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  • Patients with advanced dementia.


American Geriatrics Society 2013

  • Percutaneous feeding tubes are not recommended for older adults with advanced dementia.

  • Careful hand-feeding should be offered.



  1. Careful hand-feedings and tube-feedings have identical outcomes of death, aspiration pneumonia, functional status, and patient comfort. In addition, tube-feeding is associated with agitation, increased use of physical and chemical restraints, and worsening pressure ulcers.



  • Adults.


NICE 2018

  • Donepezil, galantamine, and rivastigmine are options for mild-to-moderate Alzheimer disease.

  • Memantine is an option for moderate Alzheimer disease in patients who cannot tolerate acetylcholinesterase inhibitors, or in severe Alzheimer disease.


  • NICE Guidance: Dementia: Assessment, Management and Support for People Living with Dementia and Their Carers. NICE guideline (NG97); June 2018.


  1. Common adverse effects of acetylcholinesterase inhibitors include diarrhea, nausea, vomiting, muscle cramps, bradycardia, and insomnia.

  2. Common adverse effects of memantine are dizziness, headache, constipation, somnolence, and hypertension.

  3. Reassess the efficacy of the pharmacological intervention. If the desired clinical effect (eg, stabilization of cognition) is not perceived by 12 wk or so, discontinue the medication (AGS, 2015).

  4. Ineffective medications include statins, NSAID, ginkgo, omega-3 fatty acids (AAFP 2017).

American Geriatrics Society 2015

  • Avoid antipsychotics as first-line agents to treat behavioral and psychological symptoms of dementia.


  • American Geriatrics Society. Choosing Wisely Campaign. 2015.


  1. Antipsychotics have limited and inconsistent benefit while posing risks including increased fall, strokes, and mortality, oversedation, and cognitive worsening.

  2. Use should be limited to cases where nonpharmacologic measures have failed, and the patients pose an imminent danger to themselves or others. First aim to identify and treat the underlying cause of the behavior change.

  3. Use may be considered in patient with dementia who are experiencing agitation, hallucinations, or delusions that are severely distressing. (NICE, 2018)



  • Adults with non-Alzheimer dementia.


NICE 2018

  • Offer donepezil or rivastigmine in patients with mild-to-moderate dementia with Lewy bodies. Consider galantamine if donepezil/rivastigmine is not tolerated.

  • Consider memantine for patient with Lewy bodies if AChE inhibitors are not tolerated or are contraindicated.

  • Only consider AChE inhibitors or memantine for people with vascular dementia if they have suspected comorbid Alzheimer dementia, Parkinson’s disease dementia, or dementia with Lewy bodies.

  • AChE inhibitors and memantine are not recommended for patients with frontotemporal dementia or cognitive impairment caused by multiple ...

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