Dementia management requires individualized patient encounters that focus on education and realistic expectations. Numerous vitamins and supplements are promoted for memory enhancement, but they lack evidence to support their use. Nonpharmacotherapy should be used through all stages of dementia. Common initial pharmacotherapy includes cholinesterase inhibitors and memantine, with use guided by dementia type, tolerability, patient goals, and disease stage. Assessment of benefit should incorporate caregiver input, functional improvements, behavioral symptoms, and tolerability. Management length is individualized. When a drug is discontinued, physicians should evaluate the patient for early worsening of cognitive or functional symptoms. Newer treatments, such as aducanumab, can reduce beta-amyloid plaques, but evidence for cognitive improvements is lacking; these treatments also are expensive and patient access is limited, resulting in barriers to widespread use. As dementia progresses, patients often develop behavioral and psychological symptoms, which are challenging for patients and caregivers. Nonpharmacotherapy is the first-line treatment for behavioral and psychological symptoms of dementia. Use of antipsychotics and benzodiazepines should be limited unless symptoms are placing the patient or others in imminent danger. Pharmacotherapy for these symptoms should be individualized, often requiring trials of various therapeutic options.

Case 3. RS is a 75-year-old patient who comes to your office with his wife, who notes RS is beginning to forget directions and recent conversations. His medical history includes atrial fibrillation and hypertension for which he takes warfarin and metoprolol. At the conclusion of the visit, you determine that he has mild cognitive impairment or early progressive dementia, possibly Alzheimer disease. His wife is concerned about his memory failing and asks about ways to reduce further decline.