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Dementia care requires treating patients, supporting caregivers
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Along with treating disease symptoms and addressing coexisting psychiatric and medical conditions, the management of dementia and Alzheimer’s disease requires sensitivity and compassion in providing support and education to patients and their families, according to the American Psychiatric Association’s guideline for Treating Alzheimer’s Disease and Other Dementias.
Assessment of a patient with Alzheimer’s disease or other dementias should include evaluation of the patient’s medical history, current mental status, level of functioning, comorbid conditions and safety, the guideline says. A neurophysical examination may be conducted to distinguish between types of dementias and to determine the degree of cognitive decline.
Caregivers should be informed about the possibility of depression and/or suicidal tendencies at the earlier stages of Alzheimer’s disease or other dementias. Similarly, the clinician should assess the patient’s likelihood of falls, unsafe wandering or other accidents. Decisions regarding an appropriate care setting should be discussed with family members or other providers, and family members should be advised to handle legal or financial matters, as well as document the patient’s advance directive.
For mildly impaired patients at the early stages of dementia, a major goal is to help the patient and family understand and come to terms with the disease. The psychiatrist may suggest some of the following practical strategies for patients with early Alzheimer’s disease or other dementias:
- making lists, using a calendar
- avoiding stressful or overwhelming situations
- joining a recreational or health club
- understanding their impairments and remaining abilities
These patients may be offered a trial of donepezil, galantamine, or rivastigmine, and also may benefit from an antidepressant. Medication for sleep disturbances may be prescribed, but patients should discontinue over-the-counter medications such as diphenhydramine, which may cause delirium and worsen sleep.
For moderately impaired patients, psychiatrists should collaborate with caregivers to ensure the patient’s safety. At each visit, safety issues should be discussed, and the potential need for additional supervision should be addressed. At this stage, patients should not drive.
Patients with moderate impairment may benefit from a combination of a cholinesterase inhibitor and memantine. Psychiatrists also may prescribe an antipsychotic medication to address symptoms of psychosis. Treatment for depression and/or sleep disturbances should be reassessed at this time.
For patients with severe symptoms, memantine and a cholinesterase inhibitor, such as donepezil, may be beneficial. While depression is less common at this stage, it should be treated robustly if present. Additionally, other psychiatric symptoms such as agitation may require treatment. It also is important to provide support and counseling to family members regarding patient care and the eventual loss of their family member.
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