Physicians who care for patients with dementia also must provide support for patient caregivers and family members. Caregiver burden requires attention from the health care team because most caregivers of patients with dementia report high levels of emotional stress. This burden is more severe when patients have comorbid conditions, behavioral and psychological symptoms of dementia, and more severe functional impairments. A functional assessment of activities of daily living can be done using standardized screening tools. Driving is a specific instrumental activity of daily living that can become dangerous in dementia; decisions about stopping driving often are complicated by patient resistance and loss of independence. Clinicians will be faced with questions regarding patient decision-making capacity, which is the ability to comprehend information and use reason to communicate an informed choice. As complex decision-making capacity is likely to diminish with dementia progression, discussing advance directives and designation of a surrogate decision-maker early in the disease course is paramount. Dementia remains an incurable progressive disease; therefore, management often is directed toward maintaining quality of life, managing symptoms, and palliating suffering. Patients with dementia may become eligible for hospice when they lose speech, locomotion, or consciousness.

Case 4. RD is a 75-year-old patient who comes to your office for further evaluation and management of dementia. He is accompanied by his daughter. He was diagnosed with Alzheimer disease 2 years ago by a neuropsychologist. RD is widowed and lives alone in a two-story house. He has been reluctant to move to assisted living, despite insistence from you and his daughter. RD has no concerns today, stating, “I feel fine; I don’t know why I’m here.” However, his daughter is concerned about drug adherence and new dents and scratches on his vehicle. She tries to check on him every morning, but she works full time and has two school-age children. RD often declines her help. His daughter becomes tearful during the visit.