Early Stage: Mild cognitive impairment with a preserved ability to self-care and undertake activities of daily living.
Expert consensus is that these practices are recommended in the care of people with dementia <strong>Treatment Goals</strong> An important treatment goal for people living with dementia is to simplify the medication regimen. Health professionals and the person living with dementia should discuss and document: * treatment goals * likely prognosis * writing an advance care directive to indicate their wishes for treatment in specific future scenarios * using a dose administration aid to support medication use Health professionals and the carer or family of the person living with dementia should discuss and document: * treatment goals * likely prognosis * document wishes for treatment in specific future scenarios <strong>Medication Side Effects</strong> People living with dementia are: * at higher risk of side effects than cognitively-intact people * often unable to recognise side effects from their medications * often unable to report side effects from their medications <strong>Principles of medication use</strong> When prescribing for people living with dementia, health professionals should: * provide a current medication list that includes indications, administration instructions, and planned dates for review * regularly monitor for actual benefit of each medication * regularly monitor for actual side effects * start new medications at the lowest therapeutic dose * review doses frequently to see if a lower dose would be adequate * change only one medication at a time * assess impact of dementia on activities of daily living <strong>Medication reviews</strong> When reviewing medications use for people living with dementia, health professionals should check that each medication is: * underpinned by a current, valid indication * effective for that individual * consistent with individual’s care goals * documented with a time frame to review A medication review should be triggered by: * a significant event (e.g. cardiovascular event, fall, fracture, hospital admission, residential care facility admission) * increasing frailty * resistance to taking medications * belief taking medications is a burden * writing a new prescription for the medication * decline in cognitive function * decline in ability to manage activities of daily living * regular use of five or more medications <strong>Preventative medication</strong> When prescribing medications intended to modify the risk of a future event for a person living with dementia, health professionals should consider: * functionality as the most important factor * the potential benefits weighed against the actual harm * potential for side effects * actual side effects * the risks of polypharmacy * the administration burden * maximise quality of life rather than prolong survival * continue annual influenza vaccines indefinitely <strong>Symptom management</strong> * trialled for withdrawal every three to six months if the symptoms are stable * reviewed regularly for efficacy * reviewed regularly for side effects * review doses frequently to see if symptoms can be adequately * maintained on a lower dose * maximised to alleviate distress <strong>Psycho-active medications</strong> * use non-pharmacological strategies in preference to medications * benzodiazepines should not generally be used, but * short acting benzodiazepines can be useful for managing acute agitation provided use is monitored * antipsychotics can be useful when prescribed at a low dose for a limited period to alleviate distressing neuropsychiatric symptoms * antipsychotics should be considered if distressing behavioural * symptoms are not responsive to other management strategies * tricyclic antidepressants have a limited role, but * tricyclic antidepressants may be useful in managing refractory neuropathic pain <strong>Medications to modify dementia progression</strong> * consider a trial of an anticholinesterase inhibitor * consider a trial of memantine * review dementia treatments with respect to desired benefits and actual side effects (i.e. memantine, anticholinesterases) * maximise cognitive function by reducing exposure to medications with sedative and anticholinergic properties
Expert consensus is that these practices are NOT recommended in the care of people with dementia <strong>Treatment Goals</strong> These treatment goals are important for people living with dementia: * the wishes and needs of family and carers should take priority over those of the person living with dementia * it is acceptable to conceal medications in food or drink if the person with dementia refuses them <strong>Symptom Management</strong> for people living with dementia, regular medications intended only to provide symptom relief should be continued indefinitely in people who are unable to reliably report symptom recurrence <strong>Preventative Medication</strong> When prescribing medications intended to modify the risk of a future event for a person living with dementia, health professionals should consider: * cease all medications that do not also provide tangible symptom relief * cease anti-platelet, anti-coagulants and anti-thrombotic agents * cease medications to manage osteoporosis * cease antihypertensive agents <strong>Psycho-active medications</strong> * for managing behavioural and psychological symptoms of dementia, antipsychotics are never appropriate for behavioural management * for people living with dementia, long acting benzodiazepines can be useful, provided the risks are weighed against the benefits