Prof J Cohen-Mansfield), and Minerva Center for Interdisciplinary Study of End of Life (Prof J Cohen-Mansfield),should consider dementia in older people without known dementia who have frequent admissions or who develop delirium. Delirium is common in people with dementia and contributes to cognitive decline. In hospital, care including appropriate sensory stimulation, ensuring fluid intake, and avoiding infections might reduce delirium incidence.Acting now on dementia prevention, intervention, and care will vastly improve living and dying for individuals with dementia and their families, and thus society.

People with dementia are usually older, often have co-morbidities and may need help in coping with these illnesses. A third of older people now die with dementia and all professionals working in endof-life care need to make this a central part of their planning and communication. In this commission, we have detailed evidence-based approaches to dementia and its symptoms. Services should be available, scalable and give value. As there are limited resources, professionals and services need to use what works, not use what is ineffective, and be aware of the difference. Overall, there is good potential for prevention and, once someone develops dementia, for care to be high-quality, accessible, and give value to an under-served, growing population. Effective dementia prevention and care could transform the future for society and vastly improve living and dying for individuals with dementia and their families. Acting now on what we already know can make this difference happen. Key Messages 1 There are increasing numbers of people with dementia globally although incidence in some countries has decreased. 2 Be ambitious about prevention: We recommend energetically treating hypertension in middle aged and older people without dementia to reduce dementia incidence. Interventions for other risk factors, including more childhood education, exercise, maintaining social engagement, reducing smoking, and management of hearing loss, depression, diabetes and obesity; may have the potential of delaying or preventing a third of dementias. 3 Treat cognitive symptoms: To maximise cognition, people with Alzheimer's dementia or Dementia with Lewy Bodies should be offered Cholinesterase Inhibitors (ChEIs)at all stages, or memantine for severe dementia. ChEIs are not effective in Mild Cognitive Impairment. 4 Individualise dementia care: Good dementia care spans medical, social and supportive care, should be tailored to unique individual and cultural needs, preferences, priorities, and should incorporate support for the family carers 5 Care for family carers. Family carers are at high risk of depression. Effective interventions reduce the risk and treat the symptoms, include START (Strategies for Relatives) or REACH (Resources for Enhancing Alzheimer's Caregiver Health intervention) and should be made available. 6 Plan for the future. People with dementia and their families value discussions about the future and decisions about possible attorneys to make decisions. Clinicians should consider capacity to make different types of decisions at diagnosis. 7 Protect people with dementia. People with dementia and society require protection from possible risks of the condition, including self-neglect, vulnerability including to exploitation, managing money, driving or using weapons. Risk assessment and management at all stages of the disease is essential but it should be balanced against the persons' right to autonomy. 8 Manage neuropsychiatric symptoms. Management of the neuropsychiatric symptoms of dementia including agitation, low mood or psyc...

Behavioral and psychological symptoms of dementia include agitation, depression, apathy, repetitive questioning, psychosis, aggression, sleep problems, wandering, and a variety of inappropriate behaviors. One or more of these symptoms will affect nearly all people with dementia over the course of their illness. These symptoms are among the most complex, stressful, and costly aspects of care, and they lead to a myriad of poor patient health outcomes, healthcare problems, and income loss for family care givers. The causes include neurobiologically related disease factors; unmet needs; care giver factors; environmental triggers; and interactions of individual, care giver, and environmental factors. The complexity of these symptoms means that there is no "one size fits all solution," and approaches tailored to the patient and the care giver are needed. Non-pharmacologic approaches should be used first line, although several exceptions are discussed. Non-pharmacologic approaches with the strongest evidence base involve family care giver interventions. Regarding pharmacologic treatments, antipsychotics have the strongest evidence base, although the risk to benefit ratio is a concern. An approach to integrating non-pharmacologic and pharmacologic treatments is described. Finally, the paradigm shift needed to fully institute tailored treatments for people and families dealing with these symptoms in the community is discussed.

A structured multicomponent intervention adapted to individual risk profiles can increase the quality of life of ethnically diverse dementia caregivers. ClinicalTrials.gov identifier: NCT00177489.