Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Safety and societal issues related to dementia

Daniel Press, MD
Michael Alexander, MD
Section Editors
Steven T DeKosky, MD, FAAN, FACP, FANA
Kenneth E Schmader, MD
Deputy Editor
Janet L Wilterdink, MD


Patients with dementia have a decreased ability to make decisions. Safety issues are therefore important aspects of the care of patients with dementia. Different safety concerns arise in a relatively predictable manner as dementia progresses. Addressing these issues proactively can prevent serious incidents.

This topic review will discuss the recognition and management of safety and societal issues related to dementia, including decision-making capacity, driving, financial capacity, cooking, wandering and becoming lost, falls, living alone, and voting. The management of neuropsychiatric symptoms of dementia and palliative care of patients with advanced dementia are discussed separately. (See "Management of neuropsychiatric symptoms of dementia" and "Palliative care of patients with advanced dementia".)

The pharmacologic treatment of memory and behavioral problems related to dementia is also discussed separately. (See "Treatment of dementia".)


Any illness or treatment that compromises cognition may be associated with reduced capacity. The likelihood of diminished capacity is related to the severity of cognitive impairment, although brief measures of overall cognition such as the Mini-Mental State Exam (MMSE) are not a substitute for an assessment of capacity. While low scores (eg, <16 out of 30 points) in patients with dementia due to Alzheimer disease are highly correlated with impaired capacity, higher scores may or may not correlate with full capacity to make decisions.

Among patients with mild to moderate stage dementia, verbal reasoning and verbal memory are the two cognitive domains that explain most of the performance on measures of capacity to consent. Measures of an individual’s insight into his or her memory problems also correlate with decision-making capacity.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Feb 09, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Drachman DA, Swearer JM. Driving and Alzheimer's disease: the risk of crashes. Neurology 1993; 43:2448.
  2. Man-Son-Hing M, Marshall SC, Molnar FJ, Wilson KG. Systematic review of driving risk and the efficacy of compensatory strategies in persons with dementia. J Am Geriatr Soc 2007; 55:878.
  3. Ott BR, Heindel WC, Papandonatos GD, et al. A longitudinal study of drivers with Alzheimer disease. Neurology 2008; 70:1171.
  4. Dawson JD, Anderson SW, Uc EY, et al. Predictors of driving safety in early Alzheimer disease. Neurology 2009; 72:521.
  5. Ball KK, Roenker DL, Wadley VG, et al. Can high-risk older drivers be identified through performance-based measures in a Department of Motor Vehicles setting? J Am Geriatr Soc 2006; 54:77.
  6. Iverson DJ, Gronseth GS, Reger MA, et al. Practice parameter update: evaluation and management of driving risk in dementia: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2010; 74:1316.
  7. Rapoport MJ, Herrmann N, Molnar FJ, et al. Sharing the responsibility for assessing the risk of the driver with dementia. CMAJ 2007; 177:599.
  8. Hunt LA, Murphy CF, Carr D, et al. Reliability of the Washington University Road Test. A performance-based assessment for drivers with dementia of the Alzheimer type. Arch Neurol 1997; 54:707.
  9. Fitten LJ, Perryman KM, Wilkinson CJ, et al. Alzheimer and vascular dementias and driving. A prospective road and laboratory study. JAMA 1995; 273:1360.
  10. Cushman LA, Stein K, Duffy CJ. Detecting navigational deficits in cognitive aging and Alzheimer disease using virtual reality. Neurology 2008; 71:888.
  11. Martin AJ, Marottoli R, O'Neill D. Driving assessment for maintaining mobility and safety in drivers with dementia. Cochrane Database Syst Rev 2013; :CD006222.
  12. Marson DC, Hebert T. Financial Capacity. In: Encyclopedia of Psychiatry and the Law, Cutler BL (Ed), Sage, Thousand Oaks, CA 2008. Vol 1, p.313.
  13. Martin R, Griffith HR, Belue K, et al. Declining financial capacity in patients with mild Alzheimer disease: a one-year longitudinal study. Am J Geriatr Psychiatry 2008; 16:209.
  14. Triebel KL, Martin R, Griffith HR, et al. Declining financial capacity in mild cognitive impairment: A 1-year longitudinal study. Neurology 2009; 73:928.
  15. Griffith HR, Belue K, Sicola A, et al. Impaired financial abilities in mild cognitive impairment: a direct assessment approach. Neurology 2003; 60:449.
  16. Okonkwo OC, Wadley VG, Griffith HR, et al. Cognitive correlates of financial abilities in mild cognitive impairment. J Am Geriatr Soc 2006; 54:1745.
  17. Widera E, Steenpass V, Marson D, Sudore R. Finances in the older patient with cognitive impairment: "He didn't want me to take over". JAMA 2011; 305:698.
  18. Rowe MA, Glover JC. Antecedents, descriptions and consequences of wandering in cognitively-impaired adults and the Safe Return (SR) program. Am J Alzheimers Dis Other Demen 2001; 16:344.
  19. Koester RJ. The lost Alzheimer's and related disorders search subject: new research and perspectives. In: Response 98 NASAR Proceedings, Chantilly, Virginia, National Association of Search and Rescue, 1998. p.161.
  20. Rowe MA, Bennett V. A look at deaths occurring in persons with dementia lost in the community. Am J Alzheimers Dis Other Demen 2003; 18:343.
  21. Rowe MA. People with dementia who become lost. Am J Nurs 2003; 103:32.
  22. Rowe MA, Feinglass NG, Wiss ME. Persons with dementia who become lost in the community: a case study, current research, and recommendations. Mayo Clin Proc 2004; 79:1417.
  23. Sura SD, Carnahan RM, Chen H, Aparasu RR. Prevalence and determinants of anticholinergic medication use in elderly dementia patients. Drugs Aging 2013; 30:837.
  24. Thorpe JM, Thorpe CT, Gellad WF, et al. Dual Health Care System Use and High-Risk Prescribing in Patients With Dementia: A National Cohort Study. Ann Intern Med 2017; 166:157.
  25. Guo Z, Wills P, Viitanen M, et al. Cognitive impairment, drug use, and the risk of hip fracture in persons over 75 years old: a community-based prospective study. Am J Epidemiol 1998; 148:887.
  26. Cooper C, Selwood A, Blanchard M, Livingston G. Abusive behaviour experienced by family carers from people with dementia: the CARD (caring for relatives with dementia) study. J Neurol Neurosurg Psychiatry 2010; 81:592.
  27. Soniat BA. Dementia patients who live alone: research and clinical challenges. J Am Geriatr Soc 2004; 52:1576.
  28. Tierney MC, Charles J, Naglie G, et al. Risk factors for harm in cognitively impaired seniors who live alone: a prospective study. J Am Geriatr Soc 2004; 52:1435.
  29. Karlawish JH, Bonnie RJ, Appelbaum PS, et al. Addressing the ethical, legal, and social issues raised by voting by persons with dementia. JAMA 2004; 292:1345.
  30. Ott BR, Heindel WC, Papandonatos GD. A survey of voter participation by cognitively impaired elderly patients. Neurology 2003; 60:1546.
  31. Nichols LO, Martindale-Adams J, Burns R, et al. Translation of a dementia caregiver support program in a health care system--REACH VA. Arch Intern Med 2011; 171:353.