Managing symptoms and complications of dementia

Management of symptoms and complications of dementia is individualised; it depends on potential benefits and burdens of treatment, and the patient’s prognosis, preferences (including preferred care setting) and goals of care—see also Principles of symptom management in palliative care.

Dementia is characterised by cognitive, communicative and functional decline. Over 90% of patients with dementia experience behavioural change and noncognitive symptoms (known as behavioural and psychological symptoms of dementia [BPSD]), neuropsychiatric symptoms of dementia, or changed or challenging behaviour of dementia, which can significantly affect the patient and their carers. For management of dementia, including cognitive impairment and behavioural and psychological symptoms, see the Psychotropic guidelines. Management of behavioural and psychological symptoms, and differentiating these from other problems especially in the last days of life can be complex; advice from a geriatrician, psychiatrist or palliative care specialist may be required.

Patients experience various other symptoms and problems associated with advancing dementia including breathlessness, anorexia and cachexia and delirium. Approximately 60% of patients with advanced dementia experience pain; it is often underdiagnosed, which causes agitation and distress, and leads to inappropriate antipsychotic use. For advice on assessing pain in patients with cognitive impairment, see Additional considerations when assessing pain in people with impaired cognition. Consider analgesic therapy for mild nociceptive pain as a component of behavioural disturbance management in patients with advanced dementia; a low-dose opioid may be considered, if effective.

Cachexia becomes increasingly common as dementia progresses. Although supporting adequate nutrition and oral intake in advanced disease is appropriate, it may not result in weight gain or improved function. Artificial feeding does not have a role in the palliative care of severe dementia; it does not improve life expectancy, quality of life, function or reduce the risk of aspiration. Consider the potential benefits and burdens of dietary support, and the patient’s prognosis, preferences and goals of care—see also Principles of symptom management in palliative care. Temporary use of parenteral fluid therapy may have a role during periods of transition and acute decline depending on goals of care. Short-term use of parenteral fluids may assist in maintaining temporary stability while further decisions are made or allow time for family members to gather, or help to improve reversible contributors to acute deterioration (such as sepsis or dehydration). If used, discussion of the goals and duration of therapy including plans for discontinuation should also occur. For advice on anorexia, weight loss and cachexia in palliative care, see Anorexia, weight loss and cachexia in palliative care.