Educational scope notice: This is a study note for medical students, not medical advice, diagnosis, or treatment guidance. Clinical management should follow local protocols and current guidelines.
Alzheimer disease typically costs 2–4 Mini-Mental State Examination points per year, over an average course of 10–15 years from first symptoms to severe impairment, with plateaus between declines. The rate itself is diagnostic information: faster decline suggests recurrent strokes, superimposed delirium, or Creutzfeldt-Jakob disease, while stability over 6–12 months should prompt reconsideration toward mild cognitive impairment or a reversible cause. The Montreal Cognitive Assessment is the more sensitive tracker in early disease, catching executive and visuospatial change the MMSE misses.
Course by cause
Each dementia has a temporal signature. Behavioural frontotemporal dementia runs faster than Alzheimer disease, averaging roughly 3–5 years, because frontal degeneration shows in behaviour early. Lewy body dementia also outpaces Alzheimer disease as motor and cognitive losses combine. Vascular dementia drops stepwise, each stroke a discrete fall with partial recovery between. Creutzfeldt-Jakob disease is visibly progressive week by week, with survival averaging months. Mixed dementia should be suspected when vascular-labelled patients decline faster than their lesions explain or show disproportionate memory loss; amyloid PET can confirm the Alzheimer contribution.
Behavioural surveillance
Agitation, aggression, delusions, hallucinations, depression, anxiety, apathy, disinhibition, and sleep-wake disruption are the main drivers of caregiver burden and placement, more than raw cognitive scores. Track their frequency, severity, and triggers with a behavioural diary. New or worsening fluctuation in Lewy body dementia should trigger a search for infection, metabolic disturbance, or medication effects, with delirium excluded first. Late-day worsening responds to light exposure, structured activity, and avoiding sedatives.
Caregiver assessment
Ask about caregiver sleep, nutrition, help available, and mood at every visit, and watch for fatigue, irritability, withdrawal, and declining health. Discuss long-term placement proactively when the patient needs round-the-clock supervision, develops unsafe behaviours such as wandering or aggression, the caregiver’s health fails, or falls become frequent. Placement is appropriate care when home care no longer suffices, not a failure of it.
Medication review
Review cholinesterase inhibitors and memantine annually: they offer modest symptomatic benefit without slowing degeneration, so treatment that no longer shows meaningful response adds side effects without purpose. Watch for bradycardia, syncope, and gastrointestinal symptoms with cholinesterase inhibitors. Attempt antipsychotic reduction or discontinuation every few months, since many patients no longer need them and sedation, falls, and cerebrovascular risk accumulate. Benzodiazepines and anticholinergics worsen cognition and falls and should be deprescribed where possible. In amyloid angiopathy, review also extends to stopping antiplatelets and anticoagulants.
Evidence anchors
- NICE. Dementia: assessment, management and support (NG97): https://www.nice.org.uk/guidance/ng97