Alzheimer disease — diagnosis, enhancers, and BPSD care (MEQ)

(i) Working diagnosis. Clinical picture meets all-cause dementia: progressive multi-domain cognitive decline interfering with complex IADLs (medications, finances) with preserved basic ADLs so far — mild-stage major NCD / mild dementia severity by function. NIA-AA probable AD dementia is appropriate: insidious onset, clear progressive course, early amnestic lead, and no stepwise vascular story or DLB/FTD core alternative volunteered. State possible AD if substantial mixed cerebrovascular disease or atypical course emerges on work-up. DSM-5-TR language: major NCD due to Alzheimer disease, probable.[1]

(ii) Investigations and biomarkers. Exclude reversible contributors and delirium drivers: FBC, U&E, LFT, B12, folate, TFT, glucose/calcium; medication review (anticholinergics, sedatives). Structural CT/MRI once for treatable structural disease and supportive pattern recognition. ECG essential here given bradycardia and beta-blocker before any AChEI. Biomarkers (CSF Aβ/p-tau, amyloid PET, emerging blood tests): specialist/research tools that can increase certainty (ATN framing: A+T+ = biological AD in 2018 research terms) but are not automatic primary-care requirements; counsel pre-test, know regional access limits, and do not delay basic care while waiting for optional advanced tests.[1][2]

(iii) Cognitive pharmacotherapy. After cardiac review (rate 52 bpm — discuss beta-blocker indication, consider cardiology/GP optimisation, risk–benefit of AChEI). If proceeding when safe: donepezil 5 mg orally once daily for at least 4 weeks, then 10 mg daily if tolerated; monitor GI effects, weight, vivid dreams, pulse/syncope. If moderate severity evolves or additional benefit sought: memantine start 5 mg daily, increase by 5 mg weekly to 10 mg twice daily, renal dose-adjust per product information. Evidence: modest AChEI benefit (Cochrane); memantine mainly moderate–severe; DOMINO-AD supports continued donepezil benefit in moderate–severe disease versus withdrawal. Review benefit ~3 months and ongoing; deprescribe if harm or no benefit.[3][4][5]

(iv) BPSD. Use DICE: Describe evening irritability and wandering (time, triggers, consequences); Investigate pain, constipation, infection, hunger, overstimulation, sleep environment, carer approach, and delirium; Create non-drug plan (routine, lighting, toileting, activity, carer education); Evaluate. Antipsychotics only if severe risk after non-drug measures and medical exclusion — lowest dose, short course, document increased mortality risk from meta-analysis, and plan review/deprescribing.[6][7]

(v) Capacity, driving, care. Capacity is decision-specific (Appelbaum: understand, appreciate, reason, communicate choice) for treatment, finances, and accommodation — not automatically lost. Driving: advise not to drive until formal assessment per local licensing rules; document discussion. Care planning: diagnosis disclosure with daughter present as appropriate, community supports, medication management aids, wandering safety, advance care planning, enduring powers/guardianship pathways if needed (jurisdiction-specific; least-restrictive principles).[8]