Approach to managing dementia

The approach to managing dementia is primarily supportive and nonpharmacological. A framework to care for patients with dementia provides a framework to collaborate with the patient and their significant others (or carers) to provide holistic patient-centred care by identifying and addressing goals and requirements.

Table 1. A framework to care for patients with dementia
[NB1] [NB2]
Care target	Intervention
Ensure the patient understands their dementia diagnosis	Provide the patient with as much information as they wish to know about dementia; encourage them to visit the Dementia Australia website or contact the National Dementia Helpline 1800 100 500 for advice including information about support and services.
Reduce the impact of cognitive and functional decline on day-to-day life [NB3]	Determine and address the patient’s unmet needs (eg organise additional help with personal care or more complex activities of daily living). Adapt the patient’s environment to their needs and consider changes to assist them to live at home as long as possible. Encourage the patient to engage in activities that promote functional independence and involve their family, carers or significant others if possible. Assess whether the patient takes their drugs properly and offer them medication aids (eg webster packs), if appropriate. Consider whether any drugs could be causing cognitive impairment (eg anticholinergics, psychotropics [especially benzodiazepines]) and consider deprescribing them—see Review and rationalise drugs [NB4]. Review driving ability and report to relevant authorities according to regulations [NB5]. Most patients with dementia lose the capacity to safely drive within a few years of diagnosis—plan alternative transport options with the patient and their significant other or carer.
Prevent and/or address behavioural and psychological symptoms of dementia (BPSD) [NB3]	Create and use a personalised multicomponent behavioural care plan that involves assessing potential triggers and optimising nonpharmacological interventions in the context of the person’s life story (including cultural, religious or social norms) and personality. Avoid using physical restraint to manage behavioural and psychological symptoms of dementia—it usually adds to the patient’s distress and disorientation. Dementia Behaviour Management Advisory Service (DBMAS) has a 24-hour helpline (1800 699 799) that provides expert advice and support to staff and carers of people with challenging behaviour of dementia in the community and in acute, primary care or residential aged-care settings.
Promote general health and wellbeing	Monitor and treat medical and psychiatric comorbidities of a person with dementia. Promote general health and wellbeing by supporting a person with dementia to: receive adequate nourishment and hydration by eating a healthy diet, and, if needed, assist them to eat and drink [NB6] maintain dental and gum health reduce their alcohol intake, if applicable maintain a healthy weight—monitor weight and assess nutritional status regularly (see Overview of vitamin, mineral and trace element deficiencies and Malnutrition) avoid or stop smoking, if applicable sleep well—see Good sleep practices and Insomnia in older people remain cognitively, socially and physically active—involve their family, carers or significant others if possible [NB7].
Review and rationalise drugs [NB3]	Regularly review the patient’s drug regimen—aim to reduce polypharmacy and administrative burden. Check if each drug: has a valid indication is effective for the patient is causing an adverse effect has a positive benefit–harm risk ratio (ie potential adverse effects are outweighed by effectiveness) supports an outcome that is consistent with the patient’s goals of care. Consider deprescribing the drug if it does not meet the above criteria—see also Rationalising acetylcholinesterase inhibitors and memantine in palliative care and Impact of deprescribing on a patient and their family [NB4].
Plan for the future	Determine whether the patient has an advance care plan and has appointed a substitute decision-maker for when they lose their decision-making capacity. If they do not have an advance care plan or substitute decision-maker, encourage and support them to start planning; see here for advice. Consider and plan for residential aged care.
Support family, carers or significant others	Support family, carers or significant others and provide them with information about dementia.
Care at end of life	For advice on managing dementia at the end of life, see Principles of palliative care for patients with dementia.
Note: NB1: Always consider whether the patient has the capacity to make decisions about their healthcare, see Capacity to make decisions about health care. NB2: Tailor interventions to the patient’s preferences. NB3: Pharmacological therapy has a limited role in the management of dementia—see text below. NB4: For advice on stopping benzodiazepines used for insomnia, see here, or anxiety, see here. NB5: See Austroads website. NB6: For advice on a healthy diet, see Australian Dietary Guidelines. NB7: For advice on physical activity, see Australia’s Physical Activity and Sedentary Behaviour Guidelines and the Australian 24-Hour Movement Guidelines.

The role of drugs in the management of dementia is limited.

Pharmacological therapy for cognitive impairment is palliative—acetylcholinesterase inhibitors and memantine can temporarily improve or stabilise symptoms of some types of dementia, but are not curative and do not modify disease progression.

Pharmacological management of behavioural and psychological symptoms of dementia is only indicated if either:

nonpharmacological methods have not improved symptoms of agitation, aggression, or psychosis that are distressing for the patient, or the patient is considered a threat to themselves or others—see Pharmacological management of behavioural and psychological symptoms of dementia
the patient develops depression and meets the criteria for antidepressant use—see Depression in dementia.

If a drug is used to treat behavioural and psychological symptoms of dementia, it should not be used as a sole intervention, but as part of a comprehensive treatment plan.

Note: Other drugs and herbal and dietary supplements do not have a role in the management of dementia.

Other drugs (eg statins, antihypertensives, nonsteroidal anti-inflammatory drugs [NSAIDs]) and herbal (eg ginkgo biloba, ginseng) and dietary supplements (eg omega-3 fatty acids, nutritional drinks, vitamin D, vitamin E) do not have a role in the management of dementia. Studies have failed to show clinically significant improvements. Avoid vitamin E—it has been associated with an increase in mortality.