D. Severely and Profoundly Impaired Patients

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Consider prescribing memantine or a cholinesterase inhibitor to treat cognitive impairment.

  • Memantine, which is FDA approved for use in patients with moderate and severe Alzheimer's disease, may provide modest benefits and has few adverse events.

  • Donepezil is FDA approved for severe Alzheimer's disease. Galantamine and rivastigmine have not been approved for late-stage disease, but they may be helpful.

  • A brief medication-free trial may be used to assess whether a medication is still providing a benefit.


Assess and treat other psychiatric symptoms.

  • Depression may be less prevalent and more difficult to diagnose, but if present, should be treated vigorously, using strategies already described.

  • Psychotic symptoms and agitation are often present and should be treated pharmacologically if they cause distress to the patient or significant danger or disruption to caregivers or to other residents of long-term care facilities, as already described.

  • Sleep disturbance should be treated as already described.


Ensure adequate nursing care, including measures to prevent bedsores and contractures.


Help the family prepare for the patient's death.

  • Ideally, discussions about feeding tube placement, treatment of infection, cardiopulmonary resuscitation, and intubation will have taken place when the patient could participate. If they have not, it is important to raise these issues with the family before a decision about one of these options becomes urgent.

  • Hospice care can provide physical support for the patient and emotional support for the family during the last months of life. A physician must certify that the patient meets hospice criteria for dementia for hospice benefits to be available.


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