Dementia: Pathophysiology, Diagnosis, and Management

A Continuing Education Article for Pharmacists

Dementia was the leading cause of death in Australia in 2024, with deaths increasing by 39% over the past decade.

Understanding Dementia

Dementia is not a single disease but a syndrome characterised by progressive cognitive decline that interferes with daily functioning. It affects memory, thinking, behaviour, and the ability to perform everyday activities.

Types of Dementia

Recognising the Signs and Symptoms

Common symptoms include memory loss, impaired planning, confusion, language difficulties, and changes in mood or behaviour. Individuals may struggle with familiar tasks, experience disorientation in time or place, and exhibit poor judgment. Personality changes and withdrawal from social activities are also frequently observed.

Diagnosis

Diagnosis involves a comprehensive physical examination combined with validated cognitive assessment tools:

• Mini-Mental State Examination (MMSE)
• General Practitioner Assessment of Cognition (GPCOG)
• Montreal Cognitive Assessment (MoCA)

For Aboriginal and Torres Strait Islander peoples, the Kimberley Indigenous Cognitive Assessment (KICA) has been validated as an appropriate screening tool.

Risk Factors

Non-Modifiable Risk Factors

• Increasing age
• Family history of dementia
• Presence of the APOE4 allele

Potentially Modifiable Risk Factors

Intervening on modifiable risk factors may prevent or delay up to 40% of dementia cases.

Key modifiable factors include:

• Smoking
• High alcohol intake
• Low educational attainment
• Head injuries
• Hearing impairment
• Hypertension
• Obesity
• Sedentary lifestyle
• Social isolation

Management: A Focus on Quality of Life

The primary goal of dementia management is to maintain quality of life and independence for as long as possible.

Non-Pharmacological Approaches

These are considered first-line treatment for changed behaviours:

• Cognitive stimulation therapy
• Physical activity programs
• Social engagement and support groups
• Environmental modifications (e.g., clear signage, reduced clutter)
• Behavioural interventions for agitation or aggression

Pharmacological Treatments

Indicated for mild to moderate Alzheimer's disease:

• Donepezil
• Galantamine
• Rivastigmine

These medications work by increasing levels of acetylcholine in the brain, which can temporarily improve symptoms. They do not slow disease progression.

Indicated for moderate to severe Alzheimer's disease. It regulates glutamate activity and may help with cognition and daily function in later stages.

New Therapies: Monoclonal Antibodies

Donanemab and lecanemab are monoclonal antibodies approved for early symptomatic Alzheimer's disease. These treatments target amyloid-beta plaques in the brain.

Important: These medications are not PBS-subsidized and require regular MRI monitoring due to the risk of brain swelling (ARIA).

Access is currently limited and requires specialist assessment in designated treatment centres.

The Pharmacist's Role in Dementia Care

Pharmacists play a critical role across the care continuum:

Medication Review and Deprescribing

Consider deprescribing anticholinesterases if:

• Used for types of dementia with limited evidence of benefit (e.g., vascular dementia alone)
• No clear benefit observed after 12 months of treatment
• Significant adverse effects occur (e.g., nausea, bradycardia, weight loss)

Supporting Carers and Families

• Provide education on proper medication administration
• Recommend adherence aids (blister packs, dosette boxes)
• Identify potential drug interactions, especially with anticholinergic medications

Monitoring and Referral

• Monitor for adverse effects
• Facilitate referrals to Dementia Australia and Carer Gateway
• Encourage use of the National Dementia Helpline

Resources for Support

• Dementia Australia – Information, counselling, and support groups
• Carer Gateway – National support service for carers
• National Dementia Helpline – 1800 100 500

Learning Outcomes

By completing this article, pharmacists should be able to:

1. Describe the causes of dementia – including Alzheimer's disease, vascular dementia, frontotemporal dementia, and Lewy body dementia
2. Identify the signs and symptoms – memory loss, impaired planning, confusion, language difficulties, and mood changes
3. Discuss management strategies – prioritising non-pharmacological approaches and understanding appropriate pharmacological options
4. Describe the pharmacist's role – medication review, deprescribing, supporting carers, and facilitating access to resources