● Collateral information:
Obtain collateral information from family members and caretakers.
● Neuropsychological testing:
Consider formal neuropsychological testing.
● Contributing factors:
Investigate contributing factors such as medications; metabolic abnormalities; depression; delirium; and other clinical and psychiatric conditions, including vascular risk from diabetes and hypertension.
● Caregivers:
Counsel families about the challenges for caregivers. The NIH Senior Health website is especially helpful about "Alzheimer caregiving." Review household safety measures.
● Drivers with dementia:
Learn the laws about reporting drivers with dementia in your state. Consult the American Academy of Neurology evidence-based practice parameters for drivers with dementia, updated in 2010, and guidelines from numerous professional organizations, including the American Medical Association. Note, however, that underlying quantitative evidence linking assessment to road safety is limited. A 2013 Cochrane review details the pitfalls of disqualifying impaired drivers, which can lead to depression and social withdrawal if disqualification is premature. The review concludes that for drivers with dementia, there is no good evidence that neuropsychological or on-road assessment will maintain mobility and improve safety. The authors call for more research to develop assessment tools "that can reliably identify unsafe drivers with dementia in an office setting" and determine what changes in function provide a threshold for disqualification, as no single validated test is available.
● Advance directives:
Encourage patient and family discussion of appointing a health care proxy and arranging for power of attorney, health care power of attorney, and advance directives while the patient can still contribute to active decision making.
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