Dementia accounts for approximately 10 per cent of the SCE Geriatric Medicine exam. NICE NG97 (Dementia: assessment, management and support for people living with dementia and their carers) is the primary reference. The exam tests diagnosis, pharmacological management, non-pharmacological approaches to behavioural and psychological symptoms, capacity assessment, and advance care planning.
Diagnosis
NICE recommends that a diagnosis of dementia should only be made by a specialist (not in primary care) following a structured clinical assessment including history (from the patient and an informant), cognitive assessment, physical examination, and appropriate investigations to exclude reversible causes.
The initial cognitive assessment should use a validated tool — the most commonly used in UK practice are the MMSE (though this is copyright-restricted), the ACE-III, and the MoCA. For initial screening in acute or community settings, the 4AT (delirium) and AMT-4 are more appropriate.
Investigations to exclude reversible causes include FBC, U&E, calcium, glucose, TFTs, vitamin B12, and folate. Neuroimaging (CT or MRI brain) is recommended to exclude structural causes and to support subtype diagnosis. MRI is preferred where available because it provides better assessment of medial temporal lobe atrophy (supportive of Alzheimer's disease) and vascular changes.
Dementia subtypes
The four main dementia subtypes are Alzheimer's disease (most common, approximately 60 per cent), vascular dementia, dementia with Lewy bodies (DLB), and frontotemporal dementia (FTD). The exam expects you to distinguish between them based on clinical features.
Alzheimer's disease presents with progressive amnestic cognitive impairment — memory loss is the predominant early feature, with later involvement of language, visuospatial function, and executive function. Medial temporal lobe atrophy on MRI supports the diagnosis.
Vascular dementia presents with cognitive impairment in a stepwise or fluctuating pattern, often with a history of cerebrovascular events and cardiovascular risk factors. White matter changes and lacunar infarcts on MRI support the diagnosis.
DLB presents with fluctuating cognition, visual hallucinations (typically well-formed and detailed), parkinsonism, and REM sleep behaviour disorder. DLB has a critical prescribing consideration — antipsychotics (particularly typical antipsychotics) cause severe neuroleptic sensitivity and should be avoided. This is a high-yield exam fact.
FTD presents with personality and behavioural change (behavioural variant) or progressive language impairment (semantic or non-fluent variants). Onset is typically younger than Alzheimer's disease (often under 65). Frontal and temporal lobe atrophy on MRI supports the diagnosis.
Pharmacological management
Alzheimer's disease: NICE recommends acetylcholinesterase inhibitors (AChEIs) — donepezil, rivastigmine, or galantamine — for mild to moderate Alzheimer's disease. Memantine is recommended for moderate to severe Alzheimer's disease, or for mild to moderate disease if AChEIs are contraindicated or not tolerated. Combination therapy (AChEI plus memantine) is an option in moderate to severe disease.
The exam tests the severity thresholds: AChEIs for mild to moderate, memantine for moderate to severe. It also tests the contraindications and side effects — AChEIs are cholinergic agents and can cause bradycardia, nausea, diarrhoea, and urinary incontinence. They should be used with caution in patients with cardiac conduction disorders, peptic ulcer disease, or asthma/COPD.
Vascular dementia: there is no licensed pharmacological treatment. AChEIs are not recommended for vascular dementia by NICE (though they may be used if there is co-existing Alzheimer's pathology — mixed dementia). Management focuses on secondary prevention of cerebrovascular disease.
DLB: AChEIs are recommended (rivastigmine has the strongest evidence in DLB specifically). Memantine may be used as an alternative. Antipsychotics must be avoided or used only with extreme caution and specialist supervision — neuroleptic sensitivity is a defining feature of DLB.
FTD: there is no licensed pharmacological treatment. AChEIs are not effective and may worsen behavioural symptoms. SSRIs may be used for behavioural symptoms (disinhibition, compulsive behaviours) but the evidence is limited.
Behavioural and psychological symptoms (BPSD)
NICE recommends non-pharmacological approaches as first-line for BPSD in all dementia subtypes: identifying and addressing underlying causes (pain, infection, constipation, environmental factors), structured activities, person-centred care, caregiver education, and environmental modification.
Pharmacological management of BPSD should only be considered when non-pharmacological approaches have failed and the symptoms are causing severe distress or risk to the patient or others. If medication is required, risperidone is the only antipsychotic licensed for BPSD in the UK (for short-term use in moderate to severe Alzheimer's disease with aggression). The dose should be low, the duration short (reviewed at 6 to 12 weeks), and the risks (stroke, mortality) discussed with the patient and family.
The exam tests the principle that antipsychotics are not first-line for BPSD, that risperidone is the only licensed option, and that antipsychotics are contraindicated in DLB.
Capacity and advance care planning
Capacity assessment follows the Mental Capacity Act 2005 — covered in detail in our MHA sections guide. The key principle for dementia is that capacity is decision-specific and time-specific. A patient with moderate dementia may have capacity to decide what to eat for dinner but lack capacity to decide about a surgical procedure. The diagnosis of dementia alone does not determine capacity — each decision must be assessed individually.
Advance care planning should be discussed early in the disease course while the patient retains capacity. This includes advance decisions to refuse treatment (legally binding if valid and applicable), lasting power of attorney (health and welfare), and preferred priorities of care (not legally binding but informative for decision-making).
iatroX's SCE Geriatric Medicine bank includes comprehensive dementia content covering diagnosis, pharmacological management by subtype, BPSD management, the DLB antipsychotic restriction, and capacity assessment. All included at £29 per month or £99 per year.