
2. Difficulty with understanding language and/or using language – The

individual usually displays decreased ability to write or speak. Sometimes the
person may not be able to “find” the right word to use in a sentence. They may
substitute any word or may wait for someone to assist them or “fill the spot” with
an appropriate word. Terms often associated with language deficits may include:
word-finding problems, echolalia, confabulation and perseveration.
3. Motor skills may become impaired – The individual may experience difficulty
with movement, especially fine coordination and control of the hands and arms.
If the individual does show signs of in-coordination and lack of control with
movement, deficits may be seen in dressing tasks, eating, writing, opening and
closing small/tight containers, etc. Sometimes, a person’s brain doesn’t always
tell the hands/body what to do and this can lead to problems as discussed above as
well as difficulty with walking, balance, and planning movements.
4. Executive functions/Cognitive and perceptual skills decline – The individual

may show problems with judgment, reasoning, problem-solving and planning.
Often the person loses the ability to think abstractly and requires concrete or
specific messages. A person may require assistance to plan more unfamiliar tasks
and organize things to ensure safety/thoroughness. A person with dementia may
begin to lose insight regarding consequences of certain actions or non-actions.
Mathematical skills often show decline due to attention and concentration as well
as the above, making it more difficult to do finances, shopping, money
management without assistance. Learning new skills is usually difficult.
Familiar, repetitive tasks are often performed more accurately and appropriately
for longer periods from the onset of the disease.
5. Emotional/personality changes may appear -- An individual may show

decreased awareness of or an inability to recognize stimuli (and at other times an
emotional response is likely due to the person’s awareness of the “changes” going
on in and around them). There are many behaviors that can be associated with the
above including: irritability, anxiety, depression, aggression, withdrawal,
paranoia, new/increased confusion, incontinence, and/or changes in personal
hygiene, sleep or sexual activity.
BASIC POINTS TO CONSIDER
Most people do NOT have dementia:
¾ Before age 65, less than ½ to 1% are affected (and of those, it is more commonly
due to head injuries, although Alzheimer Disease can occur before age 65).
¾ After 65, prevalence of dementia increases to about 5-10% of the population.
¾ After 75, the rate increases to 18-20% of the population.
¾ After age 85, the rate goes up to 35-40% (some estimates go as high as 50%).
¾ After age 65, 50-70% of the dementia cases are thought to be caused by
Alzheimer’s disease.
These low percentages translate into a high number of people with dementia.
Currently, approximately 4.5 million people in the U.S. have Alzheimer’s (the most
common form of later life dementia). This is likely to increase as the population
continues to age.
Dementia is NOT a disease:

Dementia is a diagnostic category representing some/all of the following symptoms
which are severe enough to interfere with daily functioning, noticeable in a person
who is awake or alert, and typically progressive if untreated (the pattern of losses may
be uneven):
• Memory Loss
• Loss of Judgment
• Loss of Abstract Reasoning
• Loss of Sense of Time
• Change in Emotional Responses
• Problems with Speech and Communication
• Loss of Coordination
Many other things can CAUSE dementia-like symptoms BESIDES dementia:
Stress/Fatigue
Malnutrition
Medications
Other Medical Conditions (e.g. Depression, Delirium, Stroke, Fever)
Motivation (or lack thereof)
Sensory Deficits
Ageist Expectations
HOW CAN YOU TELL WHAT IS NORMAL (AND WHAT IS NOT?)

Signs and symptoms which SHOULD trigger consideration of an evaluation:
• Progressive cognitive changes (new forgetfulness…)
• Psychiatric symptoms (withdrawal, apathy…)
• Personality changes (inappropriate friendliness, blunting…)
• Problem behavior (wandering, agitation…)
• Changes in day to day functioning (difficulty driving, etc)
A complete evaluation can give you information regarding:
• The nature of the person’s illness
• Whether the condition can be medically treated/reversed
• The extent of the disability
• The areas where a person may still function successfully
• Other health problems to be treated
• The social and psychological needs/resources of the patient and his/her family
• Changes which may be expected in the future
Some evaluative procedures:

• Complete physical medical exam
• Blood tests (e.g., infection, electrolytes)
• Neurological tests (e.g., MRI, CT, PET)
• Cognitive tests (e.g. MMSE)
WHAT IF IT IS DEMENTIA?
What is the cause of the symptoms?
Many diseases lead to dementia and they differ in the areas they affect and their
symptoms. There are about 100 or so diseases associated with the clinical symptoms of
dementia, including:
Alzheimer Disease Prion Dementias (CJD, GSS, etc.)

Vascular Dementia/Multi-Infarct Lewy Body Dementia
Frontotemporal Degeneration (Pick’s) AIDS/Syphilis Paresis, etc.
Huntington Disease
What are the possible treatments?

Medical (depends upon cause) Environmental
Behavioral Familial
Psychosocial Palliative
Things to Remember:
• People with dementia are still people
• People in the early stages have many remaining abilities
• People are often AFRAID of dementia
• Care giving can be stressful
• Being cared for can be stressful
• Cognitive losses can impact family relationships and roles
• There IS help available
HOW DO I TALK TO A PERSON WITH DEMENTIA?

Improving Your Communication Strategies:
Communication involves both the sending of messages to others (production) and the
understanding of messages sent by others (comprehension). Communication includes not
only the words we use, but also our tone and body language. Ways to improve
communication include:
Stop and Receive the Other Person’s Communication:

• Pay close attention – listen and watch their body language
• Be patient (allow time to respond – do not interrupt or rush)
• Focus on the emotional (nonverbal) cues
• Double check your understanding of what the individual has communicated
If a Person Can Not Find the Right Word:

• Encourage the individual to act out the meaning
• Encourage the person to “talk around” what they are trying to say
• Say what you think they are trying to communicate (a person with dementia may
be able to recognize words they can not generate on their own)
• Be cautious about correcting “wrong” words (this may only serve to frustrate or
embarrass a person)
If a Person Digresses or Loses Their Train of Thought:

• Repeat the last words said
• Summarize what has been discussed so far
• Ask relevant questions
• Show respect for the feelings expressed, even if the facts are wrong
• If you do not understand, it may be best to say so
Improve Your Own Verbal Communication:

• Think before you speak
• Begin each intervention by introducing yourself, giving your name and your role;
explain why you are there; socialize a little
• Explain what is going to happen
• Use short, simple sentences
• Do not use conjunctions (e.g., “and” “but”)
• Be specific, direct and explicit about what you mean
• Use concrete and common words (avoid abstract and fancy words)
• Avoid clichés, idioms, sayings, generalizations, and colloquialisms
• Use proper names and common nouns (avoid pronouns)
• Give the most important information at the end of sentences (e.g. “Do you want to
drink coffee or tea?”)
If a Person is Having Trouble Understanding You:

• Repeat what you said twice
• Revise and restate using different words
• Avoid logical discussions or debates (instead, respond to feelings the individual is
expressing)
• Provide immediate feedback, reassurance and rewards
• Assume that the person can understand more than they can express
• Remember that people with dementia will probably forget, so you may need to
repeat yourself
When Asking Questions:

• Avoid open-ended questions
• Limit the number of choices possible to two
• Give lots of time for a response
• If needed, repeat or reword questions
When Giving Instructions:

• Break instructions into small steps
• Give one direction at a time
• Allow time for completion of each direction before going on
• Give directions close to when they must be followed
• Give positive directions (what to do rather than not do)
Improving Your Nonverbal Communication:

• Gently get the person’s attention by being sure he/she can see you before saying
anything
• Approach from front so he/she can see you
• Use more than one of the five senses (e.g., say their name and touch their
shoulder)
• Use a calm, pleasant, low-pitched tone of voice
• Use open, friendly, relaxed body language
• Move slowly and gently
• Maintain appropriate eye contact
• Use positive facial gestures
• Respect personal space (do not stand too close or too far away from the person)
• Converse at eye level beside or in front of the person (never behind)
• Use objects and pictures to illustrate your message
• Use physical action to illustrate your message
• When giving instructions, demonstrate action
• Be aware of the person’s culture
• Be sure that your verbal and nonverbal communication matches
• Keep trying
Additional Things to Remember:
• A person with dementia is still a person with thoughts, feelings, and needs
• A person in the early stages of dementia has many remaining abilities
• A person with dementia may understand much more than they can communicate
• A person with dementia will often understand non-verbal cues long after they can
understand verbal communication (so tone and expression matter!)
• Often times the experience (e.g., a pleasant conversation) is more important than
the content (accuracy and reality can be overrated!)
Clinical Diagnosis of Dementia
In this module, learn about clinical diagnosis of dementia and:

• The important components of the history and exam
• Methods of evaluating cognitive function
• The relevant diagnostic studies
• The differential diagnosis of dementia
When the clinical triggers described in Dementia in Primary Care raise suspicion of
possible dementia, evaluation of the patient should include a history and physical
exam that focus on specific areas of concern. Various diagnostic studies can be used
as well to confirm the problem and assess the differential diagnosis. The physician
also needs to know when referral is appropriate, and to understand that the slow
progression of dementia may mean that a definitive diagnosis can only be made over
an extended period of time.
HISTORY
The history should be obtained from the patient as well as an additional reliable
informant. When diagnosing dementia, the important components of the history
include:
• History of cognitive impairment signs and symptoms, including timing of earliest
effects and rate of progression
• Current and past medical problems, including systemic diseases, neurological
disorders, head trauma, alcohol or substance abuse, infectious or metabolic
illnesses
• Functional status, focused on ADLs and IADLs – see Table A for the ADL and
IADL forms, and Table B for the Functional Activities Questionnaire
• Current medications, with special attention to both prescription and non-
prescription medications that have anti-cholinergic properties
• Family history, especially any early-onset dementia, neurological conditions,
and vascular diseases
• Social history, including:
o Family and social supports
o Educational background
o Literacy
o Preferred language
o Alcohol, tobacco, and other substance use
Developed by the Geriatric Education Center of Michigan (GECM), and the Michigan Primary Care Dementia
Network. All GECM activities are funded through a grant from the Bureau of Health Professions of the Health
Resources and Services Administration as authorized through Section 777(a), Title VII of the U.S. Public Health
Service Act, as amended.
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PHYSICAL EXAM
The key elements of the physical exam include:

• General appearance and behavior, including hygiene, affect, and alertness
• Pulse and blood pressure, including any orthostatic changes
• Cardiac and pulmonary auscultation
• Neurologic exam
o Focal deficits, including cranial nerves, motor and sensory exam of the
extremities, coordination, balance and gait
o Signs of Parkinson’s disease, including cogwheeling, masked facies,
bradykinesia, rigidity, and resting tremor
DIAGNOSTIC TESTING
The routine laboratory workup for dementia generally includes: CBC with differential,
chemistry profile (with electrolytes, creatinine, calcium, glucose, and liver function
tests), TSH, and vitamin B12 levels. Other laboratory tests may be indicated in
selected patients, including urinalysis, serologic tests for syphilis and/or HIV, tests for
autoimmune diseases and vasculitis, and toxicology screens. Chest x-rays, EEGs,
and exams of CSF (cerebrospinal fluid) are occasionally helpful.
Brain imaging (CT or MRI) is generally recommended in the evaluation of early or

middle stage dementia. The American Academy of Neurology has stated that,
“structural neuroimaging with either a noncontrast CT or MR scan in the routine initial
evaluation of patients with dementia is appropriate.” (Level of Evidence is “Guideline”
only.) When dementia is diagnosed in the late stage and is typical for Alzheimer’s, it
may not be necessary to perform imaging studies.
Studies have been mixed about the value of brain imaging in dementia patients, and
clinicians should bear in mind not only that abnormalities found may be unrelated to
the patient’s status but also that interventions may not lead to any improvement in
symptoms. Evaluation of possible interventions related to abnormal imaging studies
should involve experienced experts with a healthy dose of skepticism about the value
of such interventions.
COGNITIVE TESTING
There is no single tool perfect for use in diagnosing dementia. All of the instruments
that have been proposed have limitations. One of the biggest issues is that a tool with
sufficient sensitivity to diagnose early dementia will also have a relatively low
specificity—that is, a high false negative rate. A second major issue is the brevity of
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the tool – an instrument short enough to use in clinical practice by necessity gives up
a certain level of both sensitivity and specificity.
The Mini-Mental Status Exam (MMSE) (Table A) is the tool most widely used by
healthcare professionals in the U.S., and it is the most comprehensive of the short
tools available for evaluation as it tests multiple domains of cognitive function. The
Blessed Information Memory Concentration (BIMC), Blessed Orientation Memory
Concentration (BOMC), and the Short Test of Mental Status (STMS) are roughly
equivalent to the MMSE though less widely used. It is important to note that all of
these tests require adjustment for educational status, ethnicity, and socioeconomic
status, and that there is no absolute cutoff for distinguishing normal from abnormal
scores in individual patients.
The diagnosis of dementia requires identification of both memory loss and decline in
an additional domain of cognitive function. The MMSE and the other short tests are
excellent for identifying more advanced disease, but may fall short in assessing earlier
symptoms. By necessity, each domain is tested only briefly. Tests of recent memory
are the most discriminating measures overall in identifying dementia, but reliance on
this criterion alone may miss those people for whom loss in another cognitive domain
is the most prominent symptom. Declines in domains such as language ability,
psychomotor performance, or executive function may also be early symptoms of
dementia.
A comprehensive review of instruments was performed by the Agency for Health Care
Policy and Research (now the Agency for Research in Health Care Quality) (Pfeffer et
al, 1982), demonstrating that the presence of cognitive and functional decline can be
documented in many different ways. Key points from that review include:
• The Functional Activity Questionnaire is the single best test for dementia, but it
requires the presence of a reliable informant, usually a family member.
• The MMSE, BIMC, BOMC, and STMS are roughly equivalent.
Experts in the Michigan Primary Care Dementia Network have found a variety of
individualized tests to be helpful in early assessment of dementia. None of these
approaches have been rigorously tested in clinical trials:
• Testing “category fluency” – asking the patient to name as many items as

possible in one minute, in a category like fruits and vegetables or animals.
Experts suggest that a person with normal cognitive function should be able to
name at least 18 in one minute. Ten or fewer is definitely abnormal. Numbers
in between are questionable.
• Asking the patient to recall three objects as in the MMSE, but making the
objects less common and attaching adjectives to them.
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• Asking the patient to name and describe the function of a more complex object
than used in the MMSE. For example, instead of a pen, use typewriter.
• Using a ten-word list with each word on a separate card. The examiner shows
one card at a time and has the patient repeat each word individually, and then
asks the patient to recite as many words as are recalled. A “normal” score is a
recall of 5-6 words. The cards are then shuffled and the process repeated, with
a “normal” result of 7-8 words recalled. Another shuffle and repeat can be
performed, and people with no impairment usually recall 9-10 words at this
point. While memory-impaired patients do learn across the trials, the
improvement is much less that in those with no deficits.
• Expanding on the previous test 15-20 minutes later, asking the patient to name
as many of the words as can be recalled. The number of correct recalls is
typically close to the score on the third trial above. Finally, the examiner can
show twenty cards that include the first 10, asking the patient to identify which
were reviewed before. A normal result is 100% recognition of the words.
NEUROPSYCHOLOGICAL TESTING
Neuropsychological testing is the most definitive standard for diagnosis of early

dementia. Such testing may be especially useful in patients who present early in the
disease process, when the usual brief cognitive tests discussed above may lack
sufficient sensitivity and specificity for diagnosis. It can also be helpful when dementia
and depression are difficult to separate, or when atypical symptoms are present. In
addition, clearer identification of specific cognitive deficits may be helpful in designing
individualized coping strategies and behavior management.
Performance on neuropsychological testing is influenced by many factors, including

education, cultural background, and co-morbid illnesses. A referral source with
special expertise in dementia evaluation is particularly helpful when questions about
such influences arise.
We are likely to use neuropsychological testing more often in the future, as patients,
families, and physicians increasingly appreciate the benefits of early diagnosis and
treatment for dementia. Currently, referral for neuropsychological testing should be
considered when:
1. MMSE or other cognitive assessment is normal, but a family member

expresses concerns
2. Patient has an unusually high or low educational status, literacy level, or
intelligence
3. Patient is from a minority racial or ethnic background
4. MMSE is abnormal, but the functional assessment is normal
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DIAGNOSIS “OVER TIME”
It may be difficult to be certain about the diagnosis of dementia in the early stages,
and even the results of neuropsychological testing may be ambiguous. A clearer
picture often emerges over time with repeated assessments. The primary care
physician is in an ideal position for follow-up appointments that can include updated
functional assessments and cognitive evaluation, making progression of disease much
easier to identify.
REFERRAL TO SPECIALISTS
Referral to a clinician with dementia expertise (geriatrician, neurologist, or psychiatrist)

should be considered in patients with any of the following:
• Age less than 65

• Atypical presentation or unclear diagnosis
• Rapid progression or deterioration
• Strong family history of dementia
• Any focal neurological symptoms or signs, including movement disorders
• Gait disturbance or urinary incontinence in the early stages of dementia,
• Prominent language symptoms or personality change
Referral is also indicated when the primary care physician does not feel comfortable
with evaluation or management, or if the patient or family strongly desire consultation.
STAGING DEMENTIA
Clinical Diagnosis – Differential Diagnosis
Dementia can be broadly defined as a syndrome in which memory loss is

accompanied by acquired impairment in at least one other cognitive domain, including
the areas of language, motor function, personality, reasoning, and executive function
(ability to plan and organize). Formal diagnostic criteria for dementia can be found in
the Diagnostic and Statistical Manual of Mental Disorders.
Criteria for the two most common types of dementia can be found in the NINCDS-
ADRDA for Alzheimer’s and NINDS-AIREN for vascular dementia.
Alzheimer’s http://neurology.org/cgi/content/abstract/34/7/939
Vascular dementia http://neurology.org/cgi/content/abstract/43/2/250
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Identifying dementia is usually of greater importance to the primary care physician
than differentiating the precise type and cause of the disease. By far, most cases of
dementia the primary care clinician sees will be caused by Alzheimer’s disease, either
alone or in combination with another underlying cause like vascular dementia.
But in highly unusual cases, the sole source of dementia will be found to be a
reversible condition, and somewhat more commonly, such a condition will coexist with
Alzheimer’s. Those disorders should be recognized and treated separately, even
when Alzheimer’s or another irreversible disease is present. Practitioners should
know that truly reversible dementias are quite rare, especially in those over 65 in the
primary care setting, with one meta-analysis estimating that less than 1% of cases of
dementia have causes that lead to even partial reversibility (Clarfield MA, 2003).
Mild Cognitive Impairment vs. Dementia
In addition to knowing the difference between signs of dementia and changes that
relate to normal aging, we need to be able to distinguish dementia from mild cognitive
impairment (MCI).
Signs of Normal Aging Compared with Signs of Dementia
NORMAL AGING DEMENTIA

Occasional short-term memory lapses (lost Increasing short-term memory problems
details can be restored by prompts) that get in the way of daily living
(unresponsive to prompts because new
memories are not being formed and cannot
be retrieved)
Awareness of memory lapses No awareness of memory problems
Often needs reminders about
appointments, medication schedule, etc.
Forgetting where you left the car keys Forgetting what car keys are for
Occasionally misplacing items Frequently misplacing items

Leaving things in unusual places (e.g., milk
in the breadbox)
Occasionally forgetting a word Frequent inability to come up with words,

communicate clearly, understand what is
being said
Forgetting someone’s name Difficulty identifying a close friend or
relative
Taking longer to perform tasks Inability to perform familiar tasks
Taking longer to solve problems Problems with abstract thinking
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Additional symptoms that should be
recognized as possibly signs of dementia:
Withdrawal, loss of interest
Mood and behavior changes
Decreased ability to make good judgments
Trouble remembering the date, time or
place
The diagnosis of MCI recognizes that beyond a certain point, cognitive changes in
aging individuals should not be considered normal, even when they do not meet all the
accepted criteria for dementia.
A patient with MCI typically reports problems with short-term memory – such as not
remembering the names of new people, not recalling the flow of a conversation, or
misplacing an object. While these problems are seen in dementia, MCI presents clear
differences. Significant among these is the likelihood that the patient will be the one to
complain of the problem, something that is rarely true in cases of dementia, even in
the early stage. Corroboration from another informant, however, should be taken as a
sign that the patient has MCI rather than memory changes associated with normal
aging. In addition, the patient:
• Performs poorly on formal memory tests, even in comparison to people of

comparable age and education
• Shows normal general cognitive functions otherwise
• Experiences no interference with the activities of daily living and does not
require added assistance in these areas beyond the previous level of need
As in the case of Alzheimer’s and related disorders, physicians should be careful to

evaluate for coexisting or confounding depression. See the information about
depression in the Depression and Dementia section that follows in this module.
MCI may be a transitional stage. It is estimated that people diagnosed with MCI will
progress to Alzheimer’s at a rate of 10-15% per year as opposed to 1-2% in a healthy
control group. But the cognitive changes found in MCI may never progress to clear-
cut dementia in some cases. In light of the high conversion rate of MCI to
Alzheimer’s, it is especially important to recall that when signs that suggest dementia
are present, reassessment may be needed in order to make a diagnosis over time,
discussed above.
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Delirium and Dementia
Delirium represents the acute or subacute impairment of brain function due to the
effects of physical illness. The Diagnostic and Statistical Manual provides criteria for
delirium.
Delirium occurs with increasing frequency in advancing age, and dementia is a

significant underlying risk factor for the development of delirium. In fact, the
development of delirium may be the first sign of dementia in an elderly patient. In
addition, delirium may be confused with dementia, especially in milder forms of
delirium, when acute onset is not apparent. The chart below describes key
differences that can help distinguish between the two:
Delirium Dementia
Onset Acute or Gradual, insidious
subacute
Reversibility Reversible Irreversible;

Progressive
Orientation Disoriented Not impaired

(until advanced)
Consciousness Fluctuates; Intact

Clouded (until advanced)
Attention Impaired Normal

(until advanced)
Memory Confused Short-term losses
Cognitive deficits Variable Consistent
Psychomotor Hyperactive Normal

status or hypoactive (until advanced)
Subacute delirium is more common in the elderly than in any other age group. This
subacute presentation can easily cause it to be confused with dementia. Metabolic
disturbances and drug effects are the most common causes of subacute delirium in
the elderly population.
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It is important for the primary care physician to be able to identify delirium as an acute
response to a medical problem that requires urgent treatment. The clinician should
also recognize that delirium can accompany dementia, and effective treatment for the
underlying cause of delirium may still leave dementia that needs to be addressed
separately. Delirium can also be a warning sign for dementia, and should be a trigger
for the physician to investigate possible dementia.
Any patient with delirium should be evaluated for underlying dementia when stable.
Depression and Dementia
Depression in an older patient can be easily mistaken for dementia, and vice versa.
Many of the early presenting symptoms and signs are similar in both conditions:
apathy, neglect of self-care, memory loss, and other impaired cognitive functioning. A
personal or family history of depression may be helpful in recognizing depression; a
first-ever depression after age 60 is unusual in the absence of a clear precipitant like
trauma or grief. However, there are also important differences that can help the
clinician distinguish between depression and dementia as shown in the chart below.
Depression Dementia
Onset More discrete onset Insidious
Mood Low most of the day, Fluctuates without

Sadness may be pattern;
masked Mood changes in
by physical symptoms addition
to depression are
common
Physical May be prominent – Uncommon

symptoms aches and pains, GI
symptoms, headache,
etc.
Cognitive loss Fluctuates Stable and progressive
Memory loss Apathy – short and Short-term memory

long-term both much more impaired
affected
Presentation Patient likely to Relative or friend likely
present concerns to present concerns
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Patient Complains about Unaware of memory
perception memory loss loss;
Underestimates
problems
Answers to “Don’t know;” Inappropriate
Questions Incomplete answers or “near miss”
Effort on tasks Low Normal
The Geriatric Depression Scale is a valuable screening tool for depression in the
elderly.
Geriatric Depression Scale (Short Form)
Choose the best answer for how you felt the past week:
Are you basically satisfied with your life? Yes No*

Have you dropped many of your activities and interests? Yes* No
Do you often feel that your life is empty? Yes* No
Do you often get bored? Yes* No
Are you in good spirits most of the time? Yes No*
Are you afraid that something bad is going to happen to you? Yes* No
Do you feel happy most of the time? Yes No*
Do you often feel helpless? Yes* No
Do you prefer to stay at home rather than going out and doing new things?Yes* No
Do you feel you have more problems with memory than most? Yes* No
Do you think it is wonderful to be alive now? Yes No*
Do you feel pretty worthless the way you are now? Yes* No
Do you feel full of energy? Yes No*
Do you feel your situation is hopeless? Yes* No
Do you think most people are better off than you are? Yes* No
Each answer marked by an asterisk counts as one point.

(Public Domain)
The GDS has 15 yes-or-no questions on a form designed to be self-administered and

it takes only 5-10 minutes to complete. A score between 5 and 9 suggests
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depression, while a score greater than 9 correlates very strongly to depression.
Further assessment is needed to confirm the diagnosis if the GDS is positive.
The primary care physician needs to be able to identify treatable depression in older
patients. Treatment with antidepressants may alleviate all of the symptoms that mimic
dementia, but the clinician should know that depression is also a common co-
morbidity of Alzheimer’s. Depression is a recognized risk factor for dementia as well;
therefore, underlying dementia should be suspected in all elderly patients with
depression. In cases where dementia and depression coexist, it is important to identify
and treat both.
Any patient with depression should be evaluated for underlying dementia.
Major Types of Dementia
Although dementia has many causes, the three major causes account for almost all of
the cases seen and managed by primary care physicians (see referral criteria above):
Alzheimer’s disease; vascular dementia; and dementia with Lewy bodies.
Alzheimer’s Disease
Alzheimer’s disease should always be suspected when signs of dementia are

identified. It is the predominant cause of dementia and often coexists with other
disorders that contribute to the dementia syndrome. Key elements of Alzheimer’s
dementia are:
• Insidious onset
• Progressive course
• Impaired memory (both in recalling previously learned information and in
learning new information)
• Impairments in one or more of the areas of :
o Language
o Orientation
o Ability to carry out motor activities (apraxia)
o Ability to recognize or identify objects (agnosia)
o Executive function (ability to plan and organize, to abstract – this may
be subtle)
A patient may also be apathetic and emotionally withdrawn.
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Vascular Dementia
The symptoms of vascular dementia are not easily distinguishable from the symptoms
of Alzheimer’s disease, and a significant number of individuals who have dementia
from cerebrovascular causes also have Alzheimer’s. There are differences that can
be identified, however:
• Onset can be abrupt, but is more often subtle

• Progression may be stepwise
• Focal neurological signs may be present
• Cognitive deficits correlate with lesions on imaging
• Gait disturbances and urinary incontinence may be present
• Risk is higher in patients with hypertension, diabetes, and coronary artery
disease
Most significantly, vascular dementia has a temporal association between the

development of cognitive impairment and either clinical or imaging evidence of effects
of vascular disease.
However, dementia without sudden onset often goes undiagnosed following a CVA
(cerebrovascular accident, or stroke). In many studies, the rate of dementia after a
CVA is around 30%. And studies have demonstrated that many people diagnosed
with vascular dementia also have clear evidence of Alzheimer’s disease at autopsy.
Dementia with Lewy Bodies (DLB) / Dementia from Parkinson’s Disease
It is unclear whether dementia with Lewy bodies and dementia associated with
Parkinson’s disease, which has many features similar to Alzheimer’s, are two separate
entities or simply variants of one type. Like Alzheimer’s, DLB is insidious in onset and
progressive, but it may be distinguished by:
• Fluctuations in cognitive function with varying levels of alertness and

attention
• Visual hallucinations that may become evident early in the course of
disease
• Parkinsonian motor features, especially rigidity and bradykinesia
• Nighttime behavioral disturbances and daytime drowsiness
• Less prominent memory loss early in the course of the illness
• More prominent executive dysfunction early in the course of the illness
• Sensitivity to neuroleptic side effects
These three types of dementia – Alzheimer’s disease, vascular dementia, and

dementia with Lewy Bodies – have significant overlap in clinical presentation and
Rev. 04.02.07
12
treatment: cholinesterase inhibitors are valuable in slowing the progression of all three
and control of vascular risk factors is important in all three. The clinical importance of
making a clear distinction among them has been overemphasized.
Identification of dementia is far more important than precise identification of its

cause.
Rev. 04.02.07
13
TABLE A
The Mini-Mental Status Exam
Standard version – Folstein, Folstein, McHugh, 1975
(To be completed by a trained clinician)
Patient Name: __________________________________________
Date: _______________ Time: _________________
Birth Date: __________
Sex:
Male
Female
Education (years): ____
Race:
Caucasian
Black
Hispanic
Asian
Other
Orientation Questions:
Question Right Wrong

1. What is today’s date?
2. What is the month?
3. What is the year?
4. What day of the week is today?
5. What season is it?
6. What is the name of this clinic (place)?
7. What floor are we on?
8. What city are we in?
9. What county are we in?
10. What state are we in?
Immediate Recall: Ask the subject if you mat test his/her memory. Then say “ball,” “flag,” “tree” clearly
and slowly, about one second for each. After you have said all three words, ask him/her to repeat them.
The first repitition determines the score (0-3), but keep saying them until he/she can repeat all three, up to
six tries. If he/she does not eventually learn all three, recall cannot be meaningfully tested:
11. Ball
12. Flag
13. Tree
Note the Number of Trials: ___________
Attention:
A. Ask the subject to begin with 100 and count backwards by 7. Stop after 5 subtractions. Score the
correct subtractions.
14. “93”
15. “86”
16. “79”
Rev. 04.02.07
14
17. “72”
18. “65”
Serial 7’s Total: ___________
Patient Name: ______________________________________________
B. Ask the subject to spell the word “WORLD” backwords. The score is the number of letters in the
correct position. For example, “DLORW” is 3, “LROWD” is 0.
Question Right Wrong

19. “D”
20. “L”
21. “R”
22. “O”
23. “W”
“DLROW” Total: __________ Greater Score A or B:
__________
Delayed Verbal Recall: Ask the subject to recall the three words you previously asked him/her to
remember.
24. BALL?
25. FLAG?
26. TREE?
RECALL: ___________
Naming: Show the subject a wrist watch and ask him/her what it is. Repeat for pencil.
27. WATCH
28. PENCIL
29. REPITITON
Three Stage Command: Give the subject a plain piece of paper and say, “Take the paper in your hand,
fold in half, and put it on the floor.”
30. TAKES
31. FOLDS
32. PUTS
Reading: Hold up the card reading, “Close your eyes”, so the subject can see it clearly. Ask him/her to
read and do what it says. Score correctly only if the subject actually closes his/her eyes.
33. CLOSES EYES
Writing: give subject a piece of paper and him/her to write a sentence. It is to be written spontaneously. It
must contain a subject and verb and be sensible. Correct grammar and punctuation are not necessary.
34. SENTENCE LANGUAGE
Pentagons: Ask the subject to draw they the two pentagons as they appear on the paper.
35. PENTAGONS
Rev. 04.02.07
15
MMSE
Patient Name: _____________________________________________________
Calculations:
Total the number of correct responses: __________
(MMSE maximum score = 30)
24-30 normal, depending on age, education and complaints

20-23 mild
10-19 moderate
1- 9 severe
0 profound
(Public Domain; MMSE HTML @ MEDAFILE.COM)
Rev. 04.02.07
16
TABLE B
Flow Chart for Recognition and Initial Assessment of
Alzheimer’s Disease and Related Dementias 1
1
Source: Agency for Health Care Policy and Research, 1996.
Rev. 04.02.07
17
References
Agency for Health Care Policy and Research. (1996). Early Identification of
Alzheimer’s Disease and Related Dementias, AHCPR Archived Quick Reference
Guide No. 19. Note: AHCPR (Agency for Health Care Policy and Research) was
renamed and is now known as AHRQ (Agency for Healthcare Research and Quality).
Clarfield AM. (2003). The decreasing prevalence of reversible dementias: an updated

meta-analysis. Arch Intern Med, 163(18):2219-29.
Folstein MF, Folstein SE, McHugh PR. (1975). “Mini-mental state”. A practical method
for grading the cognitive state of patients for the clinician. J Psychiatr Res, 12:189-98.
Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. (1963). Studies of illness in
the aged. The index of ADL: A standardized measure of biological and psychosocial
function, JAMA, 185:914-9.
Lawton MP, Brody EM. (1969). Assessment of older people: self-maintaining and
instrumental activities of daily living. Gerontologist, 9(3):179-86.
McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. (1984).

Clinical diagnosis of Alzheimer’s disease: report of the NINCDS-ADRDA work group
under the auspices of Department of Health and Human Services Task Force on
Alzheimer’s Disease. Neurology, 34(7):939-44.
Pfeffer RI, Kurosaki TT, Harrah CH Jr, Chance JM, Filos S. (1982). Measurement of
functional activities in older adults in the community. J Gerontol, 37:323-9.
Roman GC, Tatemichi TK, Erkinjuntti T, Cummings JL, Masdeu JC, Garcia JH,
Amaducci L, Orgogozo JM, Brun A, Hofman A. (1993). Vascular dementia: diagnostic
criteria for research studies. Report of the NINDS-AIREN International Workshop,
Neurology, 43:250-60.
Rev. 04.02.07
18
Pharmacologic Treatment of Alzheimer’s Disease
In this module, learn about:
• Recommended use of Cholinesterase Inhibitors (ChEIs) and

memantine for Alzheimer’s disease
• Research findings for these treatments agents
• Common side effects
• Comparison of ChEIs
• Other treatment agents, including supplements
• When to discontinue pharmacologic treatment
No pharmacologic treatments currently available for Alzheimer’s disease offer a

“cure” for the disease. However, early diagnosis and initiation of ChEIs offer the
best possible long-term management the disease. Current treatments may slow
the rate of decline and stabilize function or behavior. For some patients (less than
one-third in most studies) treatment may actually improve function over the short-
term. In addition, growing evidence suggests that targeted dementia treatment
may offer the most effective management as well as prevent the emergence of
difficult behavioral problems – the aspect of Alzheimer’s that is commonly the
most challenging and stressful for caregivers. This module summarizes current
knowledge of the therapeutic value of cholinesterase inhibitors, memantine, and
other treatment agents that have been studied.
CHOLINESTERASE INHIBITORS (ChEIs)
ChEIs inhibit degradation of acetylcholinesterase (the enzyme that breaks

acetylcholine) within synapses that involve cholinergic neurons thereby
augmenting cholinergic function in the brain. Acetylcholine is an important
neurotransmitter involved in learning and memory. Four ChEIs are currently
available:
• Donepezil (Aricept) is started at 5 mg QD. After 4-6 weeks, it may be

increased to 10 mg QD. By convention, donepezil is given at HS.
Some physicians prefer AM dosing, especially if vivid dreams or
nightmares are a problem side effect.
• Rivastigmine (Exelon) has a starting dose of 1.5 mg BID. Increased

dosage should be tried only after a minimum of two weeks – many
Resources and Services Administration as authorized through Section 777(a), Title VII of the U.S. Public
Health Service Act, as amended.
Rev. 08.14.07
1
experts recommend four week intervals. It comes in 1.5, 3, 4.5, and 6
mg capsules, so titration can be quite slow when needed. It is
recommended that it be taken with food to slow down the rate of
absorption to decrease the GI side effects. The lowest effective dose is
3 mg BID, and the maximum dose is 6 mg BID. There is a good
possibility that an Exelon patch may be available towards the end of
2007.
• Galantamine (Razadyne -- renamed from Reminyl because of

confusion with “Amaryl”) has a starting dose of 4 mg BID, which can be
increased to the minimum effective dose of 8 mg BID after a minimum
of 4 weeks. A further increase to 12 mg BID should be attempted after
another four weeks, if the patient is tolerating the medication. For renal
insufficiency, the maximum dose should be kept at 16 mg/day.
Galantamine is also available in an extended release form (Razadyne
ER) that can be dosed once a day. It is recommended that Razadyne
be taken with food.
• Tacrine (Cognex) is rarely used because of its high GI side effects and
significant hepatotoxicity. Tacrine is not suitable for use by most
primary care physicians, and has very limited use even in the hands of
dementia specialists.
Common Side Effects of ChEIs
It is worth noting that even the “common” side effects of ChEIs are relatively
infrequent, but are seen most often during the titration periods. ChEIs are overall
well tolerated, especially when a slow approach to dose titration is used.
Specialists in dementia report quite low rates of discontinuation of ChEIs because
of side effects in clinical practice. Adverse effects may be gastrointestinal,
cardiovascular, neuromuscular, or related to the central nervous system:
Gastrointestinal: Nausea, vomiting, diarrhea or abdominal pain may

result in anorexia and weight loss.
Cardiovascular: Bradycardia, tremor or dizziness may result in asthenia

and fatigue.
Neuromuscular: Muscle cramps and weakness may result in falls.
Central Nervous System: Insomnia, nightmares, agitation or a panic-like

state.
Rev. 08.14.07
2
Adverse event profiles reported in the Physicians’ Desk Reference suggest the
most frequent side effect is nausea. Vomiting and diarrhea were reported more
frequently than anorexia, dizziness or fatigue.
Other side possible side effects are:
• Sleep disturbances, including insomnia and vivid dreams/nightmares

• Muscle cramps, fatigue, syncope
• Worsening of peptic ulcer disease
We should use caution giving any cholinesterase inhibitor to patients with severe
asthma or COPD as these drugs can cause bronchoconstriction. Close
monitoring of the pulmonary condition will keep serious problems from developing
in most patients. These pulmonary problems are NOT absolute contraindications
to the use of ChEIs – we need to consider the potential benefits as well as the
possible risks. Symptomatic bradycardia is a possible side effect, especially
when combined with digoxin or calcium channel blockers that also slow the
conduction through the AV mode.
With slow dosage titration, ChEIs are generally well tolerated.
Comparing the Three Commonly Prescribed ChEIs
A meta analysis (Ritchie 2004) of many of the trials done comparing the three
commonly prescribed ChEIs found that all three drugs showed beneficial effects
on cognitive tests, as compared with placebo. For donepezil and rivastigmine,
larger doses were associated with larger effect. This was not the case with
galantamine. The odds of clinical global improvement demonstrated superiority
over placebo for each drug, with no dose effects noted. Dropout rates were
greater with galantamine and rivastigmine. There was little difference in dropout
rate for each drug at each dose-level, except with high-dose donepezil. In
summary, all three drugs had similar cognitive efficacy, with donepezil and
rivastigmine showing a dose effect across the dosing levels studied. However,
both galantamine and rivastigmine were associated with a greater risk of trial
dropout than placebo, especially at higher dosing levels.
Prices are comparable for all three agents. Donepezil is slightly cheaper by AWP
pricing and slightly higher by Red Book data. As with all drug choices, we need to
consider individual formulary requirements in our selection.
Rev. 08.14.07
3
Donepezil has some perceived advantages over rivastigmine and galantamine:
as the agent longest on the market, it has the most data available. It has the
simplest titration schedule and the lowest GI side effects according to data
presented in the PI.
The percentages of adverse events from monotherapy titration reported in the

2006 Physicians’ Desk Reference were highest in every category (diarrhea,
nausea, vomiting, anorexia, dizziness, and fatigue) for rivastigmine (6-12 mg).
Galantamine (16-24) percentages were higher than donepezil (5-10 mg), except
for diarrhea, but the differences between galantamine and donepezil were less
substantial than the difference between rivastigmine and the other two. The data
do not represent a head-to-head comparison.
Although some experts have suggested switching from one ChEI to another if the
expected benefit is not realized, this practice is not supported by either clinical
trials or expert consensus. Switching is sometimes done when one CHEI is not
tolerated over the other, so in essence it may be done for safety purposes.
Other ChEI Considerations
Keep in mind that many drugs have anticholinergic effects (drugs for overactive
bladder, antihistamines, antidepressants, etc.) that can not only decrease the
efficacy of cholinesterase inhibitors but also independently worsen dementia,
cause delirium and other CNS side effects. Studies suggest that serum
anticholinergic activity (SAA) can be detected in most older persons in the
community and that even low SAA is associated with cognitive impairment
(Mulsant 2003). Many patients with dementia are also using many other
medications for comorbidities. The risks of prescribing cholinesteraise inhibitors
along with anticholinergic drugs needs to be diligently evaluated and monitored. It
is important to consider medications with mild anticholinergic effects along with
those with stronger effects since the anticholinergic burden is cumulative. The
cumulative anticholinergic burden is associated with higher incidence of delirium
and cognitive impairment.
Summary
ChEIs have been shown in prospective, randomized, double-blind, and placebo-

controlled trials to:
• Reduce the rate of cognitive decline for 6-12 months
• Reduce the rate of functional decline for 6-12 months
• Stabilize or improve the clinician global impression of change
after 6-12 months
Rev. 08.14.07
4
• Improve or delay the onset of neuropsychiatric and behavioral
symptoms
Many trials, however, have excluded patients with comorbid illnesses, making the
results less representative of the general population of patients with Alzheimer’s.
There have been no prospective, double-blind, placebo-controlled trials lasting

longer than 12 months, although long-term, open label data for as long as four
years exists for some of these agents. There is now an ethical argument against
the design of a placebo-controlled trial with any of these agents since we now
know that they have symptomatic benefits over and above placebo. Some other
important variables, including effects on health care costs and caregiver burden,
have also been assessed.
Trials of donepezil (Feldman 2003) and galantamine (Salo 2003) have

demonstrated a reduction in caregiver time required for patients receiving
treatment. Both studies were of 28 week duration. The donepezil trial was
conducted with moderate to severe dementia patients while the galantamine trial
was with mild to moderate dementia patients. The donepezil trial yielded a
reduction of 52.4 minutes per day caregiving time and the galantamine trial
yielded 32 minutes per day reduction.
In summary, the benefits of ChEIs are, at best, modest. Nevertheless, delay of

symptom progression is an important goal, especially for caregivers. The
American Academy of Neurology recommends the use of ChEIs, while noting that
average benefit is small. Currently, this is the best FDA approved treatment we
have to offer for mild to moderate stage dementia.
ChEI therapy is endorsed as standard first-line therapy for patients with mild
to moderate Alzheimer’s disease.
MEMANTINE (NAMENDA)
Memantine is an NMDA (N-methyl-D-aspartate) receptor blocker, currently

approved for moderate to severe Alzheimer’s disease. It is indicated for use as a
single agent and also indicated in combination with ChEIs for this purpose. There
are now trials with donepezil and rivastigmine published and the PI does not
mention only donepezil. Modest effects have been demonstrated in slowing
cognitive decline and functional decline its use as compared to placebo. A trial of
memantine (Wimo 2003) of 28 week duration with moderate to severe dementia
Rev. 08.14.07
5
patients yielded a 92 minutes per day reduction in caregiver time (compared to
the 52.4 and 32 minutes for donepezil and galantamine respectively). There is
also data to support the use of the two-drug combination (donepezil and
memantine) as being superior to donepezil alone for some domains of the
Neuropsychiatric Inventory (NPI) for behavior.
Some experts are using memantine for the mild stage of disease, both alone and
in combination with a ChEI. However, its use for the mild stage is off label since
the FDA has not approved its use for mild disease and is unlikely to do so in the
future. One U.S.-based trial has suggested it is valuable earlier in the dementia
process, but European studies have been negative.
Memantine seems to be even better tolerated than the cholinesterase inhibitors,

both as a single agent and in combination with donepezil. In some patients,
memantine causes dizziness, headache, or constipation. Less common adverse
events may include fatigue, pain, hypertension, vomiting, confusion or
somnolence, hallucinations, coughing, and dyspnea.
Start patients on 5 mg QD and slowly increase by 5 mg each week until a dose of

10 mg BID is reached. It may be taken with or without food. Dose reductions
(total dose of 5 mg/BID) for patients with moderate renal dysfunction (est CrCl 5-
29 ml/min) should be considered, and it is not recommended for patients with
severe renal dysfunction. When starting therapy with both memantine and a
ChEI, consider starting the memantine first to reduce the likelihood of adverse GI
effects from the ChEI.
Use of memantine with other NMDA receptor antagonists (amantadine,

dextromethorphan, ketamine, etc.) has not been evaluated in clinical trials, but
could be assumed to be problematic on theoretical grounds after prolonged or
high-dose use.
OTHER AGENTS
Other potential treatment agents or supplements have been suggested, and

patients or family members may ask about them.
Vitamin E: A single trial showed controversial benefit with 2,000 IU/day

vs. placebo and selegiline. (Sano) The researchers concluded that
Vitamin E was shown to delay nursing home placement and functional
disability, but not cognitive decline. Critics of the study have noted that the
study population did not reflect the general Alzheimer’s population:
Rev. 08.14.07
6
subjects were younger, had more severe dementia, and were not taking
any psychoactive medications.
A Cochrane review reported that there was insufficient evidence to

recommend Vitamin E, and the AAN says that its use “should be
considered.” A recent meta-analysis of the risk of Vitamin E
supplementation (in all users, not just those with dementia) concluded that
supplements higher than 400 mg per day were associated with a significant
increase in all-cause mortality (Miller ER, Annals of Internal Medicine 2005;
142: 37-46). Subsequently, another large study showed no difference in
cardiovascular events or cancer and related mortality, but a possible
increase in heart failure (Lonn 2005).
If you decide to use Vitamin E treatment, exercise caution in patients

already taking antiplatelet or anticoagulant drugs because of the possible
increase in the risk of bleeding.
Estrogen: Despite several descriptive studies that had shown

postmenopausal women taking estrogen supplements to have a lower rate
of dementia, a large prospective trial has now shown that use of estrogen
combined with progestin may actually increase the rate of dementia and
stroke (Shumaker 2003). And in a related large prospective trial, therapy
with estrogen alone showed an adverse effect on cognition that was
greater among women with lower cognitive function at treatment outset
(Espeland 2004).
Anti-inflammatories: Inflammation around the beta amyloid plaques and

subsequent neuronal destruction has been thought to be a key factor in the
pathogenesis of Alzheimer’s disease, and several observational studies
have demonstrated that people who regularly use NSAIDs have a
decreased incidence of Alzheimer’s. However, neither NSAIDs nor
prednisone have been shown to have any benefit in the treatment of those
identified with Alzheimer’s in prospective, randomized, placebo-controlled
trials.
Statins: Observational studies have shown a decrease in Alzheimer’s

disease as well as slowing of its progression with the use of statins. A
large cooperative randomized controlled trial of simvastatin is underway,
but results may be delayed. Researchers have found that so many
patients are now already on statins or have strong indications for their use,
that recruitment of subjects eligible for randomization has been slower than
anticipated.
Rev. 08.14.07
7
Complementary/alternative therapies: There is insufficient evidence to
support the use of any other treatments for dementia. A large NIA trial with
huperizine (an acetylcholinesterase inhibitor found in Chinese Club Moss)
is underway.
STOPPING PHARMACOLOGIC TREATMENT
There is no clear consensus regarding how or when to stop any of the

pharmacologic agents for dementia. As with most clinical decision-making, this
must be evaluated on an individual basis. We need to assess and weigh the
benefits and burdens (including cost and side effects) of treatment in light of the
patient’s earlier expressed wishes and with the caregiver or decision-maker.
Some experts recommend that pharmacologic therapy should be continued “until

there are no meaningful social interactions and quality of life has irreversibly
deteriorated” (Farlow & Cummings). This recommendation assumes that the
patient’s cognitive and functional status are monitored at six-month intervals.
When considering withdrawal of treatments aimed at altering the course of

dementia, we need to consider what function the patient still has that is worth
preserving. The answers, of course, vary according to individual values and
situations.
• Most experts do agree that ChEIs and memantine should be stopped at the
point that the patient no longer has meaningful function and/or when the
patient is enrolled in hospice services. Is this patient doing anything that
we want to preserve?
• Do NOT perform a “trial” off medication. Prior level of benefit is unlikely to

be regained and there may be a precvipitous decline after stopping.
• After a patient has been hospitalized and needs to be re-initiated on the

ChEI, the drug should be re-titrated from the starting dose. This is
especially true for rivastigmine and galantamine; even a 2-week stopping
interval necessitates restarting therapy at the lowest dose.
Rev. 08.14.07
8
References
American Academy of Neurology. AAN Guideline Summary for Patients and Their
Families: Alzheimer’s Disease. (Accessed 08/08/05 at http://www.aan.com/.)
Beier MT. Cholinesterase inhibitors and anticholinergic drugs: Is the

pharmacologic antagonism myth or reality? J Am Med Dir Assoc 2005;6(6):413-
4.
Bentué-Ferrer D, Tribut O, Polard E, Allain H. Clinically significant drug

interactions with cholinesterase inhibitors: A guide for neurologists. CNS Drugs
2003;17(13):947-963.
Espeland MA, Rapp SR, Shumaker SA, Brunner R, Manson JE, Sherwin BB, Hsia
J, Margolis KL, Hogan PE, Wallace R, Dailey M, Freeman R, Hays J. Conjugated
equine estrogens and global cognitive function in postmenopausal women:
Women’s Health Initiative Memory Study. JAMA 2004;291(24):2959-68.
Farlow MR, Cummings JL. Effective pharmacologic management of Alzheimer’s

disease. Am J Med 2007;120(5):388-97.
Feldman H, Gauthier S, Hecker J, Vellas B, Emir B, Mastev V, Subbiah P.

Efficacy of donepezil on maintenance of activities of daily living in patients with
moderate to severe Alzheimer’s disease and the effect on caregiver burden. J Am
Geriatr Soc 2003;51(6):737-44.
Lonn E, Bosch J, Yusuf S, Sheridan P, Pogue J, Arnold JM, Ross C, Arnold A,

Sleight P, Probstfield J, Dagenais GR.. Effects of long-term vitamin E
supplementation on cardiovascular events and cancer: A randomized controlled
trial. JAMA 2005;293(11):1338-47.
Miller ER 3rd, Pastor-Barriuso R, Dalal D, Riemersma RA, Appel LJ, Guallar E.

Meta-analysis: High-dosage vitamin E supplementation may increase all-cause
mortality. Ann Intern Med 2005;142(1):37-46.
Mulsant BH, Pollock BG, Kirshner M, Shen C, Dodge H, Ganguli M. Serum

anticholinergic activity in a community-based sample of older adults: relationship
with cognitive performance. Arch Gen Psychiatry, 2004. 60(2):198-203.
Ritchie CW et al. Meta analysis of randomized trials of the efficacy and safety of
Donepezil, Galantamine, and Rivastigmine for the treatment of Alzheimer
disease. Am J Geriatr Psychiatry 2004;12:358-69.
Rev. 08.14.07
9
Sano M, Wilcock GK, van Baelen B, Kavanagh S, The effects of galantamine
treatment on caregiver time in Alzheimer’s disease. Int J Geriatr Psychiatry
2003;18(10):942-50.
Sano M, Ernesto C, Thomas RG, Klauber MR, Schafer K, Grundman M,

Woodbury P, Growdon J,Cotman CW, Pfeiffer E, Schneider LS, Thal LJ. A
controlled trial of selegiline, alpha-tocopherol, or both as treatment for Alzheimer’s
disease. The Alzheimer’s Disease Cooperative Study. N Engl J Med
1997;336(17):1216-22.
Shumaker SA, Legault C, Rapp SR, Thal L, Wallace RB, Ockene JK, Hendrix SL,
Jones BN 3rd, Assaf AR, Jackson RD, Kotchen JM, Wassertheil-Smoller S,
Wactawski-Wende J, WHIMS Investigators. Estrogen plus progestin and the
incidence of dementia and mild cognitive impairment in postmenopausal women:
The Women’s Health Initiative Memory Study: A randomized controlled trial.
JAMA 2003;289(20):2651-62.
Wimo A, Winblad B, Stoffler A, Wirth Y, Mobius HJ. Resource utilization and cost
analysis of memantine in patients with moderate to severe Alzheimer’s disease.
Pharmacoeconomics 2003;21(5):327-40.
Rev. 08.14.07
10
1
Dementia in Primary Care
In this module, learn about:
• Epidemiology and under-diagnosis of dementia

• Barriers to diagnosis
• Benefits of early diagnosis
• Signs that should trigger an investigation of possible dementia
DEMENTIA – A GROWING HEALTH CONCERN
Diagnoses of Alzheimer’s disease and other dementia causing disorders have

grown rapidly in the last twenty-five years. It is estimated that 4.5 million
Americans now have Alzheimer’s - more than twice the number in 1980. Those
numbers are only expected to rise in the years to come, with projections of a 44%
increase by 2025, and perhaps a tripling of today’s number by 2050. Even in
Michigan, with a rate of growth in the elderly population significantly lower than
that of the Sunbelt states, a 12% increase in people living with Alzheimer’s is
projected for the next two decades.
The impact of dementia can also be seen in its incidence, which rises rapidly as
an older adult ages. Studies have shown that from age 65, incidence doubles
every five years, and that up to 50% of those over age 85 are suffering from
dementia.
Today, Alzheimer’s disease and other dementias account for at least 40% and, by
some estimates, up to 60% of nursing home admissions. Dementia is the third
most expensive disease to treat in the United States, after cancer and heart
disease. However, generally diagnoses of dementia are still not made until
patients are quite far into the course of the disease, even though helpful
interventions could be started much earlier.
THE ROLE OF THE PRIMARY CARE PHYSICIAN
The symptoms of Alzheimer’s disease (and many other dementias) develop so

slowly that they can go unnoticed for a very long time. Or, if they are observed,
changes may seem so slight that their significance is not recognized.
Additionally, the lack of self-awareness that is part of dementia makes it less likely
that patients will report their own problems.
Health Service Act, as amended. Rev. 02.28.07
2
Despite these and other impediments to the timely assessment of cognitive

impairment, current knowledge and assessment tools can lead to earlier
diagnoses of dementia than is now the norm. The primary care physician who
knows what signs to look for in elderly patients and what follow-up tools are
available can act as an effective early warning system. In fact, the physician who
routinely assesses elderly patients for early signs of dementia is often the key to
determining whether patients and families will receive information, guidance, and
appropriate interventions when they can help the most.
The effects of those interventions should not be underestimated. Many primary

care physicians are unaware of recent changes in treatments for Alzheimer’s and
related disorders, and of the effective medications that are available. These
medications can be successfully prescribed and managed in a primary care
setting. In general, the earlier they are started, the better.
Given the prevalence of Alzheimer’s in patients over age 65, dementia is a

possibility that ought to be in the forefront of our thinking when seeing older
patients. As primary care physicians, we can familiarize ourselves with the
common triggers that should raise the suspicion of dementia. These triggers
include communication problems, missed appointments, medication management
issues, a history of delirium, and more, discussed in detail later in this module.
Dementia is a significant problem for elderly patients, their families and society
as a whole.
Primary care physicians can improve the rate of early diagnosis and treatment.
COMMON BARRIERS TO DIAGNOSIS
Early diagnosis of dementia can make a significant difference in the lives of

patients and their families and caregivers, but it is relatively rare that a diagnosis
is made early in the course of the disease. Most diagnoses are made much later,
at a point when the patient is suffering from serious functional as well as cognitive
decline.
The insidious onset of dementia is not the only reason it goes undiagnosed.
There are also barriers to diagnosis that relate to patients and their families,
physicians and their practices, and the attitudes of the larger culture. For
example, there are individuals who may be so frightened by symptoms of mental
decline that they deny them, or busy office practices for which the time
commitment to diagnose and manage dementia might seem overwhelming. And
to the degree that the subject of dementia is considered taboo in our society, it is
easy to respond to barriers with silent acquiescence. But to a large extent, these
obstacles and the concerns that lie behind them can be addressed through
education of practitioners and the public.
3
One of the biggest concerns is that making the diagnosis of dementia will open a
whole Pandora’s Box of troubles – a series of problems that will only expand and
never be resolved. Given the degenerative course of the disease and its
incurable nature, this attitude understandably gives rise to the feeling that the
topic is best avoided. But while the frightening diagnosis of dementia might
suggest a state of affairs that is beyond control, there are steps that can be taken
to improve a difficult situation.
Understanding the facts about barriers and misconceptions is a good place to

start.
Barriers- Uncertainty about the Diagnosis
Because the symptoms of the most common dementia disorders reveal

themselves so slowly, over the course of months and years, it can be difficult for
physicians to identify dementia in its earliest stage. It may be hard to recognize
that a problem even exists especially when our encounters with a patient are
isolated and relatively brief, and concerns are not raised by family members or
office staff. Unless a patient comes in with a specific complaint related to memory
or confusion, it’s quite possible that no immediate cause for concern in those
areas will present itself.
But even when the suspicion is raised by a patient, family or office staff, or
through the use of screening tools, this is only a first step in diagnosis. We must
then ask if dementia really is involved. Or is, perhaps, a condition whose
symptoms mimic dementia, like depression or delirium, involved? Further
evaluation will be required to resolve these questions.
Physicians might also ask whether a patient’s dementia results from Alzheimer’s
disease or some other cause of dementia. Again, additional evaluation can help
provide answers, and these answers will sometimes influence treatment
decisions. But it is important to note that Alzheimer’s is by far the leading cause
of dementia in the population aged 65 and older. Alzheimer’s alone or in
combination with vascular dementia accounts for 70% of dementia in that age
group. A consensus panel representing the American Association for Geriatric
Psychiatry, the Alzheimer’s Association, and the American Geriatrics Society has
recommended Alzheimer’s be considered a “diagnosis of inclusion.” That is,
unless specific, positive findings indicate another form of dementia or a disorder
that mimics dementia, it is appropriate for the physician to make a clinical
diagnosis of Alzheimer’s. It should also be noted that Alzheimer’s disease is often
involved even when other causes of dementia are identified. Clinicians who see
dementia in elderly patients can reasonably assume that Alzheimer’s is what they
should always suspect.
4
Alzheimer’s is by far the most common cause of dementia in the elderly

population, and is often present even when other causes are identified.
The primary care physician can accurately diagnose Alzheimer’s and other
dementias in an office setting. We simply need to be alert to common triggers
and warning signs of dementia, and to employ easy-to-use cognitive screening
tools (both triggers and tools are discussed in the Clinical Diagnosis section of
this module). When findings are ambiguous, repeated observations and testing
over time will lead to a clear answer. Given dementia’s slow onset, it cannot be
overemphasized that this “diagnosis over time” is central to our ability to correctly
identify and treat it in the primary care setting.
Barriers – Mistaking Signs of Dementia for Normal Aging
Instances of mild memory loss and cognitive slowing are common as we grow
older and include: forgetting where we placed the car keys, occasionally failing to
remember a name, and slowing down on some problem solving tasks. It may be
hard to distinguish these common losses from the earliest stage of dementia.
However, as dementia progresses, the distinctions between disease and normal

signs of aging are apparent.
Signs of Normal Aging Compared with Signs of Dementia
NORMAL AGING DEMENTIA

Occasional short-term memory lapses Increasing short-term memory
(lost details can be restored by problems, which interfere with daily
prompts) living (unresponsive to prompts
because new memories are not being
formed and cannot be retrieved)
Awareness of memory lapses No awareness of memory problems
Often needs reminders about
appointments, medication schedule,
etc.
Forgetting where car keys were left Forgetting what car keys are for
Occasionally misplacing items Frequently misplacing items

Leaving things in unusual places (e.g.,
milk in the breadbox)
Occasionally forgetting a word Frequent inability to come up with

words, communicate clearly,
5
understand what is being said

Forgetting someone’s name Difficulty identifying a close friend or
relative
Taking longer to perform tasks Inability to perform familiar tasks
Taking longer to solve problems Problems with abstract thinking
Additional symptoms that should be

recognized as possible signs of
dementia:
Withdrawal, loss of interest
Mood and behavior changes
Decreased ability to make good
judgments
Trouble remembering the date, time or
place
A person might forget the location not only of keys, but of valuable objects.
Failure to recall names becomes common, and the patient may have trouble
remembering the names of close family members. Even simple tasks begin to
cause difficulties. As these problems increase, along with declines in
organizational ability and reading comprehension, they become more noticeable
to family members. Additionally, those close to the patient may see signs of
behavior changes that include paranoia, withdrawal or poor hygiene. These
symptoms are not signs of normal aging but of illness, and we ought to replace
old assumptions about what is normal aging with increased clinical suspicion of
dementia.
Barriers – Lack of Appreciation for the Impact of Early Intervention
It stands to reason that if we see no ready benefit, we will be less likely to move
quickly toward a diagnosis of dementia. That’s why it is important to know that
addressing dementia early in its course can have a substantial positive impact on
the lives of patients and families. This applies not only to drug therapies that
might slow disease progression, but to the psychosocial aspects of the illness
such as family stress and the patient’s sense of control, and to physical safety
issues. See the Benefits of Early Intervention section in this module for additional
information.
Barriers – Pessimism about Disease Progression and Outcome
6
Without a clear understanding of the benefits that drug treatments and other
interventions can bring to patients with dementia and their families, it is easy to
view dementia disorders in an extremely pessimistic light. That the disease is
incurable and irreversible may come to seem the only facts that count.
Thus, physicians may act or rather fail to act, on the unspoken assumption that
diagnosis does not matter because “there’s nothing to be done.” This message
may in turn be conveyed to patients and families even when it is not explicitly
discussed. A pessimistic outlook leads physicians not to want to talk about
dementia, and families not to want to ask.
Barriers – Inadequate Reimbursement
The familiar issue of reimbursement that rewards procedures more than thorough
doctor-patient communication can be a disincentive to evaluation and treatment of
dementia. In addition, there are ICD-9 coding issues unique to dementia.
Physicians generally tend to under-code for complex office visits, and are
therefore under-reimbursed. If physicians do not overlook aspects of the
evaluation and management of dementia patients that increase the complexity of
visits, many of visits may qualify for a higher E/M code.
Barriers – Patient and Family Awareness
People who begin to experience memory loss and confusion in the initial stage of
dementia can find the experience frightening. Yet it may be hard for them to
share their feelings and worries with family members or health professionals
because they have a sense, as we all have, that naming out loud the thing we
fear will make it so. This is the well-known phenomenon of denial, a defense
mechanism that can certainly play a positive role in people’s lives, allowing them
to digest unpleasant facts at a manageable pace. But when denial becomes fixed
and allows no room at all for reality to settle in, it stands in the way of a timely
diagnosis, and getting the help the patient needs
Just as individuals who suffer from the onset of dementia try to hide the facts from
themselves and others, family members may also practice denial. They too fear
for their loved one’s future, and so they see but refuse to acknowledge the signs
of dementia. They might even compensate for the ill person’s increasing deficits,
offering to “share” tasks but in fact taking them over because the individual is no
longer competent. This can go on for months and years, as the problem only
continues to worsen.
7
BENEFITS OF EARLY DIAGNOSIS
A diagnosis of dementia is most likely to be made well into the course of the
disease, when the patient has begun to have serious trouble carrying out the
activities of daily living and is showing impaired judgment. The disease has
reached a point where family members can no longer ignore or deny it.
What this means in practical terms is that by the time the illness is recognized for
what it is, the family is already in crisis. There may have been an accident or
hospitalization, or a scary episode in which the ill person has become lost. The
patient’s ability to do basic self-care may in practical terms be gone. Patient and
family are understandably confused and frightened, but hardly have room to
respond emotionally because there are decisions that must be made – decisions
they are totally unprepared to face.
At the same time, the physician will realize that the value of medications that
might have slowed the patient’s decline has diminished, and that time has been
irretrievably lost.
When the diagnosis is made early, at a time when symptoms are present put less
severe, it is possible to:
• Reduce family stress and burden
• Empower the person with dementia
• Use medications more effectively to improve status or slow progression of the
disease
• Help insure the patient’s safety
• Identify potentially reversible causes of dementia
• Identify disorders whose symptoms mimic dementia but require a different
treatment
Early diagnosis has many benefits for patients and their families.
Reducing Family Stress and Burden
With good reason, dementia is often called a family disease. As the patient
declines, family members must face the emotional stress of witnessing that
decline, and they are faced with new challenges of providing care. Early
diagnosis gives individuals with dementia and their families the opportunity to plan
for changes before the need becomes urgent. For families especially, the ability
to anticipate upcoming changes can reduce the stress of facing an uncertain
future, and help them cope with those changes when they do occur.
8
Education, care training and support groups help family members learn ahead of
time about the best tools for communicating with their loved one, for providing a
safe and comfortable environment, and for controlling difficult behaviors. Studies
have shown that family members who participate in training and support groups
are able to care for the patient at home longer.
Early diagnosis also prepares family members for taking over roles that the
person with dementia has previously been responsible for. And it gives them time
to do financial and end-of-life planning in a thoughtful and considered way, often
in collaboration with the dementia patient.
Empowering the Person with Dementia
When faced with an illness whose course is one of continuing losses – losses of
memory, of everyday abilities, of one’s entire sense of self – anything that puts
control in the hands of the ill person is usually welcome. A diagnosis of dementia
made early in the disease process does exactly that, affording patients some
measure of control by giving them the chance to participate meaningfully in
management and planning.
Support groups can help people with dementia adjust to changes brought on by
illness, and empower them to decide for themselves what some of those changes
will be. Patients can take charge by setting priorities and acting on them – by
choosing, to whatever extent circumstances allow, what they will do next.
At this early stage, patients can also meaningfully participate in making plans for
the future related to finances, care giving, and end-of-life decisions.
Benefits – Effects of Medication
Our understanding of the effectiveness of medications to treat the most common

forms of dementia has changed dramatically. It is now widely accepted that
cholinesterase inhibitors and memantine slow the rate of decline in cognitive
function in Alzheimer’s, which has a clearly positive impact on the lives of patients
and their families. Similar benefits have been shown in vascular dementia. The
benefits of current medications are real and significant even when there is no
measurable improvement in the patient’s symptoms.
The initial practice of giving a patient a trial of one of these drugs and then
watching for improvement is no longer appropriate. Every patient who can
tolerate these medications ought to be on them, as they have demonstrated
significant value in slowing decline, including delay in nursing home placement.
9
Cholinesterase inhibitors, which slow the progress of disease, should be

prescribed early, since lost function cannot be restored with our current
knowledge. Additionally, there is evidence to suggest that earlier treatment with
them yields greater benefits.
Medications can also be used to alleviate symptoms such as anxiety and

depression that often accompany dementia, and to address problem behaviors.
Cholinesterase inhibitors slow the rate of decline in cognitive function and

should be started as early as possible in the course of the most common
dementias in elderly patients.
Benefits – Safety Issues
It often takes a car accident, or a fall or other mishap at home, to bring families
face to face with the problems that a loved one with dementia is experiencing.
However, even these triggers might not lead to a proper diagnosis if they can be
easily explained away as isolated incidents. But early diagnosis of dementia can
help minimize the possibility these accidents will occur. The patient’s ability to
drive can be carefully assessed, and plans can be made to provide alternative
transportation solutions. At the same time, families can begin to modify the home
environment for safety.
Benefits – Identifying Potentially Reversible Causes of Dementia
Although signs of dementia most often indicate that Alzheimer’s or a related

degenerative disorder is present, differential diagnosis may reveal another factor
that is contributing to the syndrome or, in some cases, is the sole cause.
Sometimes these other disorders can be treated and their symptoms reversed.
Differentiating these separate causes sooner means earlier intervention in a
potentially reversible illness, and greater possibility that the intervention will
succeed.
Such reversible causes of dementia include: metabolic disturbances, vascular

disease, thyroid dysfunction, vitamin B12 or folate deficiency, infection, and normal
pressure hydrocephalus. They are discussed in Module 2 – Clinical Diagnosis of
Dementia.
Benefits – Identifying Conditions that Mimic Dementia
10
The primary care physician may see patients whose presentation raises suspicion
of dementia, but who in fact are exhibiting signs of another treatable disorder.
Depression and delirium in particular may be mistaken in the elderly for dementia.
It is important to be aware, however, that either delirium or depression may also

coexist with dementia. These issues are discussed in greater detail Module 2 –
Clinical Diagnosis of Dementia.
CLINICAL DIAGNOSIS TRIGGERS
When the early signs of Alzheimer’s and other dementias go undetected,

physicians miss an important opportunity to improve the lives of patients and
families. Early intervention can have significant impact on the course of the
disease and on the families’ ability to cope with it. Therefore, it is essential that
we identify the problem as soon as possible, even though the insidious onset of
the most common dementias makes this more difficult.
Physicians should also be aware that recognizing the dementia syndrome in the
first place is the biggest hurdle they face. The initial step of clearly recognizing
dementia amid the many other details of an elderly patient’s clinical presentation
is not easily done. Once this step has been accomplished, the most set of barriers
have been overcome. Differential diagnosis may bring to light a reversible cause
of dementia or affect the precise course of treatment, yet the steps to be followed
in that state of assessment are relatively easy to lay out.
Failure to recognize dementia is the single biggest problem in dementia care.
The Alzheimer’s Association lists ten warning signs of Alzheimer’s disease and
other dementias.
Ten Warning Signs of Alzheimer’s

(Alzheimer’s Association, used by permission)
1. Memory loss. Forgetting recently learned information is one of the most

common early signs of dementia. A person begins to forget more often and is
unable to recall the information later.
What’s normal? Forgetting names or appointments occasionally.
2. Difficulty performing familiar tasks. People with dementia often find it hard
to plan or complete everyday tasks. Individuals may lose track of the steps
involved in preparing a meal, placing a telephone call or playing a game.
11
What’s normal? Occasionally forgetting why you came into a room or

what you planned to say.
3. Problems with language. People with Alzheimer’s disease often forget

simple words or substitute unusual words, making their speech or writing hard
to understand. They may be unable to find the toothbrush, for example, and
instead ask for “that thing for my mouth.”
What’s normal? Sometimes having trouble finding the right word.
4. Disorientation to time and place. People with Alzheimer’s disease can

become lost in their own neighborhood, forget where they are and how they
got there, and not know how to get back home.
What’s normal? Forgetting the day of the week or where you were going.
5. Poor or decreased judgment. Those with Alzheimer’s may dress

inappropriately, wearing several layers on a warm day or little clothing in the
cold. They may show poor judgment, like giving away large sums of money to
telemarketers.
What’s normal? Making a questionable or debatable decision from time to

time.
6. Problems with abstract thinking. Someone with Alzheimer’s disease may

have unusual difficulty performing complex mental tasks, like forgetting what
numbers are for and how they should be used.
What’s normal? Finding it challenging to balance a checkbook.
7. Misplacing things. A person with Alzheimer’s disease may put things in

unusual places: an iron in the freezer or a wristwatch in the sugar bowl.
What’s normal? Misplacing keys or a wallet temporarily.
8. Changes in mood or behavior. Someone with Alzheimer’s disease may

show rapid mood swings – from calm to tears to anger – for no apparent
reason.
What’s normal? Occasionally feeling sad or moody.
9. Changes in personality. The personalities of people with dementia can

change dramatically. They may become extremely confused, suspicious,
fearful or dependent on a family member.
12
What’s normal? People’s personalities do change somewhat with age.
10. Loss of initiative. A person with Alzheimer’s disease may become very
passive, sitting in front of the TV for hours, sleeping more than usual or not
wanting to do usual activities.
What’s normal? Sometimes feeling weary of work or social obligations.
As valuable as these signs can be for family members, they cannot always be
observed in an office visit. However, the clinician is often presented with other
facts about a patient that ought to trigger an evaluation of possible dementia.
These triggers can be grouped into five main categories. Note that the office staff
may also need to be educated about these behaviors that raise the question of
dementia.
Communication
Consider dementia when an elderly patient:

• Misses office appointments
• Calls the office frequently or inappropriately
• Misses paying bills
• Has trouble handling paperwork
• Has difficulty following directions
• Is confused about medication or treatment instructions
• Has difficulty making medical decisions
• Engages in repetitive speech
Accidents
Consider dementia in cases of:

• Motor vehicle accidents
• Fractures
• Falls
• Increased frequency of emergency room visits
Medical Triggers

• Has delirium or a history of delirium
• Has suffered a CVA – incidence of dementia increases significantly
after stroke
13
• Has unexplained weight loss – increasing evidence shows this may be

a presenting sign of dementia
Change in Functional Status

• Has decreased ability to carry out the instrumental activities of daily
living
INSTRUMENTAL ACTIVITIES OF DAILY LIVING SCALE (IADL)

Lawton, M.P. & Brody, E.M. (1969). Assessment of older people: Self-maintaining and
instrumental activities of daily living. The Gerontologist, 9(3), 179-186. Copyright © The
Gerontological Society of America. Reproduced by permission of the publisher.
Need No Help Need Some Help Unable to Do At All

Activity
(2 pts. each) (1 pt. each) (0 pts. each)
1. Using the Telephone
___ ___ ___
2. Getting to Places Beyond
Walking Distance ___ ___ ___
3. Grocery Shopping
___ ___ ___
4. Preparing Meals
___ ___ ___
5. Doing Housework or
Handyman Work ___ ___ ___
6. Doing Laundry
___ ___ ___
7. Taking Medications
___ ___ ___
8. Managing Money
___ ___ ___
Total Score: ___ = (___ x 2 =) ___ + (___ x 1=) ___ + 0
• Moves to senior housing or assisted living

• Presents signs of self-neglect (e.g., hygiene, grooming)
• Becomes less compliant with medication
• Gets lost
• Requires transportation
• Is accompanied to office visits by a family member
14
• Defers to a family member in answering questions
Cognition Changes
Consider dementia when:

• An elderly patient or family member reports memory problems
• The patient is unable to list current medications
• The patient is unable to recall recommendations from a prior visit
• The patient is a poor historian
• The patient makes mistakes with medications or problems do not
respond to usual medical management
• The patient experiences late life depression
• A family member calls prior to an office visit to inform the physician of
concerns the patient may not mention
VOLUME 18 NUMBER 1
The treatment of dementia
Summary
• Dementia is a distressing and disabling condition affecting about 700,000 people in the
UK. It is associated with high health and social care costs. The most common cause of
dementia is Alzheimer’s disease.
• A guideline issued by the National Institute for Health and Clinical Excellence (NICE) and
the Social Care Institute for Excellence (SCIE) provides the framework on which the
delivery of health and social care services should be based for the support of patients
with dementia and their carers in England and Wales. In this Bulletin, only the
recommendations for the treatment of symptoms of dementia (both cognitive and non-
cognitive) are reviewed in detail.
• Although there is only limited evidence to support the use of non-drug interventions, the
NICE-SCIE guideline recommends that people with any type of mild-to-moderate
dementia should be given the opportunity to participate in a structured group cognitive
stimulation programme, irrespective of any drug prescribed for the treatment of their
cognitive symptoms.
• Evidence for the use of drugs in dementia comes mainly from industry-sponsored,
randomised, placebo-controlled trials in Alzheimer’s disease; there are few studies
comparing one drug with another.
– On a population basis, acetylcholinesterase inhibitors (AChIs: donepezil,
galantamine and rivastigmineq) and memantine demonstrate a modest, statistically
significant effect to improve/delay the deterioration in cognitive decline. However,
the drugs are associated with adverse effects, and it is not possible at present to
predict which individual people with dementia will gain any meaningful benefit from
them with regard to their day-to-day functioning and quality of life.
– Based on a detailed cost-effectiveness analysis, NICE guidance recommends that
AChIs are restricted to the subgroup of people with moderate Alzheimer’s disease
(Mini Mental State Examination [MMSE] score of 10–20 points), and that
memantine is only used in moderate-to-severe Alzheimer’s disease within well
designed clinical trials.
• People with dementia who develop non-cognitive symptoms or behaviours that challenge
should only be offered drug treatment ahead of non-drug interventions if they are
severely distressed or there is immediate risk to themselves or others.
– Benefits of antipsychotics are offset by an increased risk of cerebrovascular events
and death, but can be used after full discussion of the risks/benefits with the person
with dementia and/or their carers, and with frequent reviews.
– AChIs are an option for people with Alzheimer’s disease or dementia with Lewy
bodies (any severity) with non-cognitive symptoms causing significant distress,
where non-drug treatments or antipsychotics are inappropriate or ineffective.
However, they should only be used in vascular dementia as part of a clinical trial.
What is dementia? character behaviour. As the condition

progresses, people with dementia can present
Dementia is a progressive and largely irreversible carers and social care staff with complex
clinical syndrome that is characterised by a problems including aggressive behaviour,
widespread impairment of mental function. restlessness and wandering, eating problems,
Symptoms may include memory loss, language incontinence, delusions and hallucinations, and This publication was
impairment, disorientation, changes in mobility difficulties that can lead to falls and correct at the time of
personality, difficulties with activities of daily living, fractures.1 Dementia is one of the main causes of preparation:
self-neglect, psychiatric symptoms and out-of- disability in later life.2 November 2007
This MeReC Publication is produced by the NHS for the NHS
MeReC Bulletin Volume 18, Number 1 1

Types of dementia assessment of dementia can be found in the

NICE-SCIE guideline.1
Alzheimer’s disease is the cause of most cases
of dementia, accounting for about 60% of all How common is dementia?
cases.3 It is a degenerative cerebral disease,
with insidious onset, which is characterised by a Dementia affects about 700,000 people in the
slow progressive decline in cognition and ability UK (about 1.1% of the entire population), and
to function. Vascular dementia and dementia is forecast to increase by 38% over the next 15
with Lewy bodies (DLB) are responsible for most years.2 Age is the greatest risk factor for
other cases of dementia, although mixed cases dementia. About two-thirds of people with
(e.g. Alzheimer’s disease and vascular dementia are aged over 80 years, and one-
dementia) are commonly encountered, sixth over 90 years. Onset is rare in people
especially in older people. under the age of 65 years (termed early- as
opposed to late-onset dementia), accounting
Vascular dementia usually arises from multiple for about 2% of cases. There are about twice
infarcts or generalised small vessel disease. It as many women with late-onset dementia as
has a more sudden onset than Alzheimer’s men. About two-thirds of people with late-
disease. DLB shares many of the features of onset dementia live in private households, with
Alzheimer’s disease and Parkinson’s disease, the remainder in care homes.2
and, like Alzheimer’s disease, is slowly
progressive. Dementia also develops in about What is the financial cost of dementia?
30% to 70% of people with Parkinson’s
disease.3 Dementia is associated with high healthcare
and social costs. A recent review estimated the
Problems with memory which do not meet the total costs of late-onset dementia to be £17
diagnostic criteria for dementia, usually called billion per year (about £25,000 per person with
mild cognitive impairment (MCI), can be the first late-onset dementia per year). Accommodation
sign of an impending dementia, particularly accounted for 41% of these costs, informal
Alzheimer's disease. care costs (input from family members and
other unpaid carers) 36%, social service costs
Although vascular dementia is related to 15%, and NHS costs 8%.2
cardiovascular (CV) risk factors (e.g. smoking,
diabetes, hypertension, hyperlipidaemia), the National strategy and guidelines for
causes of other forms of dementia are unclear. dementia
Diagnosis of dementia There is currently a generally low level of

public and professional understanding of
Currently only a third of people with dementia dementia. There is widespread misattribution
receive a formal diagnosis at any time during to “old-age” and a resultant unwillingness by
their illness, and when made it may be too late some of those suffering from dementia, and
for those suffering from the illness to make their families to seek help.4 There is also a real
informed choices.4 problem of stigma and fear associated with the
disorder, which can delay early diagnosis and
There is insufficient evidence of benefit to access to good quality health care. Improving
justify population screening in primary care. awareness, providing early diagnosis and
However, there is some evidence that early appropriate interventions, and improving the
recognition and active therapy at the point quality of care for dementia, are the focuses of
where there is a sharp decline in cognitive a national dementia strategy work programme
function delays the subsequent need for announced by the Government in August 2007
nursing home care, and reduces the risk of (see www.dh.gov.uk for more details).
misdiagnosis and inappropriate management.3
In November 2006, NICE in collaboration with
Many conditions apart from dementia can SCIE issued a clinical guideline, which
present with cognitive impairments, and provides the framework on which the delivery
comprehensive assessment with appropriate of health and social care services for the
investigations are necessary to arrive at a support of patients with dementia and their
diagnosis of dementia.3 As more than 50% of carers should be based. It makes
people with MCI later develop dementia, recommendations to ensure that all people
primary healthcare staff should consider with dementia have fair access to assessment,
referring people who show signs of MCI for care and treatment on the basis of need,
assessment by memory assessment services irrespective of their age, gender, and social or
to aid early identification and diagnosis of cultural background.
specific subtypes. Assessment will include
formal cognitive assessment using a The guideline includes advice on identification,
standardised instrument, such as the Mini treatment and care of people with all types of
Mental State Examination (MMSE). Further dementia, and support of carers. It covers
details with regard to the diagnosis and primary care, secondary care and social care
2 MeReC Bulletin Volume 18, Number 1

settings. Guidance is given on diagnosis/ moderate quality RCTs (n=1,132) of

assessment and the interventions (drug and psychosocial interventions in people with
non-drug) that can be considered for the dementia.3 Cognitive stimulation was the
treatment of dementia, including cognitive only intervention with reasonable evidence (6
symptoms, non-cognitive symptoms and trials, n=299, treatment duration 4 to 24 weeks)
comorbid conditions. Further advice is given for improving cognitive symptoms (various
on inpatient services, palliative care, and measures: standardised mean difference
support and interventions for the carers of [SMD] –0.40, 95% confidence interval [CI]
people with dementia.1 –0.63 to –0.18) and quality of life (Quality of life
– Alzheimer’s disease scale: SMD –0.39,
It is beyond the scope of this Bulletin to review 95%CI –0.68 to –0.11). It also appeared to add
all the recommendations of the NICE-SCIE to the effects of donepezil in both mild and
guideline for dementia, which can be moderate Alzheimer’s disease. The NICE-
accessed online at www.nice.org.uk/guidance/ SCIE guideline recommends that all people
cg42. This Bulletin focuses on the treatment of with mild-to-moderate dementia (all types)
dementia, and the evidence supporting the should be given the opportunity to participate in
use of drug and non-drug options. a structured group cognitive stimulation
programme, irrespective of any drug
Prevention and treatment of dementia prescribed for the treatment of their cognitive
symptoms.1
Although many approaches have been
suggested, there is no known way to prevent Psychotic symptoms and behavioural
dementia, except possibly for vascular disturbances are common in people with
dementia, when it is reasonable to expect that dementia, and range from agitation, anxiety and
risk can be reduced by maintaining a healthy depression to hallucinations and aggression.
lifestyle5 and by interventions targeting CV These features are important as they cause
risk. Middle aged and older people should be particular distress to patients, place burden on
reviewed for vascular and other modifiable risk carers, are associated with more rapid cognitive
factors for dementia (e.g. smoking, excessive decline and promote institutionalisation.6 The
alcohol consumption, obesity, diabetes, NICE-SCIE guideline recommends that people
hypertension and raised cholesterol) and who develop non-cognitive symptoms should
treated where appropriate.1 In the absence of be offered an assessment at an early stage to
good clinical trial evidence, NICE-SCIE establish likely factors that may generate,
guidelines recommend not using statins, aggravate or improve behaviours, and they
hormone replacement therapy, vitamin E, or should have individual care plans.1
non-steroidal anti-inflammatory drugs as
specific treatments for the primary prevention A systematic review (162 studies) of
of dementia.1 psychological approaches to the management
of non-cognitive symptoms of dementia was
In most cases, dementia is progressive and published in 2005.7 It concluded that
incurable, and interventions are used to behavioural management therapies, specific
relieve symptoms and improve quality of life of types of caregiver and residential care staff
patients and their carers. Deterioration in education, and possibly cognitive stimulation
cognitive symptoms is a core symptom of were effective for the management of these
dementia, and this has been the major target symptoms. Conclusions on the benefits of other
of drug trials in dementia. However, changes interventions were limited by the paucity of high
in functional ability (activities of daily living), quality research studies.7
disturbances in behaviour and mood, and
comorbid emotional disorders are also Non-drug approaches should be considered
important and can have considerable effects ahead of drug treatment for people with
on the quality of life of patients and their behavioural and psychological symptoms (see
carers. section on drug treatment below), unless they
are severely distressed or there is an
Non-drug treatments immediate risk of harm to the person or
others.1,6 Non-drug approaches that can be
A wide range of psychological interventions are considered for people with less intense
available in the UK for people with dementia, distress/agitation include aromatherapy,
although their availability varies greatly. multisensory stimulation, therapeutic use of
Evidence to support the use of non-drug music and/or dancing, animal-assisted therapy
interventions is limited by an absence of large and massage. There are some promising
randomised controlled trials (RCTs), difficulties indications that family carers may be able to
of blinding and providing an appropriate use a behavioural approach, including problem
placebo, and the lack of standardisation in solving, with some success.3
therapies.
Non-drug therapies may be helpful for people
The systematic review carried out for the NICE- with dementia who have comorbid emotional
SCIE guideline identified 19 small, low-to- disorders, such as depression and anxiety. The

NICE-SCIE guideline recommends that a range guidance limits the prescribing of AChIs to
of psychological interventions (e.g. reminiscence people with moderate dementia in Alzheimer’s
therapy, multisensory stimulation, animal- disease and restricts use of memantine (and
assisted therapy and exercise) and cognitive AChIs for other forms of dementia) to use in
behavioural therapy (CBT) should be considered clinical trials (see Panel 1 on page 5). The NICE
for depression and/or anxiety.1 CBT is a TAG 111 recommendations restricting the use
recognised treatment for depression and anxiety, of AChIs in Alzheimer’s disease were
and may be delivered in outpatient or other challenged unsuccessfully by a number of
community settings on an individual or group pharmaceutical companies, medical and patient
basis, and may involve the active participation of organisations, firstly through the NICE appeal
carers.1 process and then by judicial review. However,
amendments were made to the guidance
For patients with a major depressive disorder, regarding the use of the MMSE to ensure that
antidepressants should be considered according people from different ethnic/cultural
to the NICE guideline for depression8 after a backgrounds, and people with disabilities, have
careful risk-benefit assessment. However, equal access to treatment.11 The NICE
antidepressants with anticholinergic effects, guidance, which is now national policy, should
which may adversely affect cognition, should be be the basis on which prescribing practices for
avoided.1 dementia in the NHS are based.
Carers of people with dementia are at high risk A review of the evidence for the use of drugs
of psychological morbidity and associated in the treatment of the cognitive symptoms of
breakdown in care. A recent systematic review dementia can be found in an Appendix to this
of psychological interventions found that the use Bulletin.
of individual behavioural management therapy
centred on the care recipient's behaviour was Adverse effects of drugs
effective in alleviating caregiver symptoms both
immediately and for up to 32 months. Teaching Anti-dementia drugs can produce a wide range
caregivers coping strategies, either individually of side effects (see the Summaries of Product
or in a group, also appeared effective in Characteristics [SPCs] at www.medicines.
improving caregiver psychological health, both org.uk for details), and these need to be
immediately and for some months afterwards.9 considered when deciding on the most
appropriate treatment. Common side effects
Drug treatments include nausea, vomiting, diarrhoea, anorexia,
headache, and dizziness with AChIs, and
Only a few drugs are licensed for the treatment constipation, headache, hypertension,
of dementia. Donepezil, galantamine, and dizziness and drowsiness with memantine.12
rivastigmineq are acetylcholinesterase
inhibitors (AChIs) licensed for the treatment of A meta-analysis of 16 clinical trials (n=7,954)
mild-to-moderate dementia. Memantine, an N- found that significantly more patients given
methyl d-aspartate receptor antagonist, is AChIs suffered adverse side effects (mean
licensed for treating moderate to severe difference: 8%, 95%CI 5% to 11%) and
dementia resulting from Alzheimer’s disease. withdrew because of adverse effects (mean
Rivastigmine is also licensed for treatment of difference: 7%, 95%CI 3 to 10%) compared
mild-to-moderate dementia in Parkinson’s with placebo. Donepezil appeared to be
disease. associated with fewer adverse events than
rivastigmine and galantamine (mean difference
There is considerable and ongoing debate vs. placebo: 6% vs. 8% vs. 12%, respectively)
surrounding the use of these drugs in and for dropouts due to adverse events (mean
dementia. Although they may produce clinically difference vs. placebo: 2% vs. 9% vs. 14%).
significant improvements in quality of life for However, CIs of these estimates were wide,
some patients and their carers, it is currently and higher than recommended doses of
not possible to identify reliably who will gain a galantamine were used in some of the studies.13
worthwhile benefit from their use. On a
population basis, evidence from clinical trials A pooled-analysis of eight six-month clinical
suggests a modest benefit in improving and/or trials in dementia identified no significant
delaying the progression of cognitive decline. differences between memantine and placebo in
However, these benefits may not necessarily the number of patients who experienced at least
correlate with outcomes that are important to one adverse event (72.8% vs. 73.1%; odds
patients, such as activities of daily living.10 ratio [OR] 1.09, 95%CI 0.93 to 1.27; P=0.31).
Significantly fewer patients taking memantine
The use of the AChIs and memantine for experienced agitation as an adverse event
Alzheimer’s disease was the subject of NICE (7.7% vs. 9.3%; OR 0.78, 95%CI 0.61 to 0.99;
technology appraisal guidance (TAG) 111.11 This P=0.04). Data on other adverse events were
was originally published at the same time as the not available for all the studies, although
NICE-SCIE clinical guideline on dementia,1 individual studies reported more somnolence,
which incorporated its recommendations. The constipation, or hypertension with memantine.14

Panel 1: Drug treatments for dementia: cognitive symptoms and maintenance of function11
• Consider the AChIs (donepezil, galantamine and rivastigmine) for moderate Alzheimer’s disease (an MMSE score of
10–20 points) only.*
• Treatment should be started by a specialist in dementia care. The specialist should:
– seek carers’ views on the condition of the person with dementia at baseline
– start therapy with the least expensive drug taking into account daily dose and price per dose
– consider an alternative AChI if the adverse-event profile, concordance issues, comorbidities, possible drug
interactions and dosing profiles suggest it is appropriate
– review MMSE score and global, functional and behavioural assessment every 6 months, and seek carers’ views
on the condition of the person with dementia at follow-up
– continue treatment if the MMSE score remains at or above 10 points and global, functional and behavioural
condition indicates worthwhile effect.
• Any review involving MMSE assessment should be undertaken by an appropriate specialist team, unless there are
locally agreed protocols for shared care.
• Do not use memantine in people with moderately severe-to-severe Alzheimer’s disease except as part of well
designed clinical studies.
• People with mild Alzheimer’s disease currently receiving an AChI, and those with moderately severe-to-severe
Alzheimer’s disease currently receiving memantine, may continue to receive the treatment until they, their carers
and/or specialist consider it appropriate to stop.
• AChIs or memantine should only be prescribed for cognitive decline in people with vascular dementia as part of a
properly conducted clinical study.1
*The NICE guideline advises healthcare professionals of a number of situations (e.g. people with learning or other
disabilities, or language difficulties) where the MMSE score should not be relied on, and suggests other methods are
used for assessment of the severity of disease (see NICE guideline11 for details).
Cost-effectiveness of AChIs and memantine fatigue and urinary symptoms (see SPCs for
in Alzheimer’s disease details).
The economic analysis carried out for the NICE In March 2004, the Committee on Safety of
TAG 111 identified that, for people with Medicines (CSM) advised that olanzapine and
moderate dementia, AChIs were associated risperidone should not be used for the
with a cost per quality adjusted life year (QALY) treatment of behavioural symptoms of
gained of £23,000 to £35,000, depending on dementia; there was clear evidence of an
the choice of drug. For mild dementia, increased risk of stroke in elderly patients with
estimates were from £56,000 to £72,000 per dementia, and the risk was considered
QALY gained. For memantine, the cost per sufficient to outweigh likely benefits.18 A meta-
QALY gained for treating people with analysis of four placebo-controlled RCTs in
moderately severe-to-severe dementia was elderly patients (n=1,779) with dementia
estimated as £70,000 to £90,000, depending on carried out by the MHRA identified a three-fold
the patient group or subgroup.11 increase in the risk of stroke or transient
ischaemic attack (TIA) with risperidone (OR
These findings were reflected in the final NICE 3.32, 95%CI 1.43 to 7.70).18 The CSM also
guidance, which considered that treatment of advised that if risperidone was used for the
people with moderate dementia, but not mild management of acute psychotic conditions in
dementia, with AChIs was cost-effective within elderly patients with dementia this should be
the NHS. Further details of the cost- short-term and under specialist advice. Those
effectiveness analyses can be found in NICE patients already being treated with an atypical
TAG 111, which is available on the NICE drug were recommended to have their
website (http://guidance.nice.org.uk/TA111).11 treatment reviewed.18
Drug treatment of behavioural and A meta-analysis of 15 RCTs (n=5,110),

psychological symptoms of dementia generally 10 to 12 weeks in duration, including
(BPSD) 16 contrasts of atypical antipsychotic drugs with
placebo, found that death occurred more often
Antipsychotics among patients randomised to drugs (3.5% vs.
Systematic reviews of drug treatment for BPSD 2.3%; OR 1.54, 95%CI 1.06 to 2.23; P=0.02).17
have confirmed a modest yet statistically
significant efficacy for atypical antipsychotics, A review by the European Pharmacovigilance
including risperidone, olanzapine, quetiapine Working Party found that the risk of
and aripiprazole, although any benefit is offset cerebrovascular events associated with other
by the possibility of adverse effects, which can antipsychotics was not significantly different
be serious and require discontinuation, and may from that of olanzapine and risperidone, and
even be fatal.15–17 Adverse effects include weight they advised inclusion of a warning about a
gain, cardiovascular symptoms, extrapyramidal possible risk of these events in the SPCs for all
symptoms, sedation, neurological symptoms, typical and atypical antipsychotics.19

A Canadian cohort study of 37,241 elderly according to need). Antipsychotics should not
people who were prescribed antipsychotic be prescribed to people with mild-to-moderate
medication identified a greater risk of dying DLB, as these people are particularly at risk of
within 180 days of treatment with typical serious adverse effects.1
compared with atypical antipsychotics (14.1%
vs. 9.6%; mortality ratio 1.47, 95%CI 1.39 to Where non-cognitive symptoms are causing
1.56).20 them significant distress AChIs should be
offered to people with DLB and they are an
Acetylcholinesterase inhibitors option for people with Alzheimer’s disease
Some studies have shown that AChIs may where non-drug treatments or antipsychotics
produce a small yet statistically significant are inappropriate or ineffective. AChIs should
improvement in non-cognitive symptoms of only be used in vascular dementia as part of a
dementia.15 However, a recent RCT of 272 clinical trial.1
patients with Alzheimer's disease, who had
clinically significant agitation and no response to Additional resources
a brief psychosocial treatment program, found
that donepezil 10mg daily for 12 weeks was no NICE-SCIE clinical guidelines for dementia
more effective in reducing agitation than placebo and the NICE TAG 111 for donepezil,
(difference in change of Cohen–Mansfield galantamine, rivastigmine and memantine for
Agitation Inventory scores –0.06, 95%CI –4.35 the treatment of Alzheimer’s disease, and their
to 4.22).21 The cost-effectiveness of AChIs in the associated implementation tools and costing
treatment of people with dementia with severe templates, can be found on the NICE website
non-cognitive symptoms has not been (www.nice.org.uk).
established.3
The Dementia Knowledge Week (Later Life
NICE-SCIE guideline Specialist Library of the National Library for
The NICE-SCIE guideline recommends that Heath, June 2007) contains extensive
people with dementia who develop non- additional information on dementia, pooled
cognitive symptoms or behaviour that from a variety of sources (www.library.
challenges should be offered a pharmacological nhs.uk/laterlife/ViewResource.aspx?resID=26
intervention in the first instance only if they are 2532). Included are listings of the systematic
severely distressed or there is an immediate reviews, meta-analyses and other reviews
risk of harm to the person or others.1 relating to the treatment of dementia, including
internet links to these and other sources of
Drug treatment with an antipsychotic should information.
only be offered after a full discussion with the
patient and/or their carers about the risks and Additonal patient-orientated information can
benefits, especially the risk of stroke/TIA and be found on the websites of charities such as
possible adverse effects on cognition. The dose the Alzheimer’s Society (www.alzheimers.
of antipsychotic should be low initially and org.uk) and Help the Aged (www.helptheaged.
titrated upwards, and treatment time-limited and org.uk).
regularly reviewed (every three months or

References
1. National Institute for Health and Clinical Excellence and 16. Shekelle P, Maglione M, Bagley S, et al. Efficacy and
Social Care Institute for Excellence. NICE clinical comparative effectiveness of off-label use of atypical
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and their carers in health and social care. November Agency for Healthcare Research and Quality. January
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10/09/07 17. Schneider LS, Dagerman KS, Insel P. Risk of death with
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provides NICE with the ability to secure value for money in the use of NHS funds invested in its work and enables it to influence topic selection, methodology
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inform decisions on service organisation and delivery. This publication represents the views of the authors and not necessarily those of the Institute.
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DEMENTIA

• Dementia is NOT a normal part of aging

1. Memory loss – The individual may repeat questions or statements, misplace

2. Difficulty with understanding language and/or using language – The

4. Executive functions/Cognitive and perceptual skills decline – The individual

5. Emotional/personality changes may appear -- An individual may show

Dementia is NOT a disease:

Many other things can CAUSE dementia-like symptoms BESIDES dementia:

HOW CAN YOU TELL WHAT IS NORMAL (AND WHAT IS NOT?)

Some evaluative procedures:

Alzheimer Disease Prion Dementias (CJD, GSS, etc.)

What are the possible treatments?

HOW DO I TALK TO A PERSON WITH DEMENTIA?

Stop and Receive the Other Person’s Communication:

If a Person Can Not Find the Right Word:

If a Person Digresses or Loses Their Train of Thought:

Improve Your Own Verbal Communication:

If a Person is Having Trouble Understanding You:

When Asking Questions:

When Giving Instructions:

Improving Your Nonverbal Communication:

Additional Things to Remember:

• A person in the early stages of dementia has many remaining abilities

In this module, learn about clinical diagnosis of dementia and:

The key elements of the physical exam include:

Brain imaging (CT or MRI) is generally recommended in the evaluation of early or

• The MMSE, BIMC, BOMC, and STMS are roughly equivalent.

• Testing “category fluency” – asking the patient to name as many items as

Neuropsychological testing is the most definitive standard for diagnosis of early

Performance on neuropsychological testing is influenced by many factors, including

1. MMSE or other cognitive assessment is normal, but a family member

Referral to a clinician with dementia expertise (geriatrician, neurologist, or psychiatrist)

• Age less than 65

Clinical Diagnosis – Differential Diagnosis

Dementia can be broadly defined as a syndrome in which memory loss is

Vascular dementia http://neurology.org/cgi/content/abstract/43/2/250

Mild Cognitive Impairment vs. Dementia

Signs of Normal Aging Compared with Signs of Dementia

NORMAL AGING DEMENTIA

Occasionally misplacing items Frequently misplacing items

Occasionally forgetting a word Frequent inability to come up with words,

• Performs poorly on formal memory tests, even in comparison to people of

As in the case of Alzheimer’s and related disorders, physicians should be careful to

Delirium occurs with increasing frequency in advancing age, and dementia is a

Reversibility Reversible Irreversible;

Orientation Disoriented Not impaired

Consciousness Fluctuates; Intact

Attention Impaired Normal

Memory Confused Short-term losses

Cognitive deficits Variable Consistent

Psychomotor Hyperactive Normal

Depression and Dementia

Mood Low most of the day, Fluctuates without

Physical May be prominent – Uncommon

Cognitive loss Fluctuates Stable and progressive

Memory loss Apathy – short and Short-term memory

Effort on tasks Low Normal

Geriatric Depression Scale (Short Form)

Are you basically satisfied with your life? Yes No*

Each answer marked by an asterisk counts as one point.

The GDS has 15 yes-or-no questions on a form designed to be self-administered and

Any patient with depression should be evaluated for underlying dementia.

Major Types of Dementia

Date: _ Time: ___