Dementia Cheat Sheet

Author: Daniel Carlat M.D.
Last Updated: 4/1/20

Diagnosis

Memory impairment with gradual onset and decreased functioning, eg:

• Forgetting appointments, birthdays, anniversaries
• Difficulty with instrumental ADLs, such as managing money, grocery shopping, cooking, driving, keeping track of pills.

Do MMSE or MoCA with emphasis on 5 minute recall. Quick screen: Orientation, repeat 3 objects immediately and after intervening task, recite months backwards (for concentation). CDT: “draw the face of a clock and set time to 10 minutes past 11.”

If history and exam are consistent with Alzheimers, order labs to rule out other causes:

Most patients with dementia have Alzheimer’s, (60-80%) and most AD brains will show some elements of “vascular” dementia as well, but try to consider some less common causes:

• Lewy Body dementia (VH)
• Frontotemporal (Disinhibition)
• Parkinson’s (Tremor, stiffness gait issues)

If picture is confusing or atypical (relatively young onset, minimal memory impairment and more exec functioning/personality impairment), order neuropsych testing.

Mild cognitive impairment: defined as objective memory deficits but with no decrement in functioning. 50-70% of these will develop dementia within 5 years.

Other potential causes: Alcohol related dementia, chronic traumatic encephalopathy, normal pressure hydrocephalus. Potential reversible causes of impairment: depression, medication side effects, hypothyroidism, subdural hematoma, neurosyphilis, HIV dementia.

Treatment

Cholinesterase inhibitors stabilize memory for 6-12 months, then decline continues. Treatment interruption will cause patients to decline rapidly to where they would have been with no treatment.

Donepezil (Aricept), start 5 mg daily for a month, then increase to 10 mg and maintain that dose. Can increase to 15 mg or 20 mg. Main limiting side effects: GI issues, vivid dreams.

Sustained-release galantamine, start 8 mg once QAM, then increase to 16 mg, increase to 24 mg if needed. If vivid dreams, switch to immediate-release galantamine, 4 mg QAM, increasing to 8 mg.

Rivastigmine patch option for those with intolerable GI side effects on one of the pills. More expensive and cumbersome, requires a helper to replace it daily. Start with 4.6 mg/24-hour patch and then move up to the 9.5 mg.

Memantine for moderate to severe Alzheimer’s (MMSE <15, MoCA <10).

Evaluating for placement

Options: home, nursing home, assisted living facility. If home, can set up VNA, home health care. Safety issues: Stove use, history of wandering and getting lost, any other dangerous behaviors.

Published on 4/13/2020. Copyright 2020 Inpatient Psychiatry Today.