14th February 2025

Management of dementia

Non-pharmacological intervention

Management in the early stages of dementia is mainly education for the patient and their relatives or carers, in relation to what can be expected as the condition progresses and the support available.

There are various non-pharmacological interventions, namely therapies and activities aimed at preserving cognition, independence and wellbeing. These are most suited to patients with mild-to-moderate dementia.

As a progressive, irreversible condition, advance care planning is important at all stages. Patients should be counselled on options such as: Lasting Power of Attorney (LPA), advance statement (wishes, preferences, values), advance decisions to refuse treatment, and, when near end of life, their preferred place of death.

Pharmacological intervention

Table 4 Pharmacological interventions for different causes of dementia

It is important to deprescribe medications that may worsen cognition, especially those with anticholinergic effects. Common examples include:

• Antimuscarinics: tolterodine, darifenacin, solifenacin, oxybutynin, procyclidine
• Antipsychotics: olanzapine, chlorpromazine
• Tricyclic antidepressants: amitriptyline, nortriptyline
• Antihistamines: chlorphenamine, cetirizine, cyclizine, promethazine

Patients with dementia may have significant distress and pose a risk to themselves or others. Reversible causes should always be explored first, e.g. pain, delirium or environment. If necessary and safe, acute pharmacological measures may be required, with the lowest effective dose. Note that antipsychotic use is off label, and that these drugs should be avoided in patients with Parkinson’s disease or Lewy body dementia.

References

• National Institute for Health and Care Excellence. Dementia: assessment, management and support for people living with dementia and their carers. [Internet]. NICE. 2018 [cited 2022 Jan 15]. Available from: https://www.nice.org.uk/guidance/ng97
• NHS Choices. Symptoms of Dementia – Dementia Guide [Internet]. NHS. 2019 [cited 2022 Jan 15]. Available from: https://www.nhs.uk/conditions/dementia/symptoms/
• Liberty Protection Safeguards: what they are [Internet]. GOV.UK. 2021 [cited 2022 Jan 15]. Available from: https://www.gov.uk/government/publications/liberty-protection-safeguards-factsheets/liberty-protection-safeguards-what-they-are
• Alzheimer’s Society. How many people have dementia and what is the cost of dementia care? [Internet]. Alzheimer’s Society. 2019 [cited 2022 Jan 15]. Available from: https://www.alzheimers.org.uk/about-us/policy-and-influencing/dementia-scale-impact-numbers
• Alzheimer’s Society. What is dementia? [Internet]. Alzheimer’s Society. 2021 [cited 2022 Jan 15]. Available from: https://www.alzheimers.org.uk/about-dementia/types-dementia/what-is-dementia
• Benrimoh D, Pomerleau VJ, Demoustier A, Poulin S, Maltais J-R, Brouillette J, et al. Why We Still Use “Organic Causes”: Results From a Survey of Psychiatrists and Residents. The Journal of Neuropsychiatry and Clinical Neurosciences. 2019 Jan;31(1):57–64
• Gupta A, Tampi R, Taskiran S, Lopez J, Muralee S. Assessment of dementia [Internet]. BMJ Best Practice. 2021 [cited 2022 Mar 1]. Available from: https://bestpractice.bmj.com/topics/en-gb/242