Dementia · House

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^[1]	Acetylcholinesterase inhibitor	5 mg PO once daily × 4 weeks then 10 mg daily; max 23 mg in severe Alzheimer's	—	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^[1]	Acetylcholinesterase + butyrylcholinesterase inhibitor	Oral: 1.5 mg BD start, titrate to 3–6 mg BD. Patch: 4.6 mg/24 h start, titrate to 9.5–13.3 mg/24 h	—	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^[1]	Uncompetitive NMDA receptor antagonist	5 mg PO daily × 1 week, titrate to 10 mg BD over 4 weeks	—	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^[1]

Acetylcholinesterase inhibitor

Adult: 5 mg PO once daily × 4 weeks then 10 mg daily; max 23 mg in severe Alzheimer's
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^[1]

Acetylcholinesterase + butyrylcholinesterase inhibitor

Adult: Oral: 1.5 mg BD start, titrate to 3–6 mg BD. Patch: 4.6 mg/24 h start, titrate to 9.5–13.3 mg/24 h
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^[1]

Uncompetitive NMDA receptor antagonist

Adult: 5 mg PO daily × 1 week, titrate to 10 mg BD over 4 weeks
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.

References

1.ICMR Guidelines for Management of Dementia (2022); NICE NG97 Dementia: Assessment, Management and Support; AAN Practice Parameter on Dementia Diagnosis (2022)