Tues 2026/10/06 Approach: Dementia, Part Two: Management

Part two of the dementia series, on management. It opens with the anti-amyloid antibodies, lecanemab and donanemab, working through CLARITY-AD and TRAILBLAZER-ALZ 2 in PICO form and spending real time on what the Clinical Dementia Rating Sum of Boxes measures, why a difference of about half a point becomes a "twenty-seven percent slowing," and how that compares with the smallest change patients and families notice. It covers ARIA and its ApoE4 gradient, the donanemab titration change, the anticoagulation and thrombolysis problem, and dosing burden; a JAGS study showing institutional websites present the benefit in relative terms three times as often as absolute; and real-world data showing only a third of early lecanemab users received the expected infusions, along with a VA implementation survey. Then the symptomatic drugs, cholinesterase inhibitors and memantine, with effect sizes, the side effects that drive prescribing cascades, and the evidence on stopping them. Then behavioral and psychological symptoms, using the Beers alternatives sequence and the DICE approach, antipsychotic mortality, and the WeCareAdvisor trial as a lesson in primary versus secondary outcomes. It closes with driving, including California's reporting requirement, decision-specific capacity, and care partners' use of the patient portal.