Caring for Older Patients With Cognitive Impairment
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This overview guide for health care providers suggests treatment strategies to consider when working with patients who have been diagnosed with dementia or cognitive impairment. For information on assessing patients with memory complaints or other symptoms of dementia, see Assessing Cognitive Impairment in Older Patients.
Developing a treatment plan
Review the patient's prescription and over-the-counter medications and supplements. Consider whether any drug might be contributing to cognitive decline. In particular, reassess the need for anticholinergics, antihistamines, narcotics, sedatives, and benzodiazepines. Discuss whether the patient takes medications as prescribed, uses a pill organizer, and has someone who oversees medication intake to avoid undertreatment and overdoses.
Carefully consider prescribing new medications. Several prescription drugs are approved by the U.S. Food and Drug Administration (FDA) for Alzheimer’s. Use of these medications may depend on disease stage. Medications available to help manage symptoms in people with Alzheimer’s disease include cholinesterase inhibitors and NMDA antagonists. Medications are also emerging to treat the progression of the disease. There are possible side effects to new disease-modifying immunotherapies, including amyloid-related imaging abnormalities (ARIA), which can lead to fluid buildup or bleeding in the brain. Due to this potential risk, the monitoring with routine MRIs for side effects related to ARIA is required. Discuss treatment goals and possible side effects with patients and caregivers before prescribing. Visit How Is Alzheimer's Disease Treated? for a list of currently approved Alzheimer’s medications.
For most other forms of dementia, there is relatively little information about the efficacy and safety of drug treatments. One exception is Parkinson's disease dementia, for which rivastigmine, a cholinesterase inhibitor, is FDA-approved. Learn more about treatments for Parkinson’s disease dementia and Lewy body dementia and frontotemporal disorders.
Vascular dementia is often managed with drugs that prevent strokes or reduce the risk of additional brain damage. Some studies suggest that drugs that improve memory in Alzheimer’s might benefit people with early vascular dementia. Treating the modifiable risk factors can help prevent additional stroke. Visit the NIH National Institute of Neurological Disorders and Stroke for more information on treating and managing dementia.
Evaluate behavioral problems and possible treatments. Medications may be available to treat certain behavioral and mood symptoms associated with various forms of dementia, including delusions and depression. There are also drugs to treat muscle stiffness and risk factors for vascular cognitive impairment such as high blood pressure. Discuss the patient’s home environment and lifestyle to determine if nonpharmacological approaches, such as creating a calm environment and avoiding triggering situations, could replace or delay the need for prescription medications. Consider whether other treatable conditions, such as hearing or vision problems, could be contributing to behavioral problems.
Use great caution for any off-label use of antipsychotic medications with constant monitoring for efficacy and safety. No medications are specifically approved to treat behavioral and psychotic symptoms in older adults with dementia. People living with Parkinson's disease dementia or dementia with Lewy bodies are particularly sensitive to the negative side effects of classic antipsychotics such as haloperidol. Newer atypical antipsychotics may be safer but should still be used at the lowest dose possible for the shortest amount of time needed to control symptoms.
Make an appointment for a follow-up visit within a specific timeframe (e.g., 4 to 6 weeks) especially if new medication is prescribed. As the patient’s cognitive impairment progresses, consider asking the person to bring a relative or friend to each visit.
Consider referring the patient to a geriatrician, geriatric psychiatrist, neuropsychologist, geriatric social worker, geriatric counselor, mental health counselor, or substance abuse professional for help with care management.
Tips for communicating with a patient who has cognitive impairment
Communicating with a patient with cognitive impairment can be challenging. For instance, they may have trouble following instructions about their care. The following tips may help improve your communications.
- Address the patient directly and use simple wording, presenting one idea at a time. If you’re asking questions, do so in a yes-or-no or a multiple-choice format.
- Help orient the patient. Explain (or re-explain) who you are and what you will be doing during the visit.
- Be cognizant of other health problems the patient may have that could be making communication more difficult, such as hearing or vision problems.
- Reassure the patient that they are not being judged on their responses.
- If the patient can hear you but does not understand what you are saying, try rephrasing your statement. Try not to speak too quickly or loudly.
- Call the patient and caregiver to follow-up on the care plan after the visit.
For more tips on communicating, visit Talking With Your Older Patients.
What to communicate with the patient and caregiver
Discuss the diagnosis and treatment plans. Provide written instructions and ensure that treatment plans are understandable and feasible for both the patient and caregiver.
Address potential issues of driving, getting lost, and home safety during each visit. These issues are especially critical for people with dementia who live alone.
Ask for permission to contact a close relative or friend who can serve as a care partner. Establish and maintain a dialogue with the care partner to discuss safety concerns and help monitor changes in the patient's daily routine, mood, behavior, and sleep. Also, use this opportunity to ask the care partner how they are doing, and what assistance and resources are needed to deliver care and manage stress.
Offer the patient and caregiver a checklist of next steps and resources.
Providing patient and caregiver support
Suggest aids for daily functioning, such as to-do lists, a calendar, and other reminders. Technologies to assist with medication management, safety (e.g., emergency response, door alarms), and other care are also options.
Refer the person and caregiver to national and community resources, including support groups. It is important that the caregiver learns about and uses respite care and visits their own health care providers if they are experiencing mental health issues or other health problems.
These resources may be helpful to share with the patient and caregiver:
- NIA Alzheimer's and related Dementias Education and Referral Center: 800-438-4380
- Eldercare Locator: 800-677-1166
- Local nonprofit and community organizations
Consider referring the person with impairment to a dementia specialty clinic if diagnostic or management concerns remain. In the case of young-onset dementia, planning and management concerns can be even more complex; specialty clinics can address such rare conditions.
Discussing clinical trials
Inform the patient and family about opportunities to participate in clinical trials and research studies. Find trials and resources at:
The Alzheimers.gov website has information about Talking With Your Patients About Alzheimer's and Related Dementias Clinical Trials. NIA also offers the free booklet Clinical Trials and Older Adults. Order online or call 800-438-4380.
The following offer additional information and tools related to assessing and managing patients with cognitive impairment:
- Alzheimer's and Related Dementia Resources for Professionals (NIA)
- Cognitive Care Kit (American Academy of Family Physicians)
- Disclosing an Alzheimer's Diagnosis (video from Actionalz)
- Management & Patient Care (Alzheimer's Association)
- Physicians Guide to Assessing and Counseling Older Drivers (American Geriatrics Society and National Highway Traffic Safety Administration)
In addition, NIA provides several publications and online information for people with Alzheimer’s and related dementias. Consider sharing these publications with your patients:
- Next Steps After an Alzheimer's Diagnosis
- Caring for a Person with Alzheimer's Disease
- Frontotemporal Disorders: Information for Patients, Families, and Caregivers
- Lewy Body Dementia: Information for Patients, Families, and Professionals
- Tips for Managing Agitation, Aggression, and Sundowning
For more information about Alzheimer's and dementia
NIA Alzheimer’s and related Dementias Education and Referral (ADEAR) Center
The NIA ADEAR Center offers information and free print publications about Alzheimer’s and related dementias for families, caregivers, and health professionals. ADEAR Center staff answer telephone, email, and written requests and make referrals to local and national resources.
Explore the Alzheimers.gov website for information and resources on Alzheimer’s and related dementias from across the federal government.
This content is provided by the NIH National Institute on Aging (NIA). NIA scientists and other experts review this content to ensure it is accurate and up to date.
March 15, 2023