#66684: The Aging Brain

Through the process of aging and traumatic events, mild signs of neurologic dysfunction may begin to show. MCI is a spectrum of mild but persistent memory loss that lies between normal age-related memory loss and diagnosed dementia and AD. The memory deficits are beyond those expected for the person's age, and the individual persistently forgets meaningful information that he or she wants to remember. However, other cognitive functions may be normal, there is little loss of ability to work or function in typical daily activities, and there are no other clinical signs of dementia. MCI affects 15% to 20% of the aging population [9]. The presence of MCI may be the factor that influences the course of dementia toward AD. Among those with MCI, approximately 15% develop dementia after two years and approximately 32% develop AD within five years [9]. The signs of MCI go beyond those described as normal signs of aging. This level of impairment may last for a short time or for years.

In one study of older individuals without dementia, 16% had signs of MCI. Of these, 69% had amnestic MCI and 31% had nonamnestic MCI. The prevalence of MCI increased with age and was greater in men, those who were never married, and those with an ApoE3/4 or ApoE4/4 genotype [17]. Another study found that MCI was less prevalent among those with higher educational and income levels [18]. Further, there is some evidence that brain atrophy may be slowed in those with MCI with high doses of homocysteine-lowering B vitamins [19]. The fact that women are less likely than men to have MCI suggests that they may transition from normal cognition to dementia at a later age and more abruptly.

While progressive, the first step on the pathway to dementia is not always memory loss. Impairments of other cognitive skills, such as map reading, working jigsaw puzzles, and other visuospatial skills mediated in the right hemisphere of the brain, may be early signs of cognitive impairment [14]. Researchers have found that financial decision making and arithmetic functions decline one to three years earlier than memory functions [20]. Other signs were related to executive and attentional skill decline. Such research findings are important to the process of early detection of MCI, which can lead to earlier initiation of treatment and preventative measures for more advanced cognitive impairment. Early intervention among high-risk populations is an urgent area of research and experimental studies.

Dementia is a progressive and profound disruption in brain function and intellectual capacity. The primary signs include problems with memory, language, spatial-temporal reasoning, judgment, emotionality, thought disorder, and personality. Dementia is a subtle progressive loss of cognitive functioning, with memory loss as its hallmark impairment, particularly loss of short-term memory. The ability to concentrate, make judgments, problem solve, and engage in abstract thought processes is also impaired. Personality and mood changes distinct from previous experiences are likely to develop, such as depression, apathy, elation, and anger. Impulse control becomes a major impairment with associated difficulties in social and physical relationships. Finally, grandiose and persecutory delusions are fairly common, especially in the more advanced stages of dementia [21]. It is possible for a young person to have dementia, but this is usually a result of a neurologic traumatic event or major illness with neurologic corollaries.

Dementia is a physical illness as well. It progressively shuts down the body as the brain is attacked. The first signs of dementia are generally related to reduced physical agility and strength, not just cognitive skills. Dementia can continue for years, but in the advanced stages, life expectancy is similar to that seen with advanced terminal cancer [22].

While 60% to 80% of cases of advancing dementia are categorized as the Alzheimer type, other disorders may fall within the broader classification of dementia [9]. These include but are not limited to [9,23]:

There are also many reversible conditions that can mimic dementia [9]. For this reason, dementias must be fully assessed and diagnostically clarified [24]. Specific disorders known to cause pseudodementias include but are not limited to:

Likewise, there are irreversible conditions known to play a significant and contributing role in dementia onset. These fall into three primary nosologic categories: systemic changes, neuropathologic changes, and underlying basic diseases. It is essential that the clinician or therapist is able to conduct a competent diagnostic evaluation to sort out these conditions and determine if dementia is diagnostically present or if dementia is a symptomatic trait of another medical or physical condition. A medical referral is encouraged in such cases. The following sample of physical conditions may or may not present with dementia:

An annual screening system called the Early Detection and Screen for Dementia was developed by the National Task Group on Intellectual Disabilities and Dementia Practices for the early detection of dementia (abbreviated NTG-EDSD) [25]. The NTG-EDSD is designed to be incorporated into an annual physical examination or incorporated into wellness screening programs. The results of a screening assessment indicates if a referral for neuropsychologic assessment or further evaluation is needed. A baseline should be established at 65 or 70 years of age to ensure that a reasonably accurate profile is established and false positives minimized. The NTG-EDSD is available online at https://www.the-ntg.org/ntg-edsd[25].

AD is an advanced type of dementia named for German physician, Alois Alzheimer, who first identified the neuritic plaques and neurofibrillary tangles now recognized as the classic signs of AD. It is thought that these brain changes and conditions result from the destruction of neurons that produce acetylcholine in the cerebral cortex. With AD, the brain is believed to have a loss of nerve cells in certain areas and a corresponding reduction in the levels of neurotransmitters. AD is rapidly progressive, and its pattern and progression is individualistic [28].

As noted, the primary symptoms of dementia are mild-to-moderate impairments in memory, reasoning ability, and judgment, and the same symptoms are present in AD but to a greater degree. AD also often includes personality changes, bouts of agitation and combativeness, falling, wandering, and depression. The risk of self-harm from accidents and falls becomes progressively more likely. According to the Alzheimer's Association, the warning signs of AD are [29]:

However, it is important to remember that the signs and progression of the disease varies greatly among patients. Eventually, all patients with AD will require constant care with activities of daily living. Wandering and sundowning are frequent problems. It is vital that lost patients are found within 24 hours, as after this period the odds are strong that they will develop a serious illness, be injured, or die, as patients with AD are essentially unable to ask for help.

Many people with dementia will not progress to AD. However, of all those with dementia, 60% to 80% develop the pattern of AD [9]. AD is more prevalent in women than men. Of the 6.7 million people 65 years of age and older with AD in the United States, 4.1 million are women and 2.6 million are men. Among people 65 years of age and older, 12% of women have AD and other dementias, compared with 9% of men [9]. The number of new cases of AD increases proportional to the increase of older adult populations. The annual incidence among those between 65 and 74 years of age is 0.4%. Between 75 and 84 years of age, this increases to 3.2%; it is 7.6% in those 85 years of age and older [9]. The prevalence of AD is expected to grow from 6.1 million in 2020 to nearly 14 million in 2060, largely due to the increase in the older adult population [9].

Among individuals 70 years of age, 61% of those with AD are expected to die before age 80, compared with 30% of those without the disease [9]. It is anticipated that deaths due to dementia will gradually increase from about 400,000 in 2010 to 1 million worldwide in 2030 [31]. AD is also a condition with catastrophic community impact and complex care needs. In 2022, more than 11 million Americans provided 18 billion hours of unpaid care to individuals with AD and other dementias, a contribution of nearly $340 billion [9].

Total home care with hired caretakers or placement in a nursing home is necessary as AD progresses to higher levels of impairment. While family members may wish to be the sole caretakers, the level of care needed very often reaches a point that is beyond their level of ability, stamina, and time. If the family is unable to provide the needed care themselves, they may make arrangements for care provided in a loving and compassionate manner by a third party, such as a friend, a home health care provider, or a nursing home. Who provides the day-to-day care is less important than the quality of care provided relative to the patient's needs and level of functioning.

As the progression of AD is rapid, it is important to consider if any family member has any "unfinished business" that should be constructively addressed early in the disease process. Devoting time to being a care provider is reasonable when there is a clear sign that long overdue forgiveness, past hurts, or neurotic attachments have been resolved. If there are issues that are unaddressed, this may result in further injury in addition to historical hurts and dysfunctional relationships. While the care level may look reasonable, it may really be subtly destructive. Neurotic attachments are all too common and create a host of care problems.

An estimated 1.4 million people in the United States have DLB, a total of 5% to 10% of all dementia cases [16,26,27]. DLB is not readily diagnosed, as it presents with symptoms closely aligned to AD and/or Parkinson disease. If inaccurately diagnosed, a proper care plan will not be formulated and the patient and his or her family will be unable to prepare for the disease's progression.

Lewy bodies, named for F.H. Lewy, who first described the condition in 1914, result from a buildup of alpha-synuclein protein in neurons in the brain [32]. This is distinct from the beta-amyloid protein fragments (plaques) and twisted strands of tau proteins (tangles) found in AD [32]. DLB is associated with dysfunction of the lower brain, brainstem, and subcortical, paralimbic, limbic, and cortical structures vital to movement and cognition. The severity of symptoms fluctuates over time, with improvements and regressions [28]. However, this dementia will eventually progress to catastrophic disability and death, as with AD.

The most common signs and symptoms of DLB are visual hallucinations, spontaneous parkinsonism, narcoleptic sensitivity, a tendency to act out vivid and frightening dreams, and fluctuations in cognition, alertness, clarity of thought, and attention [33].

Patients with DLB have more difficulty with visual perception and memory, processing speed, and attention/concentration [16]. Visual tasks are more likely to be distorted than in most patients with AD. Visual distortions tend to show up early in the dementia process, including distortions in writing, drawing, and misjudging distances. Brighter light may reduce visual hallucinations, as will removing reflective or patterned surfaces (e.g., mirrors, wallpaper with designs) and having the patient stare directly at the hallucination [33]. Hallucinations are often not acknowledged by the family; therapists must ask about them directly, especially early in the dementia process.

To assess DLB, a standardized and validated screening tool, such as the Mayo Fluctuations Composite Scale, should be used. Neuroimaging may be useful to distinguish DLB from vascular dementia [32]. Treatment to reduce symptoms may be indicated. Acetylcholinesterase inhibitors are the medications of choice, including donepezil, rivastigmine, and galantamine. This class of medication has been shown to improve attention, sleep, ambulation, motor coordination, and visual hallucinations for patients with DLB [16]. The medication regimen should be re-evaluated every six months and altered or maintained as the relative benefits indicate [34]. Due to neuroleptic sensitivity and reduced dopamine, typical neuroleptic or antipsychotic medications, such as haloperidol, ziprasidone, and olanzapine, must be avoided as much as possible for the treatment of psychotic symptoms. If such medication is used, patients will experience increased or worsened symptoms and become more rigid.

Traditionally, predicting the occurrence or onset of dementia has been thought to follow the threshold model. This model holds that individuals will exhibit dementia only when their functional cognitive reserve falls below a certain specific threshold. According to this theory, the brain has a certain density or reserve and functions well so long as the reserve is sufficient. Reserve capacity is considered largely an individual matter, and according to this theory, it may be replenished with cognitive exercises.

The threshold model draws much support from a seminal study comparing dementia rates among Catholic nuns [35]. In this study, nuns with a long history of a complex linguistic and prose writing style (high density) had a much lower lifetime rate of dementia and/or AD compared to nuns with a simple linguistic and prose writing style (low density). Research at Johns Hopkins University also found that Catholic nuns with advanced language skills in early life were less likely to suffer memory problems in their later years [35].

Additional studies have linked cognitive or linguistic skills in the early years of life to the level of cognitive functioning later in life, with stronger predictive value than environmental or lifestyle factors [36]. Low or poor linguistic ability in early life would then be indicative of the extent of AD or dementia brain pathology present at death. However, more research is necessary to support this hypothesis.

Certain patient behaviors and lifestyles have also been implicated in dementia onset. These patient behaviors are generally highly modifiable and are therefore a useful part of patient teaching regarding maintenance of brain health.

At least four genes have been implicated in the development of AD, including the amyloid precursor protein (APP) gene, ApoE4, and the presenilin 1 and 2 genes [56]. APP is a protein from which beta-amyloid, the chief component of plaques seen in the brains of patients with AD, is formed, while ApoE helps transport cholesterol in the blood [54]. Mutations of the presenilin 1, presenilin 2, and APP genes cause early-onset, autosomal dominantly inherited AD; mutations on chromosomes 1, 14, and 21 account for the majority of all of these cases [15,58]. ApoE4 is found in about 40% of the cases of late-onset AD [15]. It is possible to test family members with no symptoms of the disease to determine whether they carry the mutated gene, thus ascertaining their risk for developing AD. As noted, if the carrier is also a smoker and/or heavy drinker, the onset age of AD is likely to be earlier [37].

Symptoms seen with AD are partially the result of damage to the hippocampus and the cerebral cortex. The size of brain, especially the size of the hippocampus, may contribute to dementia risk. Memory storage and formation is primarily centered in the hippocampus, and neurofibrillary tangles generally build up in the hippocampus before moving to other portions of the brain. In one study, those with larger brains and larger hippocampi were found to have less brain plaque and fewer tangles. Hence, they tend to be less likely to develop AD. If true, it may be that some individuals are born with larger brains and hippocampi, which require more plaque in order for memory functions to break down. Alternatively, some other factor may protect certain brains from shrinkage and/or tangle formation [59,60,61].

In one study of healthy, symptom-free adults 44 to 48 years of age, those who performed poorly on a simple test of cognitive ability were much more likely to have a lesion in the white matter of the brain. Magnetic resonance imaging (MRI) was utilized to detect the brain's integrity and predict those at risk for developing AD in the future [62].

Researchers at the Rush University Medical Center and the Alzheimer's Disease Center have found that MRIs of patients with AD can demonstrate structural change in the substantia innominata over time [63]. The substantia innominata sends messages to the cortical areas of the brain, and thinning of these cortical areas is consistent with AD. Cortical thinning could be a biomarker to identify those at risk for AD, and research is ongoing in this area.

Still more research suggests that toxic clumps of amyloid beta called oligomers may be the main causative factor in the brain changes associated with AD, not plaque buildup. Several medications are being studied for their ability to cease or slow the production of oligomers. The research is still unclear on this underlying biologic question, and additional studies regarding the role of oligomers are necessary before conclusions may be reached [49].

The correlation between ADHD and dementia has also been an area of interest. One study found an increased incidence of adult ADHD and AD among those who had a diagnosis of ADHD as a child, especially if the disorder was untreated. The mechanism of this correlation is unclear. Children and adolescents with ADHD are at an increased risk for traumatic brain injuries, alcoholism, depression, and other neurologic problems later in life, all of which increase the risk for AD development [28].

The intake of brain toxins is another possible contributing factor in the development of MCI, dementia, and AD. Aluminum, a metal associated with chronic toxicity, has been linked with AD. High concentrations of aluminum have been found in the brains of some individuals with AD, although the exact nature of the correlation is not known [64]. The accumulation of aluminum may be responsible for the changes within the brain, or it might be secondary to the cause(s) of AD. Some research suggests that exposure to aluminum in municipal drinking water (used as a clearing agent during treatment) possesses greater potential for chronic toxicity than exposure from other sources, such as aluminum cookware, and that high intake of aluminum from tap water may be a risk factor for AD [65,66]. Other researchers speculate that fluoride ingestion (at exposure levels experienced by regular fluoridated drinking water consumption and toothpaste use) greatly enhances aluminum's neurodegenerative effects [67]. A higher level of silicon intake is thought to protect against aluminum toxicity. Research into the possible role of aluminum in the development of AD is ongoing [75].

In addition to aluminum, other transition metals (e.g., copper, zinc, iron) are implicated as possible causative factors for AD [65,68]. Oxidative stress, induced from either excesses or deficiencies of these metals, is theorized as being pathogenic. Iron overload, copper depletion, and zinc overload/depletion have been found in AD brains by various research groups. However, these findings were called into question by a 2011 meta-analysis that discovered citation bias toward irreproducible research, especially regarding iron overload [68]. Concrete evidence for transition metal pathogenesis is currently lacking.

While scholars agree that there may be several environmental factors for AD, no exposures, including pesticides, general air pollutants, lead, microplastics, and other toxins, have been positively linked to this form of dementia. Taking proactive steps to prevent oxidative damage, improve vascular health, and create a healthier lifestyle overall, seems to be the best defense against many environmental risks.

Mental status examinations alone are not definitive for establishing a diagnosis of AD; however, they are central to the diagnostic process and provide important information for developing a more complete clinical picture. Additionally, assessment offers a baseline for monitoring the progression of the disease and can be used to reassess mental status in people who have delirium or depression upon initial evaluation. All behavioral and psychologic symptoms should be assessed and documented.

There are several mental status examinations that may be used, including the Mini-Mental State Examination, the Blessed Information-Memory-Concentration Test, the Blessed Orientation-Memory-Concentration Test, the Short Test of Mental Status, and the Mini-Cog. One study found that compared to the more commonly used Mini-Mental State Examination, the Short Test of Mental Status was slightly more sensitive in identifying individuals with cognitive impairment and was significantly better at differentiating MCI from AD and predicting progression to AD [70].

The measurement of memory could also be obtained by the use of one of several informal tests of memory, such as the 10-word memory test, the 10-picture memory test, or the 10-number memory test. Additionally, memory and cognitive function may be assessed by several subjective measures, such as drawing a key or clock (with the hands at 10 minutes after 11 o'clock), asking the patient to write out a complete sentence, asking the patient to spell one or two words backward, or asking the patient to reproduce a very simple but complex design [57].

When administering and interpreting any of these tests, one must be sure to consider the presence of sensory impairments, physical disabilities, and the age, educational level, and cultural influences of the individual being studied [71].

Neuropsychologic testing may be appropriate when the mental status test is abnormal but the functional test is normal; when a family member expresses concern or dementia is suspected and results of mental status tests are within the normal range; when the patient has an advanced academic degree; or when the patient's occupation indicates high premorbid intelligence [72]. Preferably, this testing is completed by a specialist in neuropsychology.

When mental status test results indicate cognitive impairment, the results of neuropsychologic testing must be considered with the results of other assessments and the patient's history when any of the following circumstances apply:

Communication with patients regarding personal and family history is a necessary step in identifying dementia and obtaining an accurate diagnosis. When there is an obvious disconnect in the communication process between the practitioner and patient due to the patient's lack of proficiency in the English language, an interpreter is required.

MRI is able to measure with considerable accuracy the size of intracerebral structures, such as the hippocampus, that are associated with AD [73]. It has been found that patients with AD have a decreased volume of the hippocampus when compared to nonaffected individuals, and patients with some degree of atrophy are more liable to develop AD. MRI is also able to image cerebral atrophy and other abnormalities that are associated with decreased cognition or dementia. Noncontrast computed tomography can also help in the diagnosis by identifying structural changes, such as infarcts or mass lesions, that could produce cognitive changes [74].

According to the Alzheimer's Association and the Society of Nuclear Medicine and Molecular Imaging, amyloid imaging is inappropriate to determine dementia severity.

(http://s3.amazonaws.com/rdcms-snmmi/files/production/public/FileDownloads/HPRA/Appropriate%20use%20criteria%20for%20amyloid%20PET.pdf Last Accessed: March 19, 2024)

Level of Evidence: Expert Opinion/Consensus Statement

Single photon emission tomography (SPECT) and positron emission tomography (PET) are noninvasive imaging techniques that provide information about cerebral function and regional cerebral blood flow. Cerebral glucose metabolism can be studied with PET using fluorodeoxyglucose [74]. The ability to image the regional metabolism of the brain and locate areas of diminished function has been of particular importance in advancing the ability to diagnose AD. These techniques help to differentiate AD from other causes of dementia but should not be used as the primary diagnostic measure [54,76,77,78,79,96]. One of the benefits of these tests is the ability to help identify people in the early stages of AD or those with MCI who may benefit from treatments that are now being offered or may soon be developed.

While advances in several imaging techniques are being explored, one study has examined the use of PET in conjunction with a radioactive tracer. This tracer, known as Pittsburgh Compound B, adheres to amyloid clumps in the brain, which are then easily detected by PET scans. AD subjects retained the tracer, while control subjects had a rapid loss of the compound. It has been found that AD, MCI, and healthy control groups are strongly distinguished using Pittsburgh Compound B PET and are even more clearly distinguished when combined with the results of fluorodeoxyglucose PET [74].

A novel tracer compound, 18F-AV-45, is currently being researched as an alternative to Pittsburgh Compound B [80]. In several small-scale studies it has shown a high affinity for beta-amyloid plaque binding in AD brains, and stained areas match reliably with postmortem exams. In a consecutive case series of 30 patients 50 to 89 years of age being evaluated for MCI or dementia, researchers found that PET imaging with 18F-AV-45 caused a change in diagnosis in 10 patients and clarified the diagnosis in 9 patients. The procedure also prevented the initiation of incorrect or suboptimal treatment and avoided inappropriate referral to an anti-amyloid clinical trial [81].

Elder abuse is a real threat for patients with dementia [90]. They are at risk for financial, physical, emotional, and sexual abuse, particularly from caretakers, family members, and even healthcare providers. Any suspicion of abuse should be reported to the adult social services department of the state and county in which the patient is living. Abuse can be intended (e.g., physical abuse) or unintended (e.g., neglect). Perpetrators of elder abuse may be motivated by many different factors, from overwhelm and burnout to sadism [90]. Some perpetrators are financially dependent upon the victim, leading to an imbalance in the relationship and dangerous expectations. Financial abuse is common, for example, by a child or grandchild who has been dependent on the elder for years and is now seeing their "support funds" being terminated and bank accounts closed. Health and mental health providers should be vigilant for any signs of abuse or neglect.

Signs of financial abuse or neglect should be closely monitored. This can be done by monitoring the interaction of family members/carers with patients, particularly behaviors involving finances and/or signing documents such as wills, trusts, or bank accounts. If necessary, an ombudsman or the patient's attorney should be consulted. If the patient is in a care facility, the facility's attorney may be a resource.

The U.S. Preventive Services Task Force recommends screening for depression in older adults.

(https://jamanetwork.com/journals/jama/fullarticle/2806144 Last Accessed: March 19, 2024)

Level of Evidence: B (There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.)

Older Americans are at an increased risk for suicide. Individuals older than 65 years of age comprise 16.8% of the population but represent 20.0% of all suicide deaths. The rate of suicides for the elderly in 2021 was 17.3 per 100,000, with one elderly suicide every 54.5 minutes [91]. Persons older than 85 years of age, especially white men, have the highest rate. Although the elderly attempt suicide less frequently than other age groups, they have a higher completion rate [91]. Common risk factors for suicide in the elderly include [91]:

A dementia diagnosis encompasses several of these risk factors, and these patients should be monitored closely and directed to appropriate professional help. The loss of health, purpose, or meaning must be addressed at all stages of aging, but even more so in the later years of life.

Suicide among elderly patients with dementia may be subtle or camouflaged, manifesting as refusal to eat and/or drink water and fluids, rejection of prescribed medication, or intentional isolation from any social contact. These more passive suicide attempts are especially common among older persons in nursing homes or other care settings who have no other means.

Alcohol abuse/dependence in the elderly is generally a hidden problem. Many elderly individuals do not disclose alcohol abuse because they are ashamed. This is compounded by healthcare professionals' reluctance to ask older adults about alcohol abuse, mostly due to the prevalent images of young people misusing substances [92]. Older adults are more likely to hide their alcohol use and less likely to seek professional help, and their families, particularly adult children, are often in denial or are ashamed of the parent's problem [93]. Additionally, the symptoms of alcohol abuse can mimic or resemble conditions associated with aging, including dementia, thereby masking an underlying drinking or substance disorder [92,93]. Finally, some older adults may be isolated, with minimal social contacts or networks to intervene in cases in which alcohol or substance use has become a problem.

According to the National Council on Alcoholism and Drug Dependence, older adults exhibiting symptoms of alcoholism comprised 6% to 11% hospital admissions, 20% of admissions to psychiatric services, and 14% of emergency room admissions [94]. The prevalence of alcoholism in the older population is estimated to be 10% to 18%. It is the second most frequent reason for admitting elders to inpatient psychiatric facilities [95]. Less than 2% of all admissions for alcohol treatment are people older than 55 years of age [94]. Among nursing home residents, it is estimated that as many as one-half have problems related to alcohol [94,95].

Late-onset alcoholism is common in the elderly, and several risk factors may contribute to the development of alcohol use disorders in older age. Some may use alcohol to self-medicate physical symptoms, such as difficulty sleeping or chronic pain. Mourning a loved one, loss of social supports, and loneliness can also instigate alcoholism later in life [93].

One study found that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for alcohol use disorder might be difficult to apply to older adults [98]. For example, age-related physiologic changes may change an individual's response to alcohol, increasing his or her sensitivity and lowering their levels of tolerance. These persons would not meet the DSM-5 criteria for alcohol use disorder, as they would require smaller amounts of alcohol to become intoxicated. In addition, the DSM-5 criterion of giving up activities or responsibilities as a result of substance use may not be appropriate for older adults because they may engage in fewer regular activities due to diminished vocational or social responsibilities [100].

After a diagnostic assessment, treatment of alcohol abuse in the elderly may include close monitoring, attendance at 12-step programs, group therapy, increased socialization, and/or medication. For patients with dementia, the urge to drink will likely be lost eventually, but it is important to prevent overconsumption, as it may exacerbate symptoms.

Falls are common among the elderly and can cause serious injury and even death. Decreased mobility, medication side effects, and confusion/disorientation can all predispose the elderly patient with dementia to falls. Patients and their families should be counseled regarding the importance of fall prevention strategies. Elderly persons' medication profiles must be reviewed relative to their potential contribution to falling. The home environment should also be modified to decrease the risk of falls, keeping pathways cleared and well lit, removing unstable furniture, and eliminating throw rugs and extension cords. Referral to physical therapy for balance training and strengthening may be considered. In addition, occupational therapy is appropriate if modifications in the home are necessary.

It is important for older people to feel loved and cared for. Romance, connection, physical touch, and sex remain important to people as they age and should be considered part of an individual's overall health and well-being. Individuals may be encouraged to explore new ways of spending time with other people and showing affection, including hand-holding, hugging, massage, and dancing. Some may benefit from education on positive aspects of interpersonal relationships. In some patients, hypersexuality may develop. This can be a manifestation of dementia (e.g., frontotemporal dementia) or the effect of medications.

Wandering behavior is relatively common among persons with dementia, especially at sundown [103]. It can be unintentionally dangerous, and it is important for all persons with dementia to carry some for of identification (e.g., medical bracelet) at all times. It can also be helpful to alert neighbors and local law enforcement of the possibility of wandering. Door should be kept locked whenever possible, with an alarm and/or a two-step lock including a deadbolt recommended.

Individuals with dementia may become confused, frustrated, and easily agitated as they become unable to perform formerly routine tasks. When agitation is frequent or excessive, pharmacotherapy may be necessary. It is also important to take steps to protect the individual from harming him/herself and others. This may consist of creating a calm environment (e.g., quiet, reduced clutter) and providing continuing care, support, and reassurance.

Paranoia is a form of delusion in which an individual is fearful, jealous and/or suspicious of others. When a person with dementia displays paranoia, it is best not to directly react. Instead, the individual should be reassured that s/he is safe and protected. It can be helpful to redirect the individual to a different task or activity to interrupt paranoid thinking patterns.

All individuals, including those with dementia, have spiritual needs, and spiritual health is part of holistic care. As much as possible, individuals should remain part of their faith community. Spirituality and religion should be incorporated into discussions and daily activities as much as is desired. In some cases, spiritual music may be comforting. Members from the individual's faith community may be encouraged to remain connected.

The risk of driving-related accidents is increased among the older population, and impaired mental status due to cognitive impairment and/or the effects of certain medications can increase risk further. Restricting an individual's driving causes a considerable loss of independence and can be a highly sensitive issue, and the decision should be collaborative, if possible. A dementia diagnosis alone is not considered grounds to revoke driving privileges. Other factors must be present, including cognitive decline and comorbidities [101]. Many states require physicians to report impaired drivers, especially if there is a history of a closed head injury. However, laws vary regarding reporting by other service providers. Professionals are encouraged to study their own state's laws. There are driving schools and classes in many communities specifically designed to assist the elderly in maintaining their driving skills and license, which may be an option for some individuals.

It is also important to assess if alcohol or drugs are playing a role in an elderly driver's abilities. Efforts to intercede to stop drinking/substance abuse or to keep an impaired patient from driving may be necessary.

Informed consent requires awareness of relevant information and the demonstrated competency to understand the nature of an issue under consideration and its implications and consequences. Agreement from patients who lack the capacity to give consent actually results in no consent at all. In such cases, the patient requires a healthcare surrogate to be designated through the process of a conservatorship, a will and an advance directive for health care, and/or the appointment of a power of attorney. These surrogates are sometimes referred to as the responsible party (RP). Failing a provision for consent to be granted by some preauthorized RP, healthcare and/or financial decisions require court intervention.

If a patient has a preapproved healthcare surrogate, as outlined by law or an advance directive, all treating professionals and facilities should have a copy of the document on file. This is an area of frequent abuse and boundary violations, even by well-meaning family members. The provider of service must be careful to assure that informed consent or permission of the RP has been granted before proceeding, even when the intended service seems necessary and/or obviously desired. Consent to proceed with any treatment or financial dealing must be with the consent of the RP, and all communication regarding the patient is with and through the RP.

Medication management and polypharmacy are major concerns for older adults. An estimated 30% of individuals older than 65 years of age take five or more prescription medications [102]. This number does not take into account over-the-counter medications, vitamins, minerals, and dietary supplements. Taking multiple medications and supplements significantly increases the risk of interaction with foods, other medications, and alcohol.

Common medication problems include incorrect dosage, erratic drug use, misuse of over-the-counter medications, drug interactions, mixing medications and alcohol, use of drugs at the wrong time of the day, using medications prescribed for another person, using two or more medications with synergistic effects, and using several medications with profound side effects or that might be contraindicated due to comorbid conditions.

Aging itself can contribute to unforeseen medication problems. Older individuals tend to absorb, metabolize, and excrete medications at a slower rate. Many older people also have major complicating medical problems, such as Parkinson disease, cardiovascular difficulties, neurologic disorders, infections, and vertigo, that may be impacted by various medications. In general, older persons are at a greater risk for side effects. If present, cognitive deficits may lead to greater confusion regarding timed doses and medication use.

The move to a higher level of care is not an easy decision for any impaired person, family members, or healthcare providers. Each patient has different circumstances that must be taken into account. The decision usually involves consideration of a variety of psychologic, medical, financial, practical, and family issues. Often, it is based on the inability of the family to fully provide the needed level of care. If the family has been the sole care provider, burnout and exhaustion may be factors. It may even depend on the ability to adapt the home to accommodate the new needs of the patient. When selecting a facility, the focus should be on location and the competency and personability of the staff.

Generally, a patient will need to be hospitalized for three days to qualify for referral to a skilled nursing facility under the Medicare guidelines. Admission to an assisted living program, on the other hand, is not covered by Medicare or most health insurance plans. Long-term care insurance may be a financial help to offset medical costs and the costs of alternative nursing care, including home care.

Selecting a skilled nursing or assisted living facility is difficult for many families. The following may be offered to families to assist in making the best possible decision:

The number of individuals 85 years of age and older is growing steadily in the United States. In 2020, there were 6.7 million individuals in this age-group; this number is expected to grow to 19 million by 2060 [99]. Many people who live past 85 years of age fear they will outlive their resources. Providing education about healthcare savings programs throughout life may be helpful, even into the aging years. Preparation for long-term assisted living is essential, such as having long-term healthcare insurance, having a healthcare reserve fund, and being compliant with healthcare treatment plans (if possible). Regular exercise, rest, social support, and a good attitude are among the essential factors needed for healthy longevity [6].

Care providers tend to experience burnout within a few years of constant care of a loved one. In general, male caregivers experience burnout sooner than women. Care providers should try to take respite breaks at least one day per week. Taking mini-vacations can be helpful. Respite care coverage for even a few hours a day can also be helpful. The underlying lesson is for caretakers to take care of themselves physically and mentally, so they are able to continue to provide care for the loved one.