Neurocognitive Disorders
12 cases on Alzheimer's and other dementias, delirium, and the pharmacology that manages or complicates them — choose a case below to open its full multi-voice debate.
A newly diagnosed patient's family wants to start a cholinesterase inhibitor immediately. The disagreement isn't about the diagnosis — it's about how much weight a real but genuinely small measured benefit should carry against the momentum of a family already committed to "doing something."
A patient on long-term donepezil now shows new nighttime agitation as his disease advances into moderate-severe stage. The disagreement isn't whether memantine has a role — it's whether it belongs added to what he's already taking, or in place of it.
Two families ask the same question about the same drug class at an advanced stage of the same disease. The pharmacology doesn't change between them — what changes is which outcomes the evidence was ever built to measure, and whether those are still the outcomes that matter.
A highly motivated, early-stage patient wants an anti-amyloid antibody after reading about a new pooled review that found the class's average benefit too small to matter. The disagreement is whether a discouraging population average should govern a specific, biomarker-matched individual.
Two patients present with agitated behavior in dementia. Guidelines agree non-pharmacologic measures should come first in both — the two cases diverge only once that step has actually been done, and the question becomes what to do when it succeeds versus when it doesn't.
An agitated, delirious inpatient is pulling at his IV lines. The order for haloperidol is nearly automatic — the disagreement is whether the largest trial ever run on this exact practice changes what "automatic" should mean.
An intensivist wants dexmedetomidine by default for its "delirium-protective" reputation. The disagreement is about which comparison that reputation was actually built on, and whether it survives being tested against the sedative it's about to replace.
Two delirious patients, two very different verdicts on the same drug class. One case shows why benzodiazepines usually make hospital delirium worse; the other shows the specific pharmacology that makes them the correct, guideline-mandated first-line choice.
A caregiver, exhausted and frightened, asks for an antipsychotic to stop her husband's visual hallucinations. In dementia with Lewy bodies, that request runs directly into one of the sharpest, best-documented drug-hypersensitivity risks in psychiatric pharmacology.
A family asks whether the drugs that help Alzheimer's disease might help their father's stepwise, post-stroke decline too. The most specific trial ever run on that exact question already answered it — and the answer depends on which kind of vascular dementia he actually has.
A family expects the same confident pharmacology that guides Alzheimer's care. Frontotemporal dementia runs on a different neurotransmitter deficit entirely, and the evidence behind treating it is real but genuinely much thinner than what they're used to hearing about.
A patient with mild cognitive impairment, well-informed and proactive, asks to start donepezil preemptively. The largest trial ever built to answer exactly this question returned a negative headline result — with one real, specific exception hiding inside it.