Guidelines on the management of dementia-revised-2.pdf
GUIDELINES ON THE MANAGEMENT OF DEMENTIA (2003) Assessment
Assessment by members of the multi-disciplinary team, but the doctors must be involved
Wherever is appropriate and convenient to the patient and the team (e.g. OPD, Old Age
“Dementia is a syndrome ofpersistent (more than 6 months) decline in memory and other cognitive functions sufficient to affect daily life in an alert patient” Common symptoms of Dementia:
1. Memory loss affecting job skills or other activities
7. continuous misplacement of personal possessions
u History from the patient but beware that patient might minimizes or denies.
u Collateral history from the family or carers mandatory for elaboration and
clarification of the history, as well as the beginning of the discussion and
present history- the onset and the course of illness
present level of functioning in personal hygiene and care; activities of
daily living; social and interpersonal relationships, competency
evaluation if necessary (e.g. ability to make decisions such as
management of personal finances; ability to give consent to a specific
caregiver evaluation-- including stresses in carers
u Standard mental examination mandatory, with special emphasis on cognitive
assessment. Standardized cognitive tests (e.g. MMSE) desirable esp. for
following the progression of the impairment. Also screen for depression.
u Adequate physical examination especially a brief neurological examination
u The following are done if there are sufficient clinical indications:
13. CT Brain Scan- to detect brain lesions e.g subdural haematoma,
14. EEG- in mild dementia the EEG may remain entirely normal
15. Neuropsychological assessment (e.g to assist with the diagnosis of
very mild or atypical presentations, to assess level of functioning
in certain issues such as handling finances, to obtain a detailed
baseline of cognitive abilities from which to measure progress
u To be on the lookout for, and to treat, complicating and aggravating physical and/or
psychosocial factors as early as possible.
u To prevent clinical deterioration as much as is practicable.
u To maintain optimal physical functioning and well-being.
To keep the patient in the community for as long a practicable;
u Management should be by the whole multidisciplinary team.
u Effective and timely communications between the team and the family/carers, other
professionals, and between team members themselves.
u As much practical and psychological help to the family/carers as practicable, eg.
sympathetic listening adequate explanations, financial help, home help etc.
u Short-term admission to a psychogeriatric unit when necessary for diagnosis, further
investigations, or managing acute or short-term problems.
u Psychosocial treatments wherever appropriate, e.g. Reality Orientation,
Reminiscence Groups, behavioural treatment etc.
u Most medications are used for symptomatic treatment, e.g. reducing the level of
arousal and agitation, helping sleep etc. Others, e.g. nootropics may be used,
hopefully to delay or even partly to reverse the deterioration, but to date there is
insufficient evidence to show that it is useful in this regard in moderate or severe
dementia. No medications should be continued indefinitely without regular review
and monitoring. Please refer to the Appendix I for information of
u Newer medications such as cholinesterases inhibitors, e.g. donepezil and
rivastigmine are symptomatic treatment for mild to moderate Alzheimer’s disease;
the overall benefits on cognitive function and the global assessment are modest.
They also showed positive effect on emotional behaviouralsymptoms of
Alzheimer’s disease. At present, there is insufficient information to recommend that
they be given to patients suffering from severe disease or to patients in nursing home.
Although no head-to-head clinical trials have compared the 2 cholinesterase inhibitors,
similar modest improvements in ADAS-Cog scores and global clinical change have
been reported in the treatment of patients with mild-moderate AD. However these
drugs are expensive and have side effects which may be significant in some patients.
As a result these medications should only be prescribed for selected patients
individually after careful assessment of the indications and contraindications, with
provision for regular, frequent review and monitoring. (Please refer to the following
Algorithm) Algorithm for the use of cholinesterase inhibitors (C.I.) Is this patient suffering from Mild to Moderate Dementia in Alzheimer’s Disease according to ICD-10 criteria and MMSE≥10 OR Dementia with Lewy bodies with behavioural and psychological symptoms of dementia?
Is there any medical contraindication with
Is this patient compliant or is there any
reliable caregiver to ensure compliance?
Likely to be beneficial
Start with a C.I. (advice to patient and
Poor tolerability Effective Good tolerability Ineffective
improvement in cognitive functions, ADL,
emotional behavioural problems, or global
Consider discontinuation if
b. patient has entered into severe stage of dementia in
Alzheimer’s Disease (e.g. according to ICD-10
criteria, MMSE<10, institutionalized due to
3- 6 months to review clinical progress and
Closer follow-up is needed to monitor deterioration
Appendix I References for Pharmacological Treatment of Dementia Sources of Information American Psychiatric Clinical Evidence Practice Evidence-base Association (APA)- Issue 8 Parameter: briefing: dementia. Practice Guideline BMJ 2003 management of The Royal College of dementia (an Psychiatrists, 1999 evidence-based (other than APA, review)-American 1997) Academy of Neurology,2001 Treatment of Cognitive symptoms a.cholinesterase Given the evidence for modest One systematic review has The class of agents is - in light of limited current
improvement in some patients and found that donepezil versus consistently better than
the lack of established alternatives, placebo significantly placebo. However, the should not initiate treatment with
(e.g. donepezil, it is appropriate to consider a trial improves cognitive function disease eventually continues donepezil (CHSR, 1997)
of one of these agents for midly or at up to 52 weeks in people to progress despite
moderately impaired patients with with mild or moderate treatment, and the average donepezil in the treatment ofmild
Alzheimer’s disease for whom the Alzheimer's disease. One “effect size” is modest. to moderate senile dementia of
subsequent RCT in people Global changes in cognition, Alzheimer type, is borderline.
with moderate to severe behaviour, an functioning There is evidence of temporary
Alzheimer's disease has have been detected by both benefit but at a considerable cost.
found that donepezil versus physicians and caregivers, Treatment should be targeted
placebo significantly indicating that even small carefully. Any protocol for its use
improves cognitive function measurable differences may should include clear criteria and a
and functional and be clinically significant
Hydergine was ineffective at -It is not sufficiently effective to
3 mg per day and showed be routinely recommended as a
slight memory improvement treatment for dementia. (CHSR,
meet a priori benefit -It shows significant treatment
regarding its efficacy in dementia. (Olin et al, 1998) -It is effective for dementia. It is more effective than placebo in patients with vascular dementia, in in-patients compared with out-patients, and in higher compared with lower dosages. It has modest effects in patients with Alzheimer’s Disease. The conditions for obtaining benefits from it are inadequately defined. (ACP Journal Club 1995)
One systematic review has It was safe in one Class I -seven patients have to be treated found that Ginkgo biloba trail of patients with mixed with 120 mg of Gingko extract versus placebo significantly dementia, but benefits fall daily for one year for one of them improves cognitive function short of those expected for to have an improved Alzheimer’s and is well tolerated in clinically effective disease Assessment Score Alzheimer's disease. We antidementia treatments
improvement, about four patients have to be treated for one year. For a patient’s family member to notice an improvement in their daily living and social behavior about seven patients have to be treated for one year. (Bandolier, 1998) -Gingko biloba appears to have a modest stabilizing effect on the general functional decline of otherwise healthy patients with dementia. It appeared to be as safe as placebo, although the small number of patients and the short time period limits the ability to detect uncommon events. The changes reported are of a similar magnitude to those seen with tacrine and donepezil, two currently available medications that, locally, cast three times more than Gingko extracts. Whether it is safer or more effective then this medication are not clear. Recommendations to patients should be made with caution, since Gingko does not face the regulatory scrutiny of prescription medications. Nonetheless it appears that it nay have some beneficial effects in demented individuals. (Journal of Evidence-Based Practice, 1997) -Gingko biloba safely and modestly improved dementia (EBM, 1998)
Slowing of Disease Progression in Dementia a. Vitamin E
May be used in moderately One RCT in people with Doses at 2000IU per day impaired patients with Alzheimer’s Alzheimer's disease found no significantly delayed the disease in order to delay the significant difference in time to a composite outcome progression of disease. The efficacy cognitive function after 2 of primary measures reported here are for a fairly high years' treatment with vitamin indicative of clinical dose of 2000IU/day. Beware of E versus placebo, but found worsening, and fewer were worsening of coagulation defects in that vitamin E significantly institutionalized. patients with vi tamin K deficiency reduced mortality, (NB. there was no additive
institutionalisation, loss of effect from vitamin E plus ability to perform activities of selegiline) daily living, and the
proportion of people who developed severe dementia. We found no RCTs about vitamin E in vascular or Lewy body dementia.
Possible benefit. Selegiline -There is not yet enough evidence
(5mg BD) is supported by to recommend its routine use in
one study, but has a less practice (Birks & Flicker, 1998)
favourable risk-benefit -The role of seligiline in the
well-controlled, long term clinical trials. (DARE;NHS CRD, 1998) -
Preliminary evidence only. Need to One RCT in people with Not supported by
weigh the risks and benefits when Alzheimer's disease found no prospective data. Estrogen
one using or considering using significant difference in should not be prescribed to
cognitive function after 25 treat Alzheimer’s disease weeks' treatment with diclofenac plus misoprostol versus placebo. Another RCT in people with Alzheimer's disease found that indometacin versus placebo significantly improved cognitive function after 6 months' treatment. We found no RCTs of non-steroidal anti-inflammatory drugs in people with vascular or Lewy body dementia. One systematic review in women with established Alzheimer's disease has found that oestrogen versus no oestrogen improves cognition. We found no evidence about its use in people with vascular or Lewy body dementia.
Treatment for psychosis and agitation in dementia a.antipsychotics There are no efficacy data to guide
Antipsychotics should be -treatment should normally be
used to treat agitation or short-term and be reviewed
psychosis in patients with regularly.(SIGN, 1998)
dementia where -neuroleptics should normally be
environmental manipulation avoided in Lewy Body Type
fails. Atypical agents may Dementia (SIGN, 1998)
be better tolerated compared -start low, go slow (SIGN, 1998)
dementia, and compliance is often a problem. (Haines & Katona, 1992 (RCRP))
benzodiazepine disinhibition, ovesedation,falls,and
1998) -Triazolam caused sedation and impairment of psychomotor performance in elderly people (AC Journal Club, 1991)
anticonvulsants recommended with confidence for placebo significantly reduced
demented patients. Nonetheless, a people with agitation and therapeutic trial of one of these
agents may be appropriate for some Another RCT found that nonpsychotic patients, especially
those who are midly agitated or are agitation in unspecified sensitive or unresponsive to
Preliminary data suggest that SSRIs One RCT in people with
dementia plus agitated behaviour found no significant difference in agitation with trazodone versus haloperidol. Another RCT in people with Alzheimer's disease and agitated behaviours found no significant difference in outcomes between trazodone, haloperidol, behaviour management techniques, and placebo. The RCTs may have been too small to exclude a clinically important difference.
significant difference in psychiatric symptoms at 3 months with galantamine versus placebo, but another RCT found that galantamine versus placebo significantly improved psychiatric symptoms at 6 months. One RCT in people with Alzheimer's disease found that donepezil versus placebo significantly improved functional and behavioural symptoms at 24 weeks, and another RCT found no significant difference in psychiatric symptoms at 24 weeks with donepezil versus placebo.
Treatment for depression in dementia
Selected tricylics, MAOI, -Consider a trial of antidepressant
and SSRI should be medication at a therapeutic dose
considered with side effects evaluated against explicit criteria
profiles guiding the choice such as activities of daily living, of agent
level of functioning, behavioural disturbance and biological features of recent onset. -Moclobemide was an effective antidepressant in elderly patients with cognitive decline and depression
Electroconvuls- than bilateral ECT may decrease ive therapy
the risk of cognitive side effects after ECT
(ECT) Treatment for sleep disturbance in dementia
without other psychiatric symptoms beyond the dementia itself,there is little to guide the choice among agents(antipsychotic,antidepressant, anxiolytic).
Practice Guideline for the treatment of patients with Alzheimer’s Disease and other
Dementias of Late Life, American Psychiatric Association, 1997
National Guideline Clearinghouse, American Medical Directors Association
(AMDA Dementia. Columbia (MD):American Medical Directors Association
(AMDA);1998 32p (http://www.guidelines.gov)
The Expert Consensus Guideline Series— Treatment of agitation in Older persons
with Dementia (http://www.psyguides.com/gagl.html)
Practice Parameter: Management of dementia (an evidence based review): Report of
the Quality Standards Subcommittee of the American Academy of Neurology, Vol
Evidence-base briefing: dementia. A compilation of secondary research evidence,
guidelines and consensus statements. The Royal College of Psychiatrists, 1999.
Clinical Evidence Issue 8 BMJ 2003 ISBN 0-7279-14987
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