As a patient’s Alzheimer’s dementia progresses, it is critical that their treatment plan evolves accordingly. Collaboration with a specialist to manage the disease can ensure the best outcomes for patients and caregivers.

We know that the antecedents of the pathology of Alzheimer’s disease may be present in the brain for more than a decade before clinical symptoms develop. While the disease progresses at variable rates from person to person, it often will progress to more severe stages of dementia and is ultimately a significant contributor to mortality. By diagnosing and treating Alzheimer’s dementia early, we can make more of an impact in terms of slowing the progression of the disease.

Ideally, the clinician first catches symptoms of cognitive impairment prior to any functional deficit. The big differentiator between mild cognitive impairment (MCI) and early or mild Alzheimer’s disease is the functional limitation, as individuals with MCI can adapt and work around their dysfunction. It is important to note that not every case of MCI will progress to dementia; however, if it does, there is actual disability associated with the impairment itself by the time a patient has mild dementia.

The diagnosis and management of Alzheimer’s disease can be time consuming. Many of my patients with low health literacy have never heard of Alzheimer’s disease. You really must explain it to patients from the ground up and get their caregivers involved so that they are aware of the situation and can help start setting expectations regarding the disease and treatment.

If possible, as soon as a patient presents with cognitive symptoms, that is the time to perform a complete workup and recommend a referral to neurology for potential disease-modifying therapy. However, by the time I see these patients, they are often already at the stage of mild to moderate dementia, so I will usually initiate treatment with a cholinesterase inhibitor.

Because there is evidence that patients can do worse when you take them off cholinesterase inhibitor therapy, I tend to continue these drugs long-term. If they tolerate the cholinesterase inhibitor and they have evidence of more moderate dementia, I will put them on memantine as well. I realize that these medications have modest effects, but, in my clinical experience, they do seem to have an effect on slowing the rate of cognitive decline.

Regarding nondrug treatment, behavioral therapy is very important and is key in my treatment plans because it improves the patient’s quality of life, can help decrease caregiver burnout, and may delay institutionalization. Talk therapy and socialization are important and can be helpful, as they give patients an outlet and limit isolation, which is associated with a higher risk of mortality. So, participation in group settings, such as a senior center, can be valuable. Finally, teaching patients and families some best practices in terms of managing day-to-day life with cognitive dysfunction, maintaining physical and mental activity as much as possible, promoting appropriate sleep, setting routines, and limiting alcohol consumption are also important.