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Dementia

Definition
Dementia is a clinical syndrome characterized by a progressive cognitive decline that interferes with the ability to function independently.
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Pathophysiology
Dementia is mostly caused by Alzheimer's disease (60-80%), vascular injury (stroke; 20%), Lewy bodies (5-15%), and frontotemporal impairment (Pick's disease).
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Disease course
Alzheimer's disease, vascular injury, Lewy body deposition, and frontotemporal lobe impairment result in dementia, which causes clinical manifestations of gradual, persistent, and progressive decline in cognition and function. Cognitive deficits may present as memory loss, communication and language impairments, agnosia, apraxia, and impaired executive function (reasoning, judgment, and planning). Dementia progression may lead to behavioral and psychological symptoms including wandering, hoarding, sexual disinhibition, eating inappropriate objects, repetitive behaviors, restlessness, agitation, apathy, aggression, psychosis, hallucinations, and delusions causing considerable distress and safety risk for the patient and their caregivers.
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Prognosis and risk of recurrence
Annual mortality associated with dementia in men and women is 38.3% and 30.5%, respectively.
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Key sources
The following summarized guidelines for the evaluation and management of dementia are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024), the World Health Organization (WHO 2023), the U.S. Preventive Services Task Force (USPSTF 2020), the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018), the American Psychiatric Association (APA 2016; 2007), the Canadian Task Force on Preventive Health Care (CTFPHC 2016), the American Geriatrics Society (AGS 2015; 2014), the Canadian Geriatrics Society (CGS 2012), and the American Academy of Neurology (AAN 2010).
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Guidelines

1.Screening and diagnosis

Indications for screening: as per AAFP 2024 guidelines, insufficient evidence to recommend screening asymptomatic older adults for cognitive impairment.
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  • Screening tools

  • Diagnostic criteria

2.Diagnostic investigations

Initial assessment
As per APA 2016 guidelines:
Assess the type, frequency, severity, pattern, and timing of symptoms in patients with dementia.
B
Assess for pain and other potentially modifiable contributors to symptoms as well as for factors, such as the subtype of dementia, likely to influence treatment choices.
B

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  • Diagnostic imaging (CT)

  • Diagnostic imaging (MRI)

  • Diagnostic imaging (PET/SPECT)

  • Diagnostic imaging (functional MRI)

  • Diagnostic imaging (amyloid imaging)

  • Diagnostic imaging (MRS)

  • Diagnostic imaging (other imaging)

  • Laboratory tests

  • Evaluation of driving risk

3.Medical management

General principles: as per APA 2016 guidelines, provide a documented comprehensive treatment plan including appropriate person-centered nonpharmacological and pharmacological interventions as indicated in patients with dementia.
B

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  • Cholinesterase inhibitors (initiation)

  • Cholinesterase inhibitors (discontinuation)

  • NMDA antagonists

  • Antidepressants

  • Other agents

  • Management of agitation

  • Management of sleep disturbances

4.Nonpharmacologic interventions

Physical activity: advise physical exercise 3-4 times per week for 30-45 minutes for > 12 weeks in patients with dementia.
A

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  • Psychotherapy

  • Psychosocial care for caregivers

  • Driving cessation

  • Long-term care issues

5.Therapeutic procedures

Tube feeding: as per Choosing Wisely 2015 guidelines, avoid percutaneous feeding tubes in patients with advanced dementia; offer oral assisted feeding instead.
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6.Specific circumstances

Patients with early onset dementia: refer all patients with early onset dementia to a memory clinic, preferably one with access to genetic counseling and testing when appropriate.
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  • Patients with rapidly progressive dementia

7.Patient education

General counseling
Educate patients and families about the illness, its treatment, and sources of additional care and support.
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Advise patients and their families of the need for financial and legal planning due to the patient's eventual incapacity.
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8.Preventative measures

Management of hypertension: consider lowering BP in adult patients with hypertension to prevent cognitive decline and dementia.
C

9.Follow-up and surveillance

Indications for specialist referral: obtain head MRI when a radiologist/neuroradiologist and/or a cognitive specialist can interpret patterns of atrophy and other features that may provide added diagnostic and predictive value.
B

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  • Follow-up