Patient handout

Dementia / cognitive impairment

PRODUCTION

1. Your condition

This handout is for dementia / cognitive impairment. Your care team identified this based on: memory or cognitive complaint reported by patient, family, or caregiver (aan 2018 mci pmid 29282327).

Other reasons your team may use this plan: iadl/adl decline ≥6 months (nia-aa 2018 pmid 29653606); new agitation, apathy, depression, or psychotic features in older adult (apa 2024; ags beers 2023); behavioural disinhibition / apathy / executive dysfunction in patient <65 — bvftd or genetic ad (rascovsky 2011 pmid 21810890).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
donepezil	5 mg	PO	once daily at bedtime; titrate to 10 mg after 4-6 wks; 23 mg only for severe AD with caution	AAN 2018 PMID 29282327 — modest symptomatic benefit; GI + bradycardia + sleep disturbance ADRs; NICE 2024 dementia
rivastigmine	4.6 mg/24h transdermal patch	transdermal	daily; titrate to 9.5 then 13.3 mg/24h q4 wks	Patch reduces GI ADRs; FDA-approved for PDD; first-line in DLB per McKeith 2017 PMID 28592453
galantamine	8 mg ER	PO	once daily; titrate to 16 then 24 mg q4 wks	Alternative ChEI; weak nicotinic modulation (AAN 2018)
memantine	5 mg	PO	once daily; titrate to 10 mg BID	AAN 2018 — modest benefit moderate-severe AD; combination ChEI + memantine in moderate-severe; NICE 2024 dementia

Plan: Cholinesterase inhibitor + memantine for AD / DLB / PDD / vascular (AAN 2018; NICE 2024 dementia)

3. When to call your provider

Contact your care team if any of the following happen:

Behavioural crisis / aggression with safety risk → ED or geriatric psychiatry (APA 2024)
Superimposed delirium → ED (CAM positive)
Suspicion of CJD / autoimmune encephalitis → urgent neurology + LP (Zerr 2009 PMID 19773352)
Rapid decline <1 yr → urgent neurology + biomarkers
Refractory depression → psychiatry
ARIA-E/H on mAb surveillance MRI → hold mAb + dementia neurology consult
Caregiver burnout / abuse concern → adult protective services + respite

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Fluctuating cognition + recurrent visual hallucinations + REM sleep behaviour disorder + parkinsonism (≥2 of 4 core features = probable DLB per McKeith 2017 PMID 28592453); EXTREME antipsychotic sensitivity flag
Behavioural variant FTD — early personality change + disinhibition + apathy + stereotypies + hyperorality (≥3 of Rascovsky 2011 PMID 21810890 criteria) OR primary progressive aphasia (semantic / agrammatic / logopenic); FDG-PET frontal/temporal hypometabolism
Rapid cognitive decline <1 year + myoclonus + ataxia + visual disturbance + MRI DWI cortical ribboning + basal ganglia / pulvinar sign + CSF RT-QuIC positive (Zerr 2009 PMID 19773352)(life-threatening)
Acute fluctuating attentional change + altered consciousness + disorganized thinking in patient with dementia (CAM positive); identify reversible precipitant (infection, medication, retention, dehydration, pain, constipation)
Vasogenic edema (ARIA-E) or microhemorrhage / superficial siderosis (ARIA-H) on surveillance MRI during anti-amyloid mAb therapy (CLARITY-AD PMID 36449413; TRAILBLAZER-ALZ 2 PMID 37459141)

5. Follow-up

Caregiver education + support, dementia care navigator, driving evaluation, capacity assessment, advance care planning + POLST, palliative referral at FAST 7 (NICE 2024 dementia; APA 2024)

6. Sources

Guideline: AAN MCI 2018 (Petersen) + NIA-AA 2018 research framework + AAN/ADRD 2024 anti-amyloid mAb appropriate use + CLARITY-AD (lecanemab) + TRAILBLAZER-ALZ 2 (donanemab) + DLB Consortium 2017 (McKeith) + bvFTD criteria 2011 (Rascovsky) + CJD MRI criteria 2009 (Zerr) + APA Treatment of BPSD 2024 + AGS Beers Criteria 2023