Synopsis
Recognise the older-adult Alzheimer phenotype, establish functional and collateral evidence with appropriate imaging and specialist diagnosis, use cognitive medicines safely within licence and NICE guidance, and coordinate autonomy, carers and progressive support.
- Typical Alzheimer disease begins insidiously with impaired learning and retention of new episodic information, then affects orientation, language, visuospatial and executive function.
- Diagnosis combines progressive cognitive change, interference with function, collateral evidence, examination, exclusion of delirium and contributors and structural imaging.
- MRI commonly shows medial temporal and later generalised atrophy but imaging supports rather than proves the diagnosis.
Key red flags
Hours-to-days change, marked fluctuation or altered arousal suggests delirium superimposed on Alzheimer disease.
Acute inattention or altered arousal represents new physiological illness, not an overnight Alzheimer stage change.
Investigation priorities
Establish the progressive amnestic phenotype.
Management branches
An insidious amnestic and functional decline is reported.
- Exclude delirium and modifiable contributors and obtain detailed collateral with accessible cognitive testing.
- Complete examination, standard blood work and structural imaging and assess mixed pathology.
Mild-to-moderate Alzheimer disease is diagnosed and treatment is consistent with goals.
Key medicines
DonepezilStart 5 mg orally once daily, often at night; after at least one month, increase to 10 mg once daily only if tolerated and clinically appropriate.
MemantineStart 5 mg orally each morning and increase by 5 mg at weekly intervals to 20 mg once daily if tolerated; reduce the ceiling in significant renal impairment according to product information.