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 of persistent (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 Management

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 behavioural symptoms 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). References:
Practice Guideline for the treatment of patients with Alzheimer’s Disease and other Dementias of Late Life, American Psychiatric Association, 1997 (http://www.psych.org/clin_resp/pg_dementia.cfm) 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

Source: http://www.hkpga.org/upload_files/files/Guidelines_on_Dementia_mx.pdf