Dementia Care
Understanding Dementia
Dementia is a clinical syndrome characterized by a decline in cognitive function severe enough to interfere with daily life. While many conditions can lead to this decline, the most common syndromes are typically categorized by their underlying pathology and primary clinical presentations.
It’s important to clarify that dementia is not a single disease. Instead, it is an "umbrella term" used to describe a group of symptoms that affect memory, thinking, and social abilities severely enough to interfere with daily life.
The landscape of dementia care has undergone a massive shift between 2024 and 2026, moving from a diagnosis based on clinical symptoms to a biologically-defined framework. This change is driven by the arrival of disease-modifying therapies (DMTs) and highly accurate blood tests.
Below is a summary of the current (2026) consensus for diagnosis and management.
Updated Diagnostic Framework
The 2024 NIA-AA Revised Criteria and the 2026 Medscape/Alzheimer’s Association clinical guidelines now define Alzheimer’s Disease (AD) by its biology rather than the "dementia" syndrome.
Multi-Tiered Evaluation
Tier 1 (Routine): Clinical history (informant-based), cognitive screening (MoCA/MMSE), and structural imaging (MRI preferred to assess atrophy and rule out vascular pathology).
Tier 2 (Biomarkers): Blood-based biomarkers (BBMs) like p-tau217 are now integrated into clinical practice.
BBMs with ≥90% accuracy can now serve as a substitute for PET or CSF in many clinical scenarios.
The "Biological" Definition: AD is diagnosed by the presence of Core 1 Biomarkers (Amyloid-beta and phosphorylated tau), even if the patient is still in the Mild Cognitive Impairment (MCI) or asymptomatic stage.
Pharmacological Management
Management is now stratified into disease-modifying and symptomatic treatments.
Disease-Modifying Therapies (DMTs)
For patients in early stages (MCI or mild dementia) with confirmed amyloid pathology:
Lecanemab (Leqembi): Administered via IV infusion every two weeks. As of 2026, an at-home subcutaneous injectable version is available for maintenance, significantly reducing clinic burden.
Donanemab (Kisunla): Monthly IV infusion that may be stopped once amyloid plaques are cleared to a certain threshold (a "treat-to-target" approach).
Safety Monitoring: Mandatory serial MRIs are required to monitor for ARIA (Amyloid-Related Imaging Abnormalities—edema or microhemorrhage). APOE genotyping is strongly recommended before starting to assess ARIA risk.
Symptomatic Treatments
Cholinesterase Inhibitors (Donepezil, Rivastigmine): Remain first-line for mild-to-moderate AD symptoms.
NMDA Antagonists (Memantine): Used for moderate-to-severe stages, often in combination with donepezil.
Behavioral & Psychological Symptoms (BPSD)
Current 2025/2026 guidelines (including the CCSMH and Oregon OHA updates) emphasize a "Non-Pharm First" hierarchy.
The Management Hierarchy
Rule out Medical Triggers: Pain, urinary tract infections, and medication side effects (especially anticholinergics).
Environmental Optimization: Reducing clutter, maintaining routines, and addressing hearing loss (now recognized as a major modifiable risk factor for cognitive decline).
Pharmacotherapy for Refractory Symptoms:
Agitation: Citalopram or low-dose risperidone/aripiprazole may be used if there is a risk of harm.
Psychosis: Pimavanserin is increasingly used for Parkinson’s or AD-related psychosis due to a lower side-effect profile compared to traditional antipsychotics.
Tapering: Guidelines now mandate a trial of tapering every 3–6 months for patients on antipsychotics for BPSD.
Lifestyle & Risk Reduction
The 2024 Lancet Commission and US POINTER study emphasize that 45% of dementia cases are potentially preventable through 14 modifiable risk factors.
Hearing Loss: Aggressive correction with hearing aids is now a Level 1 recommendation.
Metabolic Health: Management of hypertension (<130/80) and the emerging use of GLP-1s for patients with diabetes are noted for their potential neuroprotective benefits.
Social/Cognitive Engagement: High-level evidence supports structured "brain-healthy" diets (MIND/Mediterranean) and aerobic exercise.
Clinical StagePrimary GoalKey Interventions
Pre-SymptomaticRisk ReductionBP control, Hearing aids, Exercise
MCI / Early ADDelay ProgressionDMTs (Lecanemab), Lifestyle, MoCA monitoring
Moderate / SevereQuality of LifeMemantine, BPSD management, Caregiver support
Subtypes
Alzheimer’s Disease (AD)
As the most prevalent form of dementia (60%–80% of cases), AD is typically defined by the accumulation of amyloid plaques and tau tangles.
Primary Symptoms: Early deficits usually involve episodic memory (difficulty recalling recent events or new information).
Progression: Gradual and insidious. As it advances, it affects language (aphasia), visuospatial function, and executive decision-making.
Vascular Dementia (VaD)
Caused by conditions that impair blood flow to the brain, such as strokes or small vessel disease.
Primary Symptoms: Often presents with impaired executive function (planning, organizing, and problem-solving) and slowed processing speed. Memory loss may be less prominent early on compared to AD.
Progression: Can follow a "step-wise" decline, where cognitive drops occur suddenly following vascular events, though it can also progress gradually due to chronic small vessel ischemia.
Lewy Body Dementia (LBD)
LBD is associated with abnormal protein deposits (alpha-synuclein) called Lewy bodies. This category includes both Dementia with Lewy Bodies (DLB) and Parkinson’s Disease Dementia (PDD).
Primary Symptoms: Core features include fluctuating cognition (varying levels of alertness), recurrent visual hallucinations, and spontaneous parkinsonism (rigidity, bradykinesia).
Associated Features: REM sleep behavior disorder (acting out dreams) and significant sensitivity to neuroleptic medications.
Frontotemporal Dementia (FTD)
A group of disorders caused by progressive nerve cell loss in the brain's frontal or temporal lobes, often occurring at a younger age (45–65).
Behavioral Variant (bvFTD): Marked by early changes in personality, social conduct, and emotional regulation (e.g., disinhibition, apathy, or loss of empathy).
Language Variants (PPA): Primary Progressive Aphasia involves early and isolated deficits in speech production, naming, or word comprehension.
Comparison of Key Features
Syndrome Typical Early Symptom Pathological Hallmark
Alzheimer's Short-term memory loss Amyloid plaques, Tau tangles
Vascular Executive dysfunction, slowed thinking Ischemic/Hemorrhagic damage
Lewy Body Visual hallucinations, fluctuations Alpha-synuclein (Lewy bodies)
Frontotemporal Personality change or aphasia Tau or TDP-43 protein
Symptoms commonly occurring in many dementia syndromes
Symptoms vary depending on the area of the brain affected, but they generally fall into two categories:
Cognitive Changes
Memory loss (usually noticed by someone else first).
Difficulty communicating or finding the right words.
Disorientation regarding time and place (getting lost in familiar areas).
Difficulty with complex tasks, such as managing finances or following a recipe.
Psychological Changes
Personality shifts (a gentle person becoming aggressive)
Depression or anxiety.
Inappropriate behavior in social settings.
Paranoia or seeing things that aren't there (hallucinations)
The 7 Stages of Progression
Dementia is progressive, meaning it gets worse over time. Doctors often use a 7-stage scale to track it:
No Impairment: No symptoms.
Very Mild Decline: "Senior moments" like forgetting where keys are.
Mild Decline: Noticeable forgetfulness; trouble at work or in social settings.
Moderate Decline: Difficulty with math, bills, or remembering personal history
Moderately Severe: Needs help choosing clothes or remembering their own phone number.
Severe Decline: Requires help with dressing/toileting; personality changes occur.
Very Severe: Loss of speech and physical control (swallowing, walking).
Vital Facts (2025 Statistics)
Prevalence: In 2025, an estimated 7.2 million Americans aged 65+ are living with Alzheimer’s (so far diagnosed).
Risk Factors: Age is the biggest factor, but others include genetics, smoking, untreated hearing loss, poor sleep hygiene and sedentary lifestyle.
The "Sandwich Generation": About 25% of dementia caregivers are "sandwiched," caring for both an aging parent and their own children simultaneously.
If you or someone you know is having trouble with memory or daily activities, reach out to us. Early diagnosis and support can make a big difference.
Dr. Sadikovic has experience in diagnosis, workup and treatment for dementia including management of anti-amyloid therapies.
She works closely with infusion centers to provide access to these therapies in safe and efficient way. If you are interested in scheduling an appointment for a memory assessment, please don't hesitate to reach out to us. We look forward to assisting you.