Cognitive decline ranges from normal aging to mild cognitive impairment to dementia, and depression, medications and medical conditions often mimic it. Evaluation includes cognitive testing, screening for depression and reversible causes, and coordination with neurology. Treatment addresses mood, sleep and behavioral symptoms with careful medication choices, supports caregivers, and includes cholinesterase inhibitors and memantine for Alzheimer's disease.
Stedfast Psychiatry provides geriatric psychiatric care across Florida and South Carolina: evaluation of memory concerns, treatment of the depression and anxiety that often accompany or masquerade as cognitive decline, management of the behavioral and psychological symptoms of dementia, and support for families. Through our Stedfast Living program, our providers visit patients in assisted living, independent living and skilled nursing facilities.
Symptoms of memory and dementia
- Forgetting recent conversations, appointments or events, and not recalling them later
- Repeating questions or stories
- Difficulty managing finances, medications or familiar tasks
- Getting lost in familiar places
- Trouble finding words or following conversations
- Poor judgment or uncharacteristic decisions
- Withdrawal from activities and social life
- New depression, anxiety, apathy or irritability in later life
- Suspiciousness, hallucinations or agitation
- Changes in sleep, including acting out dreams
Causes and risk factors
Alzheimer's disease, caused by the accumulation of amyloid and tau proteins, accounts for 60 to 80 percent of dementia. Vascular dementia follows strokes or chronic small-vessel disease and often coexists with Alzheimer's. Lewy body dementia involves fluctuating alertness, visual hallucinations and parkinsonism. Frontotemporal dementia affects behavior and language, often before age 65. Age, genetics (including the APOE4 gene), cardiovascular risk factors, hearing loss, head injury, depression, social isolation, low physical activity and heavy alcohol use raise risk. Reversible or treatable contributors are common and must be found: depression (sometimes called pseudodementia), thyroid disease, vitamin B12 deficiency, sleep apnea, medications with anticholinergic or sedative effects, alcohol, delirium from infection or dehydration, and normal pressure hydrocephalus.
About 6.9 million Americans aged 65 and older are living with Alzheimer's dementia in 2024, a number projected to nearly double by 2050.
Source: Alzheimer's Association, 2024 Facts and Figures
Mild cognitive impairment affects an estimated 12 to 18 percent of people aged 60 and older, and about 10 to 15 percent of those with MCI progress to dementia each year.
Source: Alzheimer's Association
Up to 40 percent of dementia cases worldwide may be attributable to modifiable risk factors such as hearing loss, hypertension, depression, physical inactivity and social isolation.
Source: Lancet Commission on Dementia Prevention, 2020
Depression affects about 1 to 5 percent of community-dwelling older adults but up to 13.5 percent of those receiving home health care and higher rates in long-term care.
Source: CDC
How we diagnose it at Stedfast Psychiatry
Our geriatric evaluation begins with a history from the patient and, with permission, a family member, since the person with memory loss may not recognize it. We use standardized cognitive screens such as the Montreal Cognitive Assessment (MoCA) or the Saint Louis University Mental Status exam, screen for depression with the Geriatric Depression Scale and the PHQ-9, and assess for anxiety, sleep problems, hallucinations and functional changes. We review every medication, prescription and over-the-counter, for drugs that impair cognition, including benzodiazepines, sleep aids, antihistamines, bladder medications and opioids. Labs include TSH, vitamin B12, folate, a metabolic panel and a complete blood count, and brain imaging is ordered or reviewed when not already done. We coordinate with neurology for formal neuropsychological testing, biomarker evaluation and consideration of newer Alzheimer's therapies when appropriate, and we assess safety, driving and capacity when needed.
Treatment options
Medication management
For Alzheimer's disease, cholinesterase inhibitors (donepezil, rivastigmine, galantamine) modestly improve or stabilize cognition and function in mild to moderate stages, and memantine is added in moderate to severe stages; we prescribe and monitor these and coordinate with neurology on the newer anti-amyloid infusions (lecanemab, donanemab) for eligible early-stage patients. Depression in older adults responds to SSRIs such as sertraline and escitalopram, started at low doses, with attention to sodium levels and fall risk; mirtazapine helps when poor sleep and appetite dominate. For the behavioral and psychological symptoms of dementia (agitation, aggression, psychosis), we use non-drug approaches first, then SSRIs such as citalopram, and antipsychotics only when symptoms are severe and dangerous, at the lowest dose for the shortest time, with full discussion of the FDA boxed warning on increased mortality in dementia; brexpiprazole is FDA-approved for agitation in Alzheimer's dementia. We avoid benzodiazepines, anticholinergics and sedating sleep aids, and we deprescribe medications that are doing harm. Lewy body dementia requires particular care because of severe antipsychotic sensitivity.
Psychotherapy and caregiver support
Psychotherapy helps older adults with depression, anxiety and adjustment to cognitive change, particularly in mild cognitive impairment and early dementia when insight is preserved; problem-solving therapy and CBT adapted for older adults are effective. For moderate to advanced dementia, treatment shifts toward the environment and the caregiver: structured routines, meaningful activity, managing triggers for agitation, sleep hygiene, and reducing overstimulation. Caregiver education and support lower caregiver depression and delay nursing home placement. We connect families with the Alzheimer's Association, area agencies on aging, adult day programs and respite resources, and we address the caregiver's own mental health.
What to expect
The first visit is a 60-minute evaluation, usually with a family member present, in person at any of our offices, by video, or at the patient's facility through Stedfast Living. We complete cognitive and mood screening, review medications and labs, and agree on a plan that may include treatment of depression or sleep, medication changes, neurology referral and family resources. Follow-ups are every four to eight weeks initially, then every three months. Telehealth is available throughout Florida and South Carolina and works well for medication follow-up with a caregiver present.
When to seek help
Seek evaluation when memory or thinking changes are noticed by family, affect daily tasks, or come with new depression, anxiety, apathy or personality change. Earlier evaluation finds reversible causes, allows planning, and opens access to treatments that work best early. Seek urgent care for sudden confusion, which can signal delirium from infection, medication or stroke. If an older adult expresses hopelessness or thoughts of not wanting to live, take it seriously: older men have the highest suicide rate of any group. Call or text 988, or call 911 in an emergency.
Stages and types of cognitive decline
Subjective cognitive decline is the experience of worsening memory with normal test results; it deserves monitoring and attention to risk factors. Mild cognitive impairment shows measurable deficits with preserved independence, and some cases remain stable or revert, particularly when depression, sleep or medication was the cause. Dementia is staged from mild (needing help with complex tasks) through moderate (needing help with daily activities) to severe (full dependence). Alzheimer's typically begins with recent memory loss. Vascular dementia progresses in steps after strokes or gradually with small-vessel disease, often with slowed thinking and gait changes. Lewy body dementia brings vivid visual hallucinations, fluctuating alertness, REM sleep behavior disorder and parkinsonism, and requires avoiding most antipsychotics. Frontotemporal dementia starts with personality change, disinhibition or language loss, usually before 65, and is often first mistaken for a psychiatric disorder.
Behavioral and psychological symptoms of dementia
Up to 90 percent of people with dementia develop behavioral or psychological symptoms at some point: apathy, depression, anxiety, agitation, aggression, wandering, sleep reversal, suspiciousness or hallucinations. These, more than memory loss, drive caregiver burnout and nursing home placement. Our approach follows the evidence: first identify triggers (pain, infection, constipation, hunger, overstimulation, a change in routine), adjust the environment and the approach of caregivers, treat depression and sleep, and use antipsychotics only for severe, dangerous symptoms with informed consent and a plan to taper. Many facilities overuse sedating medication, and our facility program works to reduce it.
Reducing risk and slowing decline
Blood pressure control, treating hearing loss with hearing aids, regular physical activity, social engagement, cognitive stimulation, treating depression and sleep apnea, limiting alcohol and managing diabetes all reduce the risk or slow the course of cognitive decline. These are worth pursuing at every stage. Structured routines, calendars and medication organizers preserve independence in MCI and early dementia. Advance care planning, including a health care surrogate, durable power of attorney and conversations about wishes, is best done early while the person can participate fully.
Caregivers
Family caregivers of people with dementia have high rates of depression, anxiety and physical illness, and their well-being directly affects the patient's. We ask how the caregiver is doing at every visit, treat caregivers who need care themselves, and connect families with respite, adult day programs, support groups and the Alzheimer's Association 24-hour helpline. Accepting help early, before exhaustion, is the most effective strategy we know.
Outlook
Dementia is progressive, but its course is shaped by how well mood, sleep, behavior, physical health and the caregiving environment are managed. Treating a reversible cause can restore function. Treating depression improves quality of life at every stage. Good behavioral management keeps people at home longer and reduces hospitalization. The goal of geriatric psychiatric care is the best possible quality of life for the patient and family through every stage, and that is an achievable goal.
Frequently asked questions
Is it normal aging or something more?
Occasionally forgetting a name or where you put your keys, and remembering later, is normal. Forgetting recent conversations entirely, repeating questions, getting lost in familiar places, struggling with finances or medications, or family noticing changes you do not are signs to be evaluated. Depression, poor sleep, medications and medical problems cause similar symptoms and are treatable, which is the strongest reason not to wait.
What is the difference between a geriatric psychiatrist and a neurologist for memory problems?
They overlap and often work together. Neurologists focus on diagnosing the specific brain disease, with imaging, biomarkers and detailed testing, and prescribe disease-specific treatments. Geriatric psychiatry evaluates and treats the mood, anxiety, sleep and behavioral symptoms that accompany or mimic cognitive decline, manages medications that affect thinking, and supports families. Many patients benefit from both, and we coordinate the referral.
Can depression look like dementia?
Yes. Depression in older adults often presents as poor concentration, slowed thinking, memory complaints and apathy rather than sadness, and it can produce test scores that look like early dementia. The difference is that depressed patients tend to complain about their memory more than demented patients do, and their cognition improves with treatment. Depression also raises the risk of later dementia, which is another reason to treat it.
What medications should older adults with memory problems avoid?
Benzodiazepines (lorazepam, alprazolam), prescription sleep aids (zolpidem), over-the-counter sleep aids and antihistamines containing diphenhydramine, bladder medications such as oxybutynin, some antidepressants like amitriptyline, muscle relaxants and opioids all impair cognition and raise fall risk. A medication review is one of the most valuable parts of our evaluation, and stopping or substituting these often produces noticeable improvement.
Do you see patients in assisted living and nursing homes?
Yes. Through our Stedfast Living program, our providers visit assisted living facilities, independent living communities and skilled nursing facilities across our service areas in Florida and South Carolina, evaluating and treating residents for depression, anxiety, dementia-related behaviors and sleep problems, and coordinating with facility staff and families. Facilities and families can contact us to arrange care.
Is geriatric psychiatric care covered by Medicare?
Yes. We accept Medicare and most Medicare Advantage plans as well as commercial insurance. Evaluations and follow-ups are billed as specialist visits, and visits in facilities are covered under Medicare Part B. Our self-pay rate for a new evaluation is $185. Cholinesterase inhibitors, memantine and most psychiatric medications are inexpensive generics covered under Part D.
Can memory evaluation be done by telehealth?
An initial evaluation is best done in person so that cognitive screening and observation are reliable, though video can work with a family member present and a quiet setting. Follow-up visits for medication, mood and behavioral symptoms work well by telehealth across Florida and South Carolina, and we use them to reduce travel for patients and caregivers.
How can I help a parent who refuses to be evaluated?
Frame the visit around something they accept, such as sleep, energy, a medication review or a checkup, rather than memory. Schedule it with their primary care provider or with us and ask to attend. Share your observations with the provider in advance, in writing, which is permitted even without the patient's consent. If safety is at stake (driving, wandering, financial exploitation), say so plainly. Most patients engage once they are in the room with a clinician who is not alarming.
Where to get treatment for cognitive decline, dementia and memory concerns
Evaluation and treatment for cognitive decline, dementia and memory concerns is available at every Stedfast Psychiatry office and by video across Florida and South Carolina.
Related conditions
If you are thinking about harming yourself, call or text 988 now, or go to the nearest emergency room. This page is educational and does not replace an evaluation. Clinical content reviewed by Dr. David Husted, board-certified psychiatrist.