Dementia
Anti-amyloid antibodies are specialist care and are not covered here.
Don't miss
- INESSS Institut national d'excellence en santé et services sociaux
- MSSS Ministère de la Santé et des Services sociaux
| Decision | Guideline |
|---|---|
| Delirium | Delirium or acute confusion:Needs particular attention, reassessment or further investigation. |
| Fast or atypical course | Reassess or investigate further with:Rapid, unexplained decline in cognition or function; Focal neurological signs or gait disorder; Marked change in general state (fever, significant weight loss). |
| Urgent BPSD | Intervene quickly and decide whether the hospital emergency department is needed when:Suicidal danger or aggression toward others; Loss of autonomy with danger at home; Exhaustion of the support network; Acute medical instability. |
| Immediate danger | Danger to self or others:Direct to emergency services. |
Diagnose
- INESSS Institut national d'excellence en santé et services sociaux
- CTFPHC Canadian Task Force on Preventive Health Care
- CCCDTD Canadian Consensus Conference on the Diagnosis and Treatment of Dementia
| Decision | Guideline |
|---|---|
| Asymptomatic people | Systematic screening is not recommended in the asymptomatic general population. INESSS 2015, sheet 1 opens in a new tabCTFPHC 2024 opens in a new tabCCCDTD5 2020 opens in a new tab |
| Assess when | Only with symptoms or warning signs:A cognitive complaint from the person; An unusual deficit or difficulty reported by family; Clinical suspicion in a person at higher risk. |
| Diagnosis rests on | Documented cognitive impairment or behaviour change that:Interferes with usual daily activities; Is a decline from the previous level; Is not explained by a physical problem or a recognized psychiatric disorder. |
| Cognitive tools | MMSE is the most widely used.MoCA when mild cognitive impairment is suspected, or when concern persists with an MMSE of 24/30 or more (1B). Do not base the diagnosis on a screening test result alone (1B). |
| Exam | Full physical exam, focused on the neurological and cardiovascular systems.Check vision, hearing and mobility. Review all medication, with or without prescription and natural products, and adherence. |
| Confounders | Look for a cause or an aggravating factor:Drug adverse effect, new drug, interaction or prescribing cascade; Mental health problem; Physical problem (metabolic or deficiency disorder, systemic disease, sleep apnea, delirium); Drug or alcohol misuse. |
| Refer | Neuropsychologist or a specialist in neurocognitive disorders when:Atypical picture (early age, family history suggesting a genetic disorder, non-memory symptoms leading); Strong suspicion or recurring complaint with results below diagnostic thresholds; The origin or exact nature needs clarifying; Diagnosis still uncertain after a first assessment and follow-up. |
Investigate
- INESSS Institut national d'excellence en santé et services sociaux
- CCCDTD Canadian Consensus Conference on the Diagnosis and Treatment of Dementia
| Decision | Guideline |
|---|---|
| Baseline blood work | Before a first diagnosis:CBC; Glucose; Calcium; Vitamin B12; TSH; Creatinine; Electrolytes. |
| Only if indicated | By clinical context:Liver tests (ALT); Syphilis or HIV serology; Folate. |
| INESSS 2020 panel | Fasting glucose or HbA1c in the basic panel.Do not repeat a test done in the past 6 months. |
| Imaging | Structural imaging in most situations, even in older people (1C).Includes onset within the past 2 years and significant vascular risk factors. MRI over CT (2C). |
| Amyloid or tau imaging | Not without memory decline, outside research (1A).Amyloid PET is for dementia experts (1A). |
Treat
- INESSS Institut national d'excellence en santé et services sociaux
- HCSC Health Canada
| Decision | Guideline |
|---|---|
| By stage | Cholinesterase inhibitor: indicated in mild and moderate Alzheimer disease; an option in severe. Memantine: indicated in moderate and severe; an option in mild. Mixed dementia: both are options. |
| Choosing the inhibitor | No reliable difference in efficacy.Choose on adverse effects, ease of use, pharmacokinetics and the person. |
| Before an inhibitor | Ask about arrhythmia, bradycardia, syncope or presyncope.Take the resting pulse (bradycardia: under 55/min). ECG: good practice if easy to get, not mandatory; do it first if any of these is present. |
| Caution with an inhibitor | Monitor closely with:Sinus bradycardia;
Sick sinus syndrome;
AV block, first degree or higher;
A beta-blocker or calcium channel blocker;
A QT-prolonging drug (INESSS 2020: especially donepezil). INESSS 2015 opens in a new tabINESSS 2020, adjustment opens in a new tab |
| Donepezil and QT | Contraindicated with a history of QT prolongation or torsade de pointes, including congenital long QT, or a history of cardiac arrhythmia (Health Canada monograph, December 2024). |
| Renal impairment | Galantamine: CrCl 9-60 mL/min, maximum 16 mg/day; under 9, contraindicated.
Memantine: CrCl 15-49 mL/min, maximum 5 mg BID (30-49 may go to 10 mg BID if tolerated for at least 7 days); under 15, contraindicated.
Rivastigmine oral, CrCl under 50 mL/min (INESSS 2020): start 1.5 mg DIE, maximum 3 mg BID. INESSS 2015 opens in a new tabINESSS 2020, adjustment opens in a new tab |
| Hepatic impairment | Galantamine: moderate, maximum 16 mg/day; severe, contraindicated.
Rivastigmine oral: mild to moderate, titrate as for sensitive people; severe, contraindicated.
Rivastigmine patch (INESSS 2020): mild to moderate, 5 cm² DIE; severe, contraindicated.
Donepezil and memantine: severe, contraindicated. INESSS 2015 opens in a new tabINESSS 2020, adjustment opens in a new tab |
| Sensitive people | Start lower (grid below) in people sensitive to adverse effects: for example low weight or over 85 (INESSS 2015); under 50 kg, over 85 or frail (INESSS 2020). INESSS 2015 opens in a new tabINESSS 2020, adjustment opens in a new tab |
Doses from the INESSS guide opens in a new tab (March 2015); sensitive-person steps for memantine from the INESSS 2020 protocol opens in a new tab.
| Drug | Start |
|---|---|
| Donepezil | 5 mg DIE, morning, with food titration: see INESSS 2015 opens in a new tab |
| Galantamine ER | 8 mg DIE, morning, with food titration: see INESSS 2015 opens in a new tab |
| Rivastigmine oral | 1.5 mg BID, morning and evening, with food titration: see INESSS 2015 opens in a new tab |
| Rivastigmine patch | 5 cm² DIE titration: see INESSS 2015 opens in a new tab |
| Memantine | 5 mg DIE, morning titration: see INESSS 2015 opens in a new tab |
| Sensitive to adverse effects | |
| Donepezil | 2.5 mg DIE 5 mg DIE maximum titration: see INESSS 2015 opens in a new tab |
| Rivastigmine oral | 1.5 mg DIE 3 mg BID maximum titration: see INESSS 2015 opens in a new tab |
| Memantine | 5 mg DIE titration: see INESSS 2020 opens in a new tab |
Behavioural and psychological symptoms
- MSSS Ministère de la Santé et des Services sociaux
- CCSMH Canadian Coalition for Seniors' Mental Health
| Decision | Guideline |
|---|---|
| First approach | Personalized non-drug plan first:Basic approach; Environment change; Occupational approach; Intervention on the causes found. |
| Severe agitation, aggression or psychosis | Atypical antipsychotic in Alzheimer, vascular or mixed dementia:Risperidone for agitation or psychosis; Aripiprazole or brexpiprazole for agitation; Quetiapine second line if those are not tolerated or are contraindicated. |
| Antipsychotic risks | Higher stroke risk and higher mortality. |
| Consent | Informed or substitute consent is required because of these risks. |
| Lewy body or Parkinson disease | Cholinesterase inhibitor for agitation, aggression or psychotic symptoms: rivastigmine, donepezil or galantamine ER.Severe psychotic symptoms: quetiapine. |
| Moderate symptoms | When non-drug approaches fail, in Alzheimer, vascular or mixed dementia:Citalopram or escitalopram for anxious symptoms or moderate psychotic symptoms; Sertraline or duloxetine, first line in geriatric major depression. Risks: gastrointestinal bleeding and hyponatremia (SIADH); QTc prolongation with citalopram and escitalopram. |
| Not for agitation | Do not use olanzapine (except short-term emergency treatment of severe agitation) or valproic acid or sodium divalproex.Suggest against trazodone, sertraline, mirtazapine, fluoxetine, paroxetine, fluvoxamine, tricyclic antidepressants, and initiating a cholinesterase inhibitor or memantine for agitation. |
| Trial length | Discontinue if ineffective after 8 weeks of treatment, including at least two weeks at a therapeutic dose.No polypharmacy for agitation. No long-acting injectable antipsychotic unless there is a co-occurring chronic psychotic illness that requires it. |
| Depressive symptoms, no depression | No drug treatment for depressive symptoms without a concurrent diagnosis of depression. |
| Sleep | No benzodiazepine, Z-drug or sedating antipsychotic for a sleep disorder without comorbidity.Options in the table: trazodone or melatonin. |
| Next step | Refer to psychiatry, geriatrics or geriatric psychiatry if first-line drug trials fail. |
Doses from the MSSS 2024 table opens in a new tab (Annexe 1, updated April 2024). Antidepressant, trazodone, melatonin and Lewy body doses are in the document.
| Drug | Start | Maximum |
|---|---|---|
| Risperidone | 0.25-0.5 mg DIE | 2 mg DIE |
| Aripiprazole | 2-5 mg DIE | 10 mg DIE |
| Brexpiprazole | 0.5 mg DIE | 3 mg DIE |
| Second line, if those are not tolerated or are contraindicated | ||
| Quetiapine | 12.5-25 mg DIE | 200 mg DIE |
Follow-up
- INESSS Institut national d'excellence en santé et services sociaux
- MSSS Ministère de la Santé et des Services sociaux
- CCCDTD Canadian Consensus Conference on the Diagnosis and Treatment of Dementia
- CCSMH Canadian Coalition for Seniors' Mental Health
| Decision | Guideline |
|---|---|
| After a start | Within 3 months: phone or visit for tolerance and adherence. At 6 months: visit for the effect on cognition, mood, behaviour, daily activities and social interaction; renew if needed. Then at least once or twice a year. |
| Switching | Do not switch for loss of benefit, especially after more than a year; the loss usually reflects the disease. |
| When to stop | Consider stopping when:Adverse effects are bothersome or intolerable; The person got worse after the start; Other illness makes the risk unacceptable or the treatment futile; The person or their representative chooses to stop, once informed; Dementia has reached an advanced stage (for example stage 7 on the Global Deterioration Scale); Adherence cannot be fixed. |
| How to stop | Taper over 2-4 weeks before stopping.Stopping in moderate to severe Alzheimer disease can worsen cognition and function. |
| Deprescribe antipsychotics | Deprescribe in people who do not have a history of severe agitation or psychosis or another potentially appropriate indication for antipsychotics such as a history of serious mental illness.Suggest deprescribing in people who initially had severe agitation or psychosis, after considering current symptoms, the total duration of antipsychotic treatment, dosage of medication required to stabilize BPSD, and initial severity of symptoms. Decrease the dose by 25-50% every 1-2 weeks until discontinued; stop dosage reduction at the lowest effective dose if BPSD worsen. |
| Keep despite decline | Keep a cognitive enhancer that clearly reduced psychosis or other neuropsychiatric symptoms, even with cognitive and functional decline (2B). |
| Driving | Start the driving talk early.Reassess every 6-12 months, sooner after a major change in health or function or an event such as a crash (INESSS). INESSS 2017, sheet 6 opens in a new tabMSSS 2024 opens in a new tab |
| Frontotemporal dementia | Stop an inhibitor or memantine prescribed for frontotemporal dementia or any indication other than Alzheimer, Parkinson disease, Lewy body or vascular dementia (inhibitors 1B, memantine 1C). |
| Mild cognitive impairment | Deprescribe inhibitors and memantine (1B). |
Reviewed 17 October 2026 against the official sources below.
Sources
Blue square: Québec · red round: Canada. The code names the body; each section's key gives its full name.