Red Flags
- Rapidly progressive cognitive decline (weeks–months) — investigate for autoimmune encephalitis, prion disease, malignancy, vasculitis; tertiary cognitive neurology[1]
- Acute confusion overlying baseline cognition (delirium) — admit; identify and treat underlying cause (infection, drug, metabolic, retention); not a dementia exacerbation[1]
- Behavioural and psychological symptoms (aggression, psychosis, severe agitation) endangering patient or others — admit; safety planning before adding antipsychotic; review reversible triggers (pain, infection, environment)[1]
- Antipsychotic in dementia — increased mortality and cerebrovascular risk; reserve for severe distress or risk; lowest dose, shortest duration, regular review[1]
First-line treatment
Interventions
- Diagnosis disclosure and care planning[1]Sensitive disclosure with family; advance care planning while capacity preserved; lasting power of attorney; driving assessment and licence notification per local rules; financial and legal counselling
- Non-pharmacological cognitive and lifestyle interventions[1]Cognitive stimulation therapy (group, ≥7 weeks), regular aerobic and resistance exercise, social engagement, structured routine, optimised vision and hearing aids; treat depression and sleep disorders
- Vascular risk factor management[1]Treat hypertension, diabetes, dyslipidaemia, atrial fibrillation; smoking cessation; alcohol reduction; especially important in vascular and mixed dementia
- Carer education and support[1]Structured education programmes (e.g., START, REACH), respite care, day services; address caregiver burnout and depression; in family-care contexts target inter-generational dynamics and stigma reduction
- Behavioural and psychological symptom management[1]Identify and treat reversible triggers first (pain, constipation, infection, sensory deprivation, medication); environmental and behavioural strategies; psychotropic only when distress is severe and refractory
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Donepezil | Acetylcholinesterase inhibitor | October 2019 ICMR STW: donepezil 5 mg after breakfast daily for 1 month, then 10 mg after breakfast daily. [2] | — | Mild–moderate Alzheimer's, mixed Alzheimer's-vascular, dementia with Lewy bodies; monitor weight, GI tolerability, bradycardia, syncope; review benefit at 3–6 months |
| Rivastigmine | Acetylcholinesterase + butyrylcholinesterase inhibitor | October 2019 ICMR STW: oral rivastigmine 1.5 mg twice daily for 1 month, then 3 mg twice daily for 1 month, then 4.5 mg twice daily for 1 month, then 6 mg twice daily after meals for 1 month. [2] | — | Alternative to donepezil; patch reduces GI side effects; preferred in Parkinson's disease dementia and dementia with Lewy bodies |
| Galantamine[1] | Acetylcholinesterase inhibitor with nicotinic modulation | 8 mg PO daily ER × 4 weeks, titrate to 16–24 mg daily ER | — | Mild–moderate Alzheimer's; similar profile to donepezil |
| Memantine | Uncompetitive NMDA receptor antagonist | October 2019 ICMR STW: memantine 5 mg twice daily for 1 month, then 10 mg twice daily, for moderate to severe dementia. [2] | — | Moderate–severe Alzheimer's; combine with cholinesterase inhibitor; renal dose adjustment in severe CKD |
| Lecanemab or donanemab (selected disease-modifying)[1] | Anti-amyloid monoclonal antibody | Lecanemab 10 mg/kg IV every 2 weeks; donanemab 700 mg IV every 4 weeks × 3 doses then 1400 mg every 4 weeks | — | Early symptomatic Alzheimer's with biomarker-confirmed amyloid; APOE4 genotyping; MRI surveillance for ARIA; specialist memory clinic with infusion capability |
| Risperidone or quetiapine (BPSD when essential)[1] | Atypical antipsychotic | Risperidone 0.25 mg PO BD start, max 1 mg BD; quetiapine 12.5–25 mg PO night start, titrate cautiously | — | Time-limited (≤6 weeks) for severe agitation, aggression, or psychosis when non-pharmacological measures fail; informed discussion of stroke and mortality risk; review and discontinue |
Donepezil
Acetylcholinesterase inhibitor
- Adult
- October 2019 ICMR STW: donepezil 5 mg after breakfast daily for 1 month, then 10 mg after breakfast daily. [2]
- Paediatric
- —
Mild–moderate Alzheimer's, mixed Alzheimer's-vascular, dementia with Lewy bodies; monitor weight, GI tolerability, bradycardia, syncope; review benefit at 3–6 months
Rivastigmine
Acetylcholinesterase + butyrylcholinesterase inhibitor
- Adult
- October 2019 ICMR STW: oral rivastigmine 1.5 mg twice daily for 1 month, then 3 mg twice daily for 1 month, then 4.5 mg twice daily for 1 month, then 6 mg twice daily after meals for 1 month. [2]
- Paediatric
- —
Alternative to donepezil; patch reduces GI side effects; preferred in Parkinson's disease dementia and dementia with Lewy bodies
Galantamine[1]
Acetylcholinesterase inhibitor with nicotinic modulation
- Adult
- 8 mg PO daily ER × 4 weeks, titrate to 16–24 mg daily ER
- Paediatric
- —
Mild–moderate Alzheimer's; similar profile to donepezil
Memantine
Uncompetitive NMDA receptor antagonist
- Adult
- October 2019 ICMR STW: memantine 5 mg twice daily for 1 month, then 10 mg twice daily, for moderate to severe dementia. [2]
- Paediatric
- —
Moderate–severe Alzheimer's; combine with cholinesterase inhibitor; renal dose adjustment in severe CKD
Lecanemab or donanemab (selected disease-modifying)[1]
Anti-amyloid monoclonal antibody
- Adult
- Lecanemab 10 mg/kg IV every 2 weeks; donanemab 700 mg IV every 4 weeks × 3 doses then 1400 mg every 4 weeks
- Paediatric
- —
Early symptomatic Alzheimer's with biomarker-confirmed amyloid; APOE4 genotyping; MRI surveillance for ARIA; specialist memory clinic with infusion capability
Risperidone or quetiapine (BPSD when essential)[1]
Atypical antipsychotic
- Adult
- Risperidone 0.25 mg PO BD start, max 1 mg BD; quetiapine 12.5–25 mg PO night start, titrate cautiously
- Paediatric
- —
Time-limited (≤6 weeks) for severe agitation, aggression, or psychosis when non-pharmacological measures fail; informed discussion of stroke and mortality risk; review and discontinue
Safety-net
- Sudden change in alertness, confusion, or behaviour is delirium until proven otherwise — same-day medical review for fever, urinary symptoms, constipation, falls, or new medications[1]
- Driving — many people with dementia must stop driving safely; check local rules and have a structured driving assessment[1]
- Use a single pharmacy for all prescriptions — anticholinergic burden from over-the-counter cold remedies, antihistamines, and bladder medications worsens confusion[1]
Referral criteria
- All suspected new dementiaMemory clinic, geriatric medicine, or cognitive neurology[1]
- Young-onset (<65 years), rapidly progressive, atypical, or familial patternTertiary cognitive neurology with biomarker workup[1]
- Severe BPSD with risk to patient or carer despite non-pharmacological measuresOld-age psychiatry[1]
- End-of-life care planning, severe functional decline, or carer crisisPalliative care and social care[1]
Clinical summary
Diagnosis, pharmacological and non-pharmacological management of major neurocognitive disorders in adults including caregiver support.