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Help the patient and family recognize and accept the illness and its limitations.

  • Suggest pragmatic coping strategies such as making lists, using a calendar, and avoiding overwhelming situations.

  • Consider referring the patient to health promotion activities and recreation clubs.

  • Identify specific impairments and highlight remaining abilities.

  • Provide psychotherapeutic interventions for patients struggling with the diagnosis.

  • Address caregiver well-being, driving, and legal and financial issues, as already described.

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Offer patients with early Alzheimer's disease a trial of donepezil, galantamine, or rivastigmine.

  • These three cholinesterase inhibitors are approved by the U.S. Food and Drug Administration (FDA) for the treatment of the cognitive symptoms of mild to moderate Alzheimer's disease and are commonly used.

  • Given the possible risks of long-term high-dose vitamin E and selegiline and the minimal evidence for their benefit, they are no longer recommended. Nonsteroidal anti-inflammatory agents, statin medications, and estrogen supplementation have shown a lack of efficacy and safety in placebo-controlled trials in patients with Alzheimer's disease and therefore are not recommended.

  • A cholinesterase inhibitor should also be considered for patients with mild to moderate dementia associated with Parkinson's disease. Only rivastigmine has been FDA approved for this indication, but there is no reason to believe the benefit is specific to rivastigmine.

  • A cholinesterase inhibitor can be considered for patients with dementia with Lewy bodies.

  • The constructs of mild cognitive impairment and vascular dementia are evolving and have ambiguous boundaries with Alzheimer's disease. The efficacy and safety of cholinesterase inhibitors for patients with these disorders is uncertain; therefore, no specific recommendation can be made at this time, although individual patients may benefit from these agents.

  • There is some evidence of the benefit of memantine in mild Alzheimer's disease and very limited evidence of its benefit in vascular dementia.

  • Patients may be interested in referrals to local research centers for participation in clinical trials of experimental agents.

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Evaluate for depression and treat if present.

  • The best approach to diagnosing depression co-occurring with dementia is not yet clear. In addition to the symptoms outlined in DSM-IV-TR, irritability, social withdrawal, and isolation may indicate depression needing treatment. Symptoms may be unstable and fluctuate over time.

  • Conditions that may cause or contribute to depression include other psychiatric disorders (e.g., alcohol or sedative-hypnotic dependence), other neurologic problems (e.g., stroke, Parkinson's disease), general medical problems (e.g., thyroid disease, cardiac disease, cancer), and the use of certain medications (e.g., corticosteroids, benzodiazepines).

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Treatment

  • Depression may worsen cognitive impairment associated with dementia. Therefore, one goal of treating depression in dementia is to maximize cognitive functioning. Treatment of depression may also reduce other neuropsychiatric symptoms associated with depression such as aggression, anxiety, apathy, and psychosis.

  • Clinical consensus supports a trial of an antidepressant to treat clinically significant, persistent depressed mood in patients with dementia. Selective serotonin reuptake inhibitors (SSRIs) may be preferred because they appear to be better tolerated than other antidepressants. Alternative agents to SSRIs include but are not limited to venlafaxine, mirtazapine, and bupropion.

  • Electroconvulsive therapy (ECT) may be considered for patients with moderate to severe depression that is life-threatening or refractory to other treatments.

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Evaluate for sleep disturbance and treat if present.

  • Sleep problems have been reported in 25%–50% of patients with dementia. Major causes include physiological changes associated with aging, pathological involvement of the suprachiasmatic nucleus, the effects of co-occurring medical or psychiatric disorders or medications, untreated pain, and poor sleep hygiene. Cholinesterase inhibitors can also cause insomnia.

  • Some over-the-counter sleep medications (e.g., diphenhydramine) can contribute to delirium and paradoxically worsen sleep. Thus, it is important to ask if the patient is using over-the-counter or herbal preparations to treat sleep disturbance and to recommend discontinuance of diphenhydramine if it is being used.

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Treatment

  • Treatment goals include decreasing the frequency and severity of insomnia, interrupted sleep, and nocturnal confusion; increasing patient comfort; decreasing disruption to families and caregivers; and decreasing nocturnal wandering and nighttime accidents.

  • When sleep disturbance is an isolated problem, clinical practice favors beginning with nonpharmacological approaches, such as training caregivers in the importance of sleep hygiene, establishing regular sleep and waking times, limiting daytime sleeping, avoiding fluid intake in the evening, establishing calming bedtime rituals, and providing adequate daytime physical and mental activities.

  • Underlying medical and psychiatric conditions that could disturb sleep should be evaluated and treated. Medications that could interfere with sleep should be adjusted if possible.

  • Pharmacological treatment should be instituted only after other measures have been unsuccessful and the potential benefits outweigh the risk of side effects. It is particularly important to identify sleep apnea, which may affect 33%–70% of patients with dementia. This condition is a relative contraindication to the use of benzodiazepines or other agents that suppress respiratory drive.

  • If another behavioral or neuropsychiatric condition is present and medications used to treat that condition have sedative properties, clinical practice favors prescribing that agent at bedtime, if appropriate (e.g., an antidepressant with sedative properties, a second-generation antipsychotic).

  • Pharmacological interventions include trazodone or a non-benzodiazepine hypnotic such as zolpidem or zaleplon. Benzodiazepines may be used but are generally recommended only for short-term sleep problems because of the possibility of tolerance, daytime sleepiness, rebound insomnia, worsening cognition, falls, disinhibition, and delirium. Rebound insomnia and daytime sleepiness can occur with any of these agents. Triazolam is not recommended for individuals with dementia because of its association with amnesia.

References

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