Five drugs that instantly tell me a patient has dementia
Key Highlights
- Recognize common dementia medications like Aricept, Exelon, and Namenda to tailor dental care approaches accordingly.
- Understand the risks of prescribing NSAIDs and other medications, especially considering age-related pharmacokinetic changes and drug interactions.
- Learn behavioral management techniques to de-escalate agitation during dental visits, including shorter appointments and quiet communication.
- Be vigilant for signs of pain in non-verbal patients, as untreated oral infections can mimic or exacerbate cognitive decline.
- Emphasize the dentist's responsibility to identify oral health issues that may impact overall health and quality of life in dementia patients.
You could be practicing in a private practice, a DSO, or an FQHC. Regardless of your setting, you will encounter a patient with dementia or Alzheimer's disease. Here is a number worth sitting with: 7.4 million.1 That is how many Americans aged 65 and older are living with clinical Alzheimer's dementia today. By 2060, it is projected to nearly double to 13.8 million. A landmark 2025 study2 in Nature Medicine found that nearly 42% of Americans over age 55 may develop dementia in their lifetime. Read that again. Nearly half. These are not statistics about a distant future; they describe who is already sitting in your waiting room, and who will arrive in even greater numbers with each passing year.
Recognizing the patient before the chart tells you
I recently treated a patient with advanced dementia. One of the most reliable tip-offs that your patient has dementia is their medication list. If you see donepezil (Aricept), rivastigmine (Exelon), galantamine (Razadyne), memantine (Namenda), or the newer agent donanemab (Kisunla), you are looking at a dementia patient. These drugs span different stages of the disease, so a quick look up in a dental-specific resource like MedAssent DDS3 can help you instantly recognize them and reframe how you approach the appointment. In this patient's case, seeing haloperidol (Haldol) on the list told me something equally important: this patient had a history of agitation. When I asked the caretaker about it, she explained that he had struck another resident at the memory care facility.
When the chair becomes unpredictable: Agitation and antipsychotics
There are many medications commonly prescribed by physicians to manage aggressive or agitated behavior in elderly patients. Examples include brexpiprazole (Rexulti), haloperidol (Haldol), quetiapine (Seroquel), or lorazepam (Ativan). The choice often depends on the patient's existing medications and comorbidities.
Patients with advanced dementia can become agitated suddenly and without warning. There is often no identifiable trigger, although the sustained sensory input of a dental appointment (the sounds, the instruments, and the unfamiliar surroundings) can absolutely contribute. I know this firsthand. During one visit, a patient became acutely agitated with no warning whatsoever. We had to quickly temporize and reschedule. While there is no magic appointment length that guarantees calm, shorter morning visits are strongly advisable to avoid sundowners. And if a patient does become agitated, never argue with them. Speak quietly, acknowledge what they are experiencing, and de-escalate.
When agitation is recurring or severe, a conversation with the treating physician is warranted. The physician can prescribe a medication on an as-needed basis for agitation, administered before or after your appointment. Knowing this has real pharmacological consequences. Commonly prescribed medications such as haloperidol (Haldol) or quetiapine (Seroquel) can prolong4 the cardiac QT interval, and combining them with epinephrine found in local anesthetics is contraindicated.5 These are not hypothetical concerns; they are the scenarios that produce preventable adverse events.
What They're Already Taking: Alzheimer's Medications and the Dental Chair
Most patients with mild to moderate Alzheimer's are taking donepezil (Aricept), rivastigmine (Exelon), or galantamine (Razadyne). Those with moderate to severe disease are commonly prescribed memantine (Namenda) as well. These are not interchangeable from a dental standpoint.
Donepezil, galantamine, and memantine all list xerostomia6 as a recognized side effect. As we know, dry mouth accelerates caries.7 Consider prescribing a fluoride supplement such as PreviDent and also instruct the caretaker on the instructions.
The drugs we prescribe: A more complex landscape than It looks
NSAIDs are a reflex prescription after dental procedures, but in elderly dementia patients they require real caution. Many of these patients are already taking an NSAID for arthritis or chronic pain, and adding another creates serious risk. My husband, a hospitalist, once admitted a patient for a GI bleed after a dentist prescribed ibuprofen without realizing the patient was already taking celecoxib. That patient required multiple units of blood, and this was a completely preventable outcome.
Age-related declines in renal and hepatic function change the pharmacokinetics of nearly every drug you prescribe in this population. The geriatric patient is also more vulnerable to respiratory depression and CNS side effects. If possible, avoid prescribing an opioid, benzodiazepine, or muscle relaxant. Avoid co- prescribing an NSAID and a corticosteroid, as the combination significantly increases GI bleeding risk and may affect blood pressure. If necessary, use the lowest effective dose for the shortest possible duration.
Macrolide antibiotics such as azithromycin, clarithromycin, or erythromycin should be avoided, as they prolong the cardiac QT interval. Do not overlook antifungals: fluconazole, often prescribed for the oral candidiasis that is endemic in this population, interacts with a remarkable number of medications that elderly patients commonly take.
The thing we rarely say out loud
The most urgent issue in treating dementia patients is one we rarely discuss directly: they cannot reliably tell us8 they are in pain. Language deficits emerge in the moderate stage of Alzheimer's and may progress to near-complete verbal loss9 in end-stage disease. A patient with a fractured tooth, a draining abscess, or a spreading infection may express that pain only through behavioral changes by refusing to eat, have a sudden functional decline, or escalating agitation that appears to have no cause. There are documented cases10 in which what looked like Alzheimer’s disease progression resolved entirely once an undetected oral infection was treated. An undiagnosed toothache is not merely a dental problem. In a patient who cannot say "my tooth hurts," it is a medical emergency hiding in plain sight.
The standard we owe them
The patient I treated that day had a family that loved her deeply and a facility that cared for her with genuine attention. And yet her mouth told a story that none of them had been equipped to read. Take this as both an opportunity and a responsibility. These patients cannot advocate for themselves. We can.
References
1. Alzheimer’s Association. 2024 Alzheimer’s disease facts and figures. Alzheimer’s & Dementia. 2024;20(5):3708–3821. https://www.alz.org/getmedia/ef8f48f9-ad36-48ea-87f9-b74034635c1e/alzheimers-facts-and-figures.pdf.
2. Fang EF, et al. Global burden and trends of Alzheimer’s disease and other dementias, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021. Nature Medicine. 2024. doi:10.1038/s41591-024-03340-9. https://www.nature.com/articles/s41591-024-03340-9.
3. MedAssent DDS. Alzheimer’s disease article. https://www.medassentdds.com/?utm_source=dentistryiq&utm_medium=affiliate&utm_campaign=alzheimer-article.
4. Blom HJ, Tan HL, Roos-Hesselink JW, et al. Differential changes in QTc duration during in-hospital haloperidol use. PLoS ONE. 2011;6(9):e24648. doi:10.1371/journal.pone.0024648. https://pubmed.ncbi.nlm.nih.gov/21961030/.
5. U.S. Food and Drug Administration. Aricept (donepezil hydrochloride) prescribing information. 2009. https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/018701s059lbl.pdf.
6. Gil-Montoya JA, Barrios R, Sánchez-Lara I, et al. Prevalence of drug-induced xerostomia in older adults with cognitive impairment or dementia: an observational study. Drugs & Aging. 2016;33(8):611–618. doi:10.1007/s40266-016-0386-x. https://pubmed.ncbi.nlm.nih.gov/27438469/.
7. Li W, Sun L, Xiao S, et al. Prevalence, incidence, influence factors, and cognitive characteristics of amnestic mild cognitive impairment among older adults: a 1-year follow-up study in China. Frontiers in Psychiatry. 2020;11:75. https://pubmed.ncbi.nlm.nih.gov/31752149/.
8. Zwakhalen SMG, Hamers JPH, Abu-Saad HH, Berger MPF. Pain in elderly people with severe dementia: a systematic review of behavioural pain assessment tools. BMC Geriatrics. 2006;6:3. https://pmc.ncbi.nlm.nih.gov/articles/PMC12661616/.
9. Alzheimer’s Society. Later stages of dementia. https://www.alzheimers.org.uk/about-dementia/stages-and-symptoms/later-stages-dementia.
10. Wu B, et al. Oral infections and inflammatory burden in Alzheimer’s disease: implications for cognitive decline. Case Reports in Dentistry. 2017. https://pmc.ncbi.nlm.nih.gov/articles/PMC5619174/.
About the Author
Lisa Chan, DDS
Lisa Chan, DDS, is chief executive officer and cofounder of MedAssent DDS. She has more than 35 years of dentistry experience, including roles as a hospital dentist at Kaiser Permanente, a private practitioner, and a California State Dental Board consultant. With a DDS from USC, she focuses on promoting equity and integrated care anad addressing challenges in patient safety. Dr. Chan serves on educational and community boards, including Santa Monica College, UC San Diego, Los Angeles FBI, and the Salvation Army.