Assess whether the patient requires supervision to remain safe.

  • Safety issues should be addressed at every evaluation.

  • Families should be advised about the possibility of accidents (e.g., fires while cooking), difficulties coping with household emergencies, and wandering.

  • Family members should also be advised to determine whether the patient is handling finances appropriately and to consider taking over the paying of bills and other responsibilities.

  • At this stage, nearly all patients should not drive, and families should be counseled to undertake measures to prevent patients from driving, as many patients lack insight into the risks.


Address family and caregiver issues (e.g., provide referral for respite care, discuss possible transfer of the patient to a long-term care facility).


Consider treating cognitive symptoms with a combination of a cholinesterase inhibitor plus memantine.

  • Evidence suggests that the combination is more likely to improve cognitive function or delay symptom progression than a cholinesterase inhibitor alone.


Treat psychosis and agitation, which commonly occur in moderately impaired patients.

  • Treatment of psychosis and agitation can increase the comfort and safety of the patient and ease care by the family and other caregivers.

  • Consideration of the risks and benefits of treatment, discussion of these with the patient and caregivers, and documentation of these discussions should precede treatment.

  • If psychotic symptoms cause minimal distress to the patient and are unaccompanied by agitation or combativeness, they are best treated with environmental measures, including reassurance and redirection.

  • If the symptoms do cause significant distress or are associated with behavior that may place the patient or others at risk, treatment with low doses of antipsychotic medication is indicated in addition to nonpharmacological interventions. Treatment with an antipsychotic medication is also indicated if a patient is agitated or combative in the absence of psychosis, because antipsychotics have the most support in the literature. However, the potential benefits of antipsychotic medications need to be weighed against the potential for increased mortality when they are used by individuals with dementia.

  • When antipsychotics are ineffective, carbamazepine, valproate, or an SSRI may be used in a careful therapeutic trial. If behavioral symptoms are limited to specific times or settings (e.g., a diagnostic study), or if other approaches fail, a low-dose benzodiazepine may prove useful, although side effects in the elderly can be problematic. Although mood stabilizers and SSRIs are commonly used in clinical practice to treat agitation, delusions, and aggression, they have not been consistently shown to be effective in treating these symptoms, nor is there substantial evidence for their safety. Thus, in making decisions about treatment, these agents should not be seen as having improved safety or comparable efficacy compared with antipsychotic medications.

  • As a dementing illness evolves, psychosis and agitation may wax and wane or may change in character. As a result, the continued use of any intervention for behavioral disturbances or psychosis must be evaluated and justified on an ongoing basis.


Assess and treat depression and sleep disturbance, if present, using strategies already described.


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