Some people with dementia experience mild changes that barely affect daily life, while others require full-time support for basic activities like feeding or personal care. Alzheimer’s disease is the most common form, but several other types exist, each with unique symptoms and progression patterns.

Signs and Symptoms of Dementia

Symptoms vary depending on the type of dementia, but common signs include:

• Memory loss and confusion
• Difficulty with speech, reading, writing, or expressing thoughts
• Wandering or getting lost in familiar areas
• Trouble managing money or paying bills
• Repeating questions or conversations
• Unusual word usage or misnaming objects
• Slower completion of routine tasks
• Loss of interest in daily activities
• Hallucinations, delusions, or paranoia
• Impulsivity or reduced empathy
• Balance and movement problems

Recognizing early changes is crucial. Subtle shifts in behavior, judgment, or independence often prompt families to seek guidance before problems escalate.

Different Types of Dementia And Their Causes

Dementia results from changes in the brain that cause neurons to stop functioning, lose connections, and eventually die. Causes include:

• Genetic variants (rare)
• Protein buildups (amyloid plaques, tau tangles, alpha-synuclein)
• Brain injuries or strokes
• Chronic health conditions affecting blood flow or oxygen
• Lifestyle and environmental factors

Some conditions mimic dementia, such as vitamin deficiencies, thyroid issues, medication side effects, or delirium. Early assessment can identify reversible causes.

Different Types of Dementia

Understanding the type of dementia helps families provide tailored support. Common types include:

Alzheimer’s Disease

• Gradual memory loss and disorientation
• Slow decline in independence for complex tasks
• Most prevalent form among older adults

Vascular Dementia

• Caused by reduced blood flow, strokes, or cardiovascular issues
• Slowed thinking, planning difficulties, and mood changes
• Progresses unevenly with sudden declines

Lewy Body Dementia

• Fluctuating alertness and attention
• Visual hallucinations and sleep disturbances
• Motor symptoms similar to Parkinson’s disease

Frontotemporal Dementia

• Often appears before age 60
• Personality changes, impulsivity, or language difficulties
• Memory may be relatively preserved early on

Mixed Dementia

• Combination of two or more types, commonly Alzheimer’s and vascular
• Symptoms overlap, requiring adaptable care strategies

LATE (Limbic-Predominant Age-Related TDP-43 Encephalopathy)

• Similar symptoms to Alzheimer’s, primarily in adults over 80
• Caused by abnormal TDP-43 protein clusters
• Currently diagnosable only postmortem

Diagnosing Dementia

Accurate diagnosis involves several steps:

1. Medical History & Physical Exam: Blood pressure, lab tests, and family history
2. Cognitive and Neurological Tests: Memory, problem-solving, language, reflexes, and balance
3. Brain Imaging: CT, MRI, or PET scans to detect structural or functional changes
4. Psychiatric Evaluation: Identifies mood or behavioral contributors
5. Genetic Testing: In rare cases to identify hereditary risk
6. CSF & Blood Tests: Detect biomarkers such as beta-amyloid for Alzheimer’s

Early detection allows for better care planning, symptom management, and participation in research studies like brain donation programs.

Caring for Someone with Dementia

Families often face uncertainty when cognitive changes appear. Moreover, ElderMaze emphasizes clarity, structure, and thoughtful guidance, helping families interpret early signs and plan ahead.

Key strategies include:

• Observing and documenting changes in behavior and function
• Consulting professionals for early guidance and diagnosis
• Adjusting routines and environments to support safety and independence
• Encouraging meaningful engagement and social connection
• Tailoring care strategies to the specific type of dementia

Different Types of Dementia: Why Understanding the Type of Dementia Matters

Different dementias progress in unique ways and respond differently to treatments. Understanding the type allows families to:

• Anticipate cognitive and behavioral changes
• Adjust expectations and care approaches
• Support independence and emotional well-being
• Reduce frustration and stress for both the individual and caregivers

A thoughtful, structured approach ensures care evolves with the person rather than reacting to crises.

Moving Forward

Dementia does not follow a single path. Therefore, early recognition, combined with informed guidance and compassionate care, creates a foundation for improved quality of life, meaningful connections, and safer daily routines. Additionally, ElderMaze offers expert guidance for families navigating dementia, providing clarity without pressure and fostering confidence in decision-making.

Learn More and Get Support:
ElderMaze Dementia Guidance
Call (412) 486-6677 for personalized guidance
Email info@eldermaze.com

The post Understanding Dementia: Symptoms, Types, and How It’s Diagnosed appeared first on Elder Maze Solutions.

This report was written by Senior Policy Attorney Toby S. Edelman.

Administering antipsychotic drugs to more than a quarter of a million nursing home residents meets the definition of elder abuse and, left unanswered, is a national scandal.

The Administration on Aging defines a subcategory of elder abuse – “physical abuse” – as “inflicting physical pain or injury on a senior, e.g. slapping, bruising, or restraining by physical or chemical means.”[1]

Antipsychotic Drugs Are Dangerous When Administered to People Who Do Not Need Them.

More than a decade ago, the U.S. Food and Drug Administration (FDA) gave its highest level of warning to the public about antipsychotic medications and warned that older people with dementia who were prescribed these drugs are at greater risk for death and other serious harm.[2]  Since then, recommendations of experts repeat, with increasing urgency, that antipsychotic drugs should not be given to older people.  In November 2015, the American Geriatrics Society’s evidence-based update of its Beers Criteria for “potentially inappropriate medication use in older adults” stated unequivocally that that antipsychotic medications should be avoided for older people, “except for schizophrenia, bipolar disorder, or short-term use as an antiemetic during chemotherapy.”[3]  Citing “increasing evidence of harm associated with antipsychotics and conflicting evidence on their effectiveness in delirium and dementia, the rationale to avoid was modified to ‘avoid antipsychotics for behavioral problems unless nonpharmacological options (e.g., behavioral interventions) have failed or are not possible, and the older adult is threatening substantial harm to self or others [italics in original].’”[4] Thus, there is a very limited category of people for whom the drugs could be appropriate.

Multiple ongoing studies continue to document that antipsychotic drug use is associated with increased risk for falls and fractures,[5] acute kidney injury,[6]  myocardial infarction (heart attack),[7] hospitalization,[8] and death,[9] among other poor outcomes suffered by older people who are given antipsychotic drugs.  Some of these studies focus, in particular, on older people with dementia who are administered antipsychotic drugs for reasons not approved by the FDA – so-called “off-label” uses.

Over a Quarter of a Million Nursing Home Residents Are Given Antipsychotic Drugs.

Despite the clear, consistent, and ever-growing body of evidence that antipsychotic drugs should not be prescribed for older people, hundreds of thousands of nursing home residents are given these drugs on a regular basis.  The Centers for Medicare & Medicaid Services (CMS) reports that, in the first quarter of 2016, information self-reported by nursing facilities indicates that 20.77% of 1,300,222 nursing home residents – 270,056 individuals – took antipsychotic drugs.[10]  The overwhelming majority of these residents have not been diagnosed with a psychosis that could possibly support the administration of antipsychotic drugs.  Instead, these residents have dementia or are otherwise unable to explain with words what is causing them stress or discomfort.

Why are residents chemically restrained and abused?  There are two critical reasons: inadequate staffing levels at nursing facilities and inadequate enforcement of federal standards of care.

Inadequate Nurse Staffing

Too often, nursing facilities use antipsychotic drugs to control residents when they do not have sufficient numbers of nursing staff – professional registered nurses, licensed practical nurses, and certified nursing assistants – to provide direct, hands-on care to residents.  In 2012, analyzing nationwide data that it received from the federal government about nurse staffing levels and antipsychotic drug use, the Boston Globe reported “a clear link between the rate of antipsychotic use in a nursing home and its staffing level.”[11]  The investigative journalists reported, “Homes that most often used these drugs for conditions not recommended by regulators had fewer registered nurses, who direct care, and nurses’ aides, who provide most of the hands-on care.”[12]  Simply stated, in the absence of sufficient numbers of professional and paraprofessional nursing staff, facilities inappropriately use antipsychotic drugs to quiet and control residents.

There is a solution to this form of elder abuse!  Improve staffing levels in nursing facilities.  Long-standing evidence confirms that nursing facilities employ too few nurses to meet residents’ needs.

Fifteen years ago, a comprehensive Congressionally-mandated national study documented that nursing facilities do not have sufficient nursing staff to meet residents’ needs.[13]  The study looked at staffing levels in two ways.  An empirical analysis evaluated actual practices in more than 5,000 nursing facilities in 10 states; a time-motion simulation estimated the nurse aide time needed to meet certain key care functions.

The empirical analysis found that 97% of nursing facilities failed to meet one or more nurse staffing standards and 52% failed to meet all of the nurse staffing standards.[14]  Below these staffing levels, quality of care was compromised and residents were at risk of harm.  The time-motion study estimated that 91% of facilities did not have sufficient nurse aides to meet residents’ needs in five care processes (“1) dressing/grooming independence enhancement, 2) exercise, 3) feeding assistance, 4) changing wet clothes and repositioning residents, 5) providing toileting assistance and repositioning residents”).[15]

Although residents’ needs have increased since the federal government’s staffing study was completed fifteen years ago as sicker people are cared for in SNFs, staffing has not increased sufficiently to meet these needs.

Non-Enforcement of Federal standards of care

A second key reason for the over-administration of antipsychotic drugs to nursing home residents who have dementia is the failure of federal and state government survey agencies to effectively enforce long-standing regulations limiting the use of antipsychotic drugs.

The federal Nursing Home Reform Law sets out the standards of care that nursing facilities must meet in order to participate in, and be eligible for reimbursement under, the Medicare or Medicaid programs, or both.[16]  The Law also establishes the survey protocol by which state survey agencies determine facilities’ compliance with federal standards of care[17] and the enforcement actions that may, or, in some instances, must, be imposed when facilities are determined not to be in substantial compliance with the standards.[18]  Under the federal nursing home enforcement system, enforcement sanctions are generally imposed only if a facility’s noncompliance is classified as occurring at a “harm” or “immediate jeopardy” level.[19]  “No harm” deficiencies lead to no enforcement.

Since 1992, federal regulations implementing the Reform Law have expressly prohibited the use of “unnecessary drugs.”[20] They have also explicitly required that antipsychotic drugs be administered only to treat a resident’s specific medical condition and, even then, use of the drugs is required to be reduced and, if possible, eliminated.[21]  Unfortunately, these explicit requirements are rarely enforced.

In cooperation with CMS, the Center for Medicare Advocacy and Lerner Consulting conducted a study of antipsychotic drug deficiencies in seven states.[22]  Analyzing all 295 antipsychotic drug deficiencies cited in those states in 2010 and 2011, the study found that 95% of deficiencies were cited at a “no harm” (D or E) level, regardless of the poor outcomes for residents, the total number or proportion of residents affected by deficient practices, and the number of specific federal requirements violated by the facility.

Three states cited a total of 15 harm-level deficiencies, and 11 of these deficiencies were cited by a single state.  Four states did not cite a single harm-level antipsychotic drug deficiency in the two-year period.

CMS does not describe enforcement of federal rules about antipsychotic drugs as part of its antipsychotic drug agenda.  In a June 3, 2016 report on its five-year old National Partnership to Improve Dementia Care in Nursing Homes, CMS never once mentions the imposition of sanctions as a method of reducing the inappropriate administration of antipsychotic drugs to nursing home residents.[23]  Instead, CMS focuses on training, state coalitions, partnerships, awarding a grant to the Eden Alternative for a project entitled “Creating a Culture of Person-Directed Dementia Care,” posting of resources about antipsychotic drugs on the website of Advancing Excellence, publicly reporting antipsychotic drug rates on its website Nursing Home Compare, and developing and testing of a Focused Dementia Care Survey.

[1] Administration on Aging, “What is elder abuse?” http://www.aoa.gov/AoA_programs/Elder_Rights/EA_Prevention/whatIsEA.aspx/
[2] In April 2005, the FDA issued “black box” warnings against prescribing atypical antipsychotic drugs for patients with dementia, cautioning that the drugs increased dementia patients’ mortality. FDA, “Public Health Advisory: Deaths with Antipsychotics in Elderly Patients with Behavioral Disturbances” (April 11, 2005), http://www.fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandproviders/ucm05317 In June 2008, the FDA extended its warning to all categories of antipsychotic drugs, conventional as well as atypical, and directly and unequivocally advised health care professionals, “Antipsychotics are not indicated for the treatment of dementia-related psychosis.” FDA, “Information for Healthcare Professionals: Conventional Antipsychotics,” FDA Alert (June 16, 2008), http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm124830.htm.
[3] The American Geriatrics Society 2015 Beers Criteria Update Expert Panel, “American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults,” Journal of the American Geriatrics Society, Vol. 63, No. 11, page 2233, Table 2 (Nov. 2015), http://onlinelibrary.wiley.com/doi/10.1111/jgs.13702/pdf
[4] Id. 2242.
[5] Lisa-Ann Fraser, Kuan Liu, Kyla L. Naylor, Y. Joseph Hwang, Stephanie N. Dixon, Salimah Z. Shariff, Amit X. Garg, “Falls and Fractures With Atypical Antipsychotic Medication Use: A Population-Based Cohort Study,” JAMA Intern Med. 2015;175(3):450-452,  http://archinte.jamanetwork.com/article.aspx?articleid=2089230.
[6]  Y. Joseph Hwang, Stephanie N. Dixon, Jeffrey P. Reiss, Ron Wald, Chirag R. Parikh, Sonja Gandhi, Salimah Z. Shariff, Neesh Pannu, Danielle M. Nash, Faisal Rehman, Amit X. Garg, “Atypical Antipsychotic Drugs and the Risk for Acute Kidney Injury and Othr Adverse Outcomes in Older Adults: A Population-Based Cohort Study,” Ann Intern Med. 2014; 161(4):242-248, http://archinte.jamanetwork.com/article.aspx?articleid=2089230; http://annals.org/article.aspx?articleid=1897100.
[7]  Zheng-he Yu, Hai-yin Jiang, Li Shao, Yuan-yue Zhou, Hai-yan Shi, Bing Ruan, “Use of Antipsychotics and Risk of Myocardial Infarction: A Systematic Review and Meta-analysis,”  British Journal of Clinical Pharmacology (accepted for publication), http://onlinelibrary.wiley.com/doi/10.1111/bcp.12985/pdf.
[8]  Rajender R. Aparasu, Satabdi Chatterjee, Hua Chen, “Risk of Hospitalization and Use of First- Versus Second-Generation Antipsychotics Among Nursing Home Residents,”    Psychiatric Services, Vol. 65, Issue No. 6, 781-788 (June 2014), http://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201300093
[9] Donovan T. Maust, Hyungjin Myra Kim, Lisa S. Seyfried, Claire Chiang, Janet Kavanagh, Lori S. Schneider, Helen C. Kales, “Antipsychotics, Other Psychotropics, and the Risk of Death in Patients With Dementia; Number Needed to Harm,” JAMA Psychiatry. 2015; 72(5): 438-445, http://archpsyc.jamanetwork.com/article.aspx?articleid=2203833.
[10]https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/Minimum-Data-Set-3-0-Public-
Reports/Minimum-Data-Set-3-0-frequency-report.html [site visited May 19, 2016].
[11] Kay Lazar and Matt Carroll, “A rampant prescription, a hidden peril,” Boston Globe (April 29, 2012), http://archive.boston.com/news/local/massachusetts/articles/2012/04
/29/nursing_home_residents_with_dementia_often_given_antipsychotics_despite_health_warnings/?page=full.
[12] Id.
[13] CMS, Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, Phase 1, Vol. I (Winter 2001), http://phinational.org/sites/phinational.org/files/clearinghouse/Phase_I_VOL_I.pdf; Vol II, http://phinational.org/legislation-regulations/report-congress-appropriateness-minimum-nurse-staffing-ratios-nursing-
home-1; Vol. III, http://phinational.org/sites/phinational.org/files/clearinghouse/Phase_I_VOL_III.pdf.  CMS, Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes Phase II, Vol. I (March 2002), http://phinational.org/sites/phinational.org/files/clearinghouse/PhaseIIVolumeIofIII.pdf; Vol. II, http://phinational.org/sites/phinational.org/files/clearinghouse/PhaseIIVolumeIIofIII.pdf; Vol. III, http://phinational.org/sites/phinational.org/files/clearinghouse/PhaseIIVolumeIIIofIII.pdf.
[14] CMS, Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes Phase II, Vol. II, pages 3-16 and 3-17, http://phinational.org/sites/phinational.org/files/clearinghouse/PhaseIIVolumeIIofIII.pdf.
[15] Id. 3-19.
[16] 42 U.S.C. §§13958-3(b)-(d), 1396r(b)-(d), Medicare and Medicaid, respectively.
[17] 42 U.S.C. §§1395i-3(g), 1396r(g).
[18] 42 U.S.C. §§1395i-3(h, 1396r(h).
[19] CMS, Nursing Home Enforcement Reports Through December 31, 2014, page 5, attached to CMS, “Public Release of Nursing Home Enforcement Information Announcement,” S&C: 16-27-NH (June 3, 2016) (Memorandum from David R. Wright, Director, Survey and Certification Group, to State Survey Agency Directors), (CMS confirming that “most enforcement actions are taken in response to deficiency findings at the actual harm and immediate jeopardy levels”),  https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-27.pdf.
([20] 42 C.F.R. §483.25(l)(1), Unnecessary drugs, provides:
(l) Unnecessary drugs—
1) General. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used:
(i) In excessive dose (including duplicate drug therapy); or
(ii) For excessive duration; or
(iii) Without adequate monitoring; or
(iv) Without adequate indications for its use; or
(v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(vi) Any combinations of the reasons above
[21] 42 C.F.R. §483.25(l)(2) provides:
(2) Antipsychotic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that—
(i) Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and
(ii) Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.
[22] “CMA Report: Examining Inappropriate Use of Antipsychotic Drugs in Nursing Facilities,”  http://www.medicareadvocacy.org/cma-report-examining-inappropriate-use-of-antipsychotic-drugs-in-nursing-facilities/#.
[23] CMS, “Update Report on the National Partnership to Improve Dementia Care in Nursing Homes,” S&C: 16-28-NH (June 3, 2016) (Memorandum from David R. Wright, Director, Survey and Certification Group, to State Survey Agency Directors), https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-28.pdf.

This report was written by Senior Policy Attorney Toby S. Edelman.

The post Treating Dementia with Antipsychotic Drug appeared first on Elder Maze Solutions.

Reality therapy:

Interact with the person with dementia within his or her own frame of reference for the world, even if it has little to do with reality.

Validation therapy:

Encourage and validate the person’s view of reality rather than correcting or contradicting it by really listening and asking questions.

Redirection:

Be creative in redirecting conversation without contradicting or denying the person’s statements. Use any opportunity possible to try to elicit fond memories or remind the person of tasks or appointments.

Memory Cueing:

Use words and visuals to cue old or recent memories. For example, play CD’s of family events; place reminder notes in plain view; color code or number things in the order.

Successful communication:

One of the most successful approaches to reducing inappropriate behaviors is to communicate within the affected person’s frame of reference. Consider how your loved one sees the world and interact with respect for that “reality.”

It can also be helpful to engage the person in reminiscing about happier times by sharing memories and old photos; interactions that are focused on past times that the person might be able to recall may be less stressful than trying to communicate about current or recent events, which may not be accessible to the person.

Tips for communicating better:

1. Try to anticipate and address needs or concerns proactively.
2. Listen and communicate patiently; try to reduce the frustrations the person may feel from not being able to communicate effectively.
3. Use memory cues – verbal, visual, auditory – to help the person stay on track during conversations or day-to-day tasks. For example, place clothes prominently in plain sight, in the order in which they should be put on, or visually guide the person during dressing.
4. Write notes to the person to remind him/her to do routine tasks, and provide clear, written directions for accomplishing tasks.

Therapeutic activities help manage the symptoms of Alzheimer’s

Planning structured individualized activities that involve and interest the person with Alzheimer’s may reduce many of the more disturbing behavioral symptoms of AD, such as agitation, anger, frustration, depression, wandering or rummaging.

Elder Maze Solutions’s Life Care Managers who work with Alzheimer’s clients on a regular basis can attest to the success when therapeutic activities focus on the person’s previous interests; cueing the person to old and recent memories while taking advantage of the person’s remaining skills minimizes the impact of skills that may be compromised.

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