Dementia Management
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Direct answer
Cognitive decline confirmed objectively by brief testing (MMSE or MoCA) with functional impairment defines dementia, and the work-up's first duty is excluding the treatable: depression (pseudodementia), hypothyroidism, vitamin B12 and folate deficiency, neurosyphilis and HIV, plus structural imaging to catch subdural haematoma, normal-pressure hydrocephalus or a mass. Alzheimer disease — insidious onset, progressive, with early episodic memory loss — is treated with an acetylcholinesterase inhibitor: donepezil 5 mg nightly titrated to 10 mg, rivastigmine or galantamine; memantine 10 mg twice daily is added or substituted in moderate-to-severe disease. Behavioural and psychological symptoms are managed non-pharmacologically first, with antipsychotics reserved at the lowest dose for the shortest time because they increase mortality in dementia.
What you must remember
- Dementia versus delirium versus depression: dementia — chronic, progressive, clear consciousness; delirium — acute, fluctuating attention, hallucinations, usually a medical cause; depression — "I don't know" answers and poor effort rather than near-miss answers — the three-way discrimination the exam sets every year.
- Alzheimer markers: hippocampal atrophy on MRI, low cerebrospinal fluid amyloid with raised tau in specialised settings; apraxia, agnosia and language dissolution follow memory loss.
- Cholinesterase inhibitors: donepezil 5-10 mg nightly, rivastigmine (patch available), galantamine — mild-to-moderate disease; cholinergic adverse effects are nausea, bradycardia, vivid dreams.
- Memantine (NMDA antagonist): moderate-to-severe disease or when cholinesterase inhibitors are not tolerated; safer profile, dizziness and confusion occasionally.
- BPSD rules: identify pain, infection, retention and constipation as precipitants first; non-drug measures (routine, familiar carers, sensory input); then consider SSRIs for agitation-depression, and antipsychotics only for severe distress or danger — lowest dose, shortest duration, with mortality warning.
- Vascular dementia: stepwise decline, executive dysfunction early, gait disorder and pseudobulbar signs; treatment is aggressive vascular risk-factor control — no cholinesterase inhibitor benefit is as established as in Alzheimer disease.
- Lewy body dementia discriminators: fluctuating cognition, visual hallucinations early, parkinsonism, and severe antipsychotic sensitivity — haloperidol can be catastrophic; these patients respond relatively well to rivastigmine.
- Reversible/treatable list: B12 deficiency, hypothyroidism, neurosyphilis, HIV, subdural haematoma, normal-pressure hydrocephalus (gait apraxia, urinary incontinence, dementia), and depression — the screen every new patient deserves.
How to work through a memory-clinic referral
A 72-year-old retired schoolteacher is brought by her daughter: two years of forgetting conversations, repeating questions, misplacing household items, and last month leaving the gas on. She scores 19/30 on the MMSE with disorientation to time, three-word recall failure and impaired construction; her daughter confirms functional decline in cooking and finances. The first consultation is spent excluding the treatable — thyroid function, vitamin B12, complete blood count, renal and liver tests, and a CT brain that shows disproportionate medial temporal atrophy without a structural lesion. A screening depression questionnaire is negative, and her history is chronic and progressive rather than fluctuating, so the working diagnosis is Alzheimer disease of moderate severity.
Treatment begins with donepezil 5 mg at night, titrated after a month, alongside the caregiver conversation that does more than the prescription: daily routine, safety at the stove, financial safeguards, and a named carer — India's care still resting overwhelmingly on families. When visual hallucinations and agitation emerge a year later, the first questions are practical ones — is she in pain, constipated, retaining urine, or frightened by poor lighting at night — and only after these are treated is low-dose quetiapine considered briefly. Memantine is added as cognition advances; the daughter is asked about advance directives while her mother can still answer.
How the FMGE frames it
The three-way stems — dementia, delirium, depression — are the most reliable questions in geriatric medicine at FMGE: the fluctuating-attention post-operative patient is delirium, the "don't know" anorexic elderly man is depression, and the two-year forgetting is dementia. Within dementia, the pattern-recognition pairs are tested as one-liners: Lewy body (hallucinations plus parkinsonism plus antipsychotic sensitivity), vascular (stepwise, executive, pseudobulbar), frontotemporal (disinhibition and personality change with preserved memory early), normal-pressure hydrocephalus (wet, wobbly, wacky). Drug questions rank therapy by stage — cholinesterase inhibitors for mild-to-moderate, memantine for moderate-to-severe — and test the antipsychotic mortality warning as a safety MCQ. The Indian layer is epidemiological and social: rising prevalence with an ageing population, caregiver-dependent care, and the B12-deficiency screen — vegetarian diets make it a genuinely Indian catch.
Frequently asked questions
What distinguishes dementia from delirium at the bedside?
Dementia is chronic and progressive with preserved attention early; delirium is acute and fluctuating with impaired attention, usually on a medical or drug trigger.
Which drugs are used for Alzheimer disease and at what stage?
Acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine) for mild-to-moderate disease; memantine for moderate-to-severe disease or cholinesterase intolerance.
Which treatable causes of cognitive decline must be excluded?
Depression, hypothyroidism, vitamin B12 and folate deficiency, neurosyphilis, HIV, subdural haematoma, normal-pressure hydrocephalus and mass lesions.
Why are antipsychotics used cautiously in dementia?
They increase mortality, stroke and falls in dementia patients, so behavioural symptoms are first treated non-pharmacologically after excluding pain, infection and retention.
Which dementia shows severe sensitivity to antipsychotic drugs?
Dementia with Lewy bodies — visual hallucinations, fluctuating cognition and parkinsonism, with haloperidol potentially causing catastrophic deterioration.