Further Outpatient Care
Workup for most cases of newly recognized dementia can be completed in an outpatient setting. In some cases, admission is needed until an appropriate living situation or a nursing home placement is arranged.
Further Inpatient Care
All patients with unresolved delirium require admission and often require telemetry or ICU care.
Inpatient & Outpatient Medications
Outpatient medications for primary dementia are coordinated best by health care providers who have continuing contact with the patient. Medications may include the following:
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Anticholinesterase inhibitors, such as donepezil (Aricept), galantamine (Razadyne), and rivastigmine (Exelon): These medications are useful early in the disease course, but they lose their effectiveness or may worsen mental status in advanced stages of the disease.
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N -methyl D -aspartate (NMDA) receptor antagonists, including memantine (Namenda)
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Antidepressants, especially the selective serotonin reuptake inhibitors or bupropion. Avoid tricyclic antidepressants because of their anticholinergic properties which can worsen dementia.
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Benzodiazepines for sedation or sleep. However, these drugs may worsen cognitive deficits, increase the risk of falls and are best avoided if possible.
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Antipsychotics for psychotic ideation or aggressive behavior: High-potency agents are preferred. Risperidone (Risperdal), a newer atypical antipsychotic, is well tolerated and useful for sundowning. However, the atypical antipsychotics as a group have been associated with a slightly higher death rate in patients with dementia (3.5% vs. 2.3% for placebo). Despite a US Food and Drug Administration (FDA) black box warning, experts warn against abandoning this class of medications in the treatment of dementia-related psychosis and aggression.
Deterrence/Prevention
Various substances to prevent or retard the onset of dementia have been proposed and/or studied. Prevention mechanisms have included preservation of CNS supporting cells, prevention of CNS inflammation, or free-radical inhibition. Unfortunately, no supplement or medication has been conclusively shown to prevent or retard the progression of dementia.
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Vitamin E: The suggested dose for prevention is 200-400 IU/d; much higher doses are sometimes given for treatment. The mechanism of action may be antioxidant, free-radical inhibition. Efficacy is controversial and vitamin E can increase mortality risk. Therefore, should only be considered for patients with AD or at high risk for AD.
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Vitamin B-6, vitamin B-12, and folate: These reduce levels of homocysteine, a potential brain neurotoxin. Efficacy is controversial and recent studies show no benefit.
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Statin cholesterol-lowering medications: Reports suggest that these drugs substantially protect against dementia via an effect not related directly to blood levels of cholesterol. Mechanisms of action may be reduction of insulin levels in the brain and/or C-reactive protein (CRP) levels in the blood (indicative of inflammation). A study of more than 17,000 adults older than 60 years in Finland concluded that statins appeared to reduce risk by 58%. [15] Other studies have found no benefit to statins in delaying dementia progression in patients with AD.
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Estrogen replacement: This is being studied, but no evidence of benefit has been found at present.
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Ginko biloba: This is a medicinal herb considered safe but of questionable efficacy. Preparations are of uncertain purity and dose consistency.
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High caloric intake in concert with obesity and sedentariness is associated with an increased risk of Alzheimer disease.
Undertreated depression, hypertension, diabetes mellitus, hypercholesterolemia and obesity have all been associated with higher risk of Alzheimer disease.
Excessive amounts of alcohol act as a neurotoxin and can increase Alzheimer disease risk. In moderate doses, alcohol inhibits cerebrovascular disease although it may still enhance brain atrophy. However, recent studies suggest that moderate drinking is protective against dementia as compared with abstinence. Antioxidants in wine (bioflavonoids) may be additionally beneficial (over spirits and beer).
Sedentary lifestyle is an independent risk factor for dementia. Regular exercise is protective.
Complications
Delirium is a true medical emergency. Failure to recognize and aggressively treat the underlying cause can be catastrophic.
Delayed recognition of dementia can result in trauma secondary to cognitively impaired driving or the use of other hazardous equipment, including cooking stoves.
Patients with dementia are at increased risk of victimization by predatory business practices, Internet scams, and other fraudulent or criminal attacks.
Prognosis
Delirium is fully reversible in most cases with proper recognition and treatment of the etiology. However, some cases of delirium can last weeks or months and can become chronic.
Dementia is usually insidious and relentlessly progressive. However, about 20-30% of cases are due to reversible causes. On average, patients with Alzheimer disease die within 8 years of onset, with a range of 2-15 years. Younger patients usually have a more fulminant course. Pick disease has a similar course.
Subacute encephalopathy, may be reversible, persistent, or progressive.
Patient Education
For excellent patient education resources, visit eMedicineHealth's Brain and Nervous System Center. Also, see eMedicineHealth's patient education articles Dementia Overview, Dementia Medication Overview, and Possible Early Dementia.
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Coronal T1-weighted MRI scan in a patient with moderate Alzheimer disease. Brain image reveals hippocampal atrophy, especially on the right side.
