guidelines for management of dementia

Guidelines for Management of DEMENTIA

DR. RAVI SONI, DM-SR IIIDEPARTMENT OF GERIATRIC MENTAL HEALTH,

K.G.M.U. LUCKNOW

We always have this feeling for guidelines for Dementia Management

Obviously we don’t like to do this

It is really difficult and boring to search literature on our own

So, we will go through different guidelines

We will learn and identify important issues in management of Dementia and accordingly modify our clinical practice

Dementia management guidelines

1. APA guidelines for management of Alzheimer’s Disease and other dementias [American Psychiatrists Association]

2. NICE guidelines for management of Dementias [National Institute for Clinical Excellence]

3. SIGN guidelines for management of Dementias [Scottish Intercollegiate Guidelines Network]

Guidelines are divided under following headings

SIGN: Introduction Diagnosis Non-Pharmacological interventions Pharmacological interventions Information for discussion with patients and

carers Implementation, resource implications and audit Development of Guideline Including Diagnostic criteria for different types of

Dementias

SIGN guideline is simplest and easiest to follow, Specific differing aspects from other guidelines will be discussed in the end

KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONS

Introduction to Dementia

Definitions and brief introduction of Dementia Alzheimer’s Disease Vascular Dementia Dementia with Lewy bodies Fronto-temporal dementia Mixed dementias

DiagnosisA. History Taking and differential Diagnosis: Detailed history is an important part of the assessment of

someone with suspected dementia Attention should be paid to

A. Mode of onset, B. Course of progression, C. Pattern of cognitive impairment and D. Presence of non-cognitive symptoms such as behavioral

disturbance, hallucinations and delusions Sufficient information should be gathered to apply the

diagnostic criteria As a person with dementia may not be able to give a fully

accurate history a relative or carer should also be interviewed

Recommendation for Diagnosis criteria

Grades of Recommendations: B: DSM-IV or NINCDS-ADRDA criteria should be used

for the diagnosis of Alzheimer’s disease B: The Hachinski Ischemic Scale or NINDS-AIRENS

criteria may be used to assist in the diagnosis of vascular dementia.

C: Diagnostic criteria for dementia with Lewy bodies and fronto-temporal dementia should be considered in clinical assessment. Clinical criteria for dementia with Lewy bodies

(Consortium for DLB criteria) fronto-temporal dementia (Lund-Manchester criteria) are not closely associated with neuropathological diagnoses but can still provide useful differentiating clinical features

DiagnosisB. Initial Cognitive Testing: MMSE is used widely for screening purpose It provides superficial assessment of memory, language,

visuoperceptual function. Processing speed and executive function are not tested. Evidence from a systematic review has shown that the

MMSE is suitable for the detection of dementia in individuals with suspected cognitive impairment

Grade B: In individuals with suspected cognitive impairment, the MMSE should be used in the diagnosis of dementia.

Initial cognitive testing can be improved by the use of Addenbrooke’s Cognitive Examination

A questionnaire, such as the IQCODE, completed by a relative or friend may be used in the diagnosis of dementia

DiagnosisC. Screening for comorbid conditions: Screen for coexisting medical conditions and for

potential causes of dementia at first presentation There is no evidence that routine batteries of laboratory

tests improve the accuracy of the clinical diagnosis of dementia, nor is there evidence for the routine use of genetic markers or syphilis serology to increase the predictive value of a diagnosis.

Physical investigations including laboratory tests should be selected on clinical grounds according to history and clinical circumstances.

Grade B: As part of the assessment for suspected dementia, the presence of comorbid depression should be considered. A systematic review found that people with depression and

cognitive impairment are highly likely to have dementia diagnosed during longitudinal follow up and that 12% of people with dementia were also depressed

DiagnosisD. The use of Imaging: The ability of clinical examination (for example, history-taking

and physical examination) to predict a structural lesion has been reported as having sensitivity and specificity of 90%. Imaging can be used to detect reversible causes of dementia and to

aid in the differential diagnosis of dementia. The choice of imaging technique varies widely, and includes CT scan, MRI, SPECT and PET.

Assessment of delayed recall is at least as good as volumetric MRI in distinguishing people with probable AD from controls.

Grade C: structural imaging should ideally form part of the diagnostic workup of patients with suspected dementia.

Grade C: CT may be used in combination with CT to aid the differential diagnosis of dementia when the diagnosis is in doubt.

DiagnosisE. The role of cerebrospinal fluid and

electroencephalography:

There is insufficient evidence to support routine use of CSF markers in the diagnosis of dementia.

Grade B: CSF and EEG examinations are not recommended as routine investigations for dementia.

CSF and EEG examinations may be useful where CJD is suspected.

Diagnosis F. Neuropsychological testing: Assessment of cognition is useful in both the initial and

differential diagnosis of dementia It is possible to detect even very early Alzheimer’s

disease using neuropsychological testing. Neuropsychology is superior to imaging in discriminating

people with AD from controls. Neuropsychological testing also aids in the differential

diagnosis of dementia: FTD is characterized by deficits of semantic memory and

attention/executive function rather than the episodic memory deficit seen in AD

Dementia with Lewy bodies has more pronounced visuoperceptual and frontal impairment compared to AD

Vascular dementia exhibits executive dysfunction Depression shows a subcortical pattern of cognitive

impairment

Recommendations for neuropsychological testing

Grade B: Neuropsychological testing should be used in the diagnosis of dementia, especially in patients where dementia is not clinically obvious.

It may be useful to repeat neuropsychological testing after six to 12 months in patients where: The diagnosis is unclear Measurement of the progression of deficits in a typical

pattern supports a diagnosis of dementia and helps in differential diagnosis.

Non-Pharmacological Interventions

Non-pharmacological interventions are used to ensure that underlying causes of behavioral disturbance are explored and to provide personalized approaches to presenting problems.

CORE SYMPTOMS: Cognitive decline Functional decline Social decline

ASSOCIATED SYMPTOMS: Agitation Aggression Depression Psychosis Repetitive Vocalization Sleep disturbance Non-specific behavior Disturbance


1. COGNITIVE DECLINE: Cognitive stimulation: may occur informally through recreational

activities, or formally through: a program of memory provoking, problem-solving and conversational

fluency activities the spaced retrieval method face name training

Formal cognitive stimulation produced a positive clinical impact on cognitive function in people with dementia.

Grade B: Cognitive stimulation should be offered to individuals with dementia.

Reality Orientation Therapy: [ROT] The purpose of ROT is to reorientate the person by means of continuous stimulation and repetitive orientation to the environment.

This may be done formally in a daily group session, or informally using a way of communicating that is very individual to the person and involves orientation to time, place and person during every direct contact with the individual

Grade D: Reality orientation therapy should be used by a skilled practitioner, on an individualized basis, with people who are disorientated in time, place and person.


2. Functional Decline: Caregiver intervention programs: Caregiver intervention

ranges from the simplest reassurance to the most complex multi-faceted interaction with the person with dementia, including in one case, a caregiver residential program.

Improvement in associated symptoms of dementia Improvement in basic daily activities and other functional

activities Delay in nursing home placement Grade B: Caregivers should receive comprehensive

training on interventions that are effective for people with dementia.

Reality orientation therapy has been also found to be effective

3. Social Decline: No robust evidence identified

Non-Pharmacological Interventions for associated symptoms

1. Agitation: Aromatherapy and recreational activities are beneficial

2. Aggression: no robust evidence identified3. Depression: Behavior management is beneficial4. Psychosis: no robust evidence identified5. Repetitive vocalization: no robust evidence identified6. Sleep disturbance: no robust evidence identified7. Non-specific behavior disturbance: Care giver

intervention and training, multisensory stimulation and recreational activities have shown benefits

Behavior management [level 1+]

The term “behavior management”, is used to reflect structured, systematically applied and normally

time-limited interventions usually carried out by carers or care home staff under the

supervision of a professional with expertise in this area. Although affective symptoms associated with dementia,

including facial expression, contentment and interest can be improved by behavior management, there was no evidence for significant reduction in disruptive behavior in nursing home residents or those in the community

There is evidence to support the use of behavioral management to reduce depression in people with dementia living in the community with a caregiver [behavioral therapy either involving pleasant events or problem solving]

Grade B: Behavior management may be used to reduce depression in people with dementia.

Multilevel behavioral management interventions may be more effective than individual interventions at improving behavior and well-being in people with dementia.

Environmental design [level 3]

Residential unit design, such as corridor configuration, can influence restlessness, anxiety and disorientation in institutionalized people with dementia

A descriptive systematic review showed that changes in environment can have a positive impact on associated symptoms of dementia.

The studies examined: Environmental comparisons Design features Environmental services and policies Problem behaviors in people with dementia in different

physical environments. The most common outcome measures were impact on

problem behaviors, on ADLs and on cognitive and social function.

Environmental design [level 3]

Measures which should be considered when planning an environment for people with dementia include:

incorporating small size units separating non-cognitively impaired residents from people with dementia offering respite care as a complement to home care relocating residents, when necessary, in intact units rather than individually incorporating non-institutional design throughout the facility and in dining

rooms in particular moderating levels of stimulation incorporating higher light levels using covers over fire exit bars and door knobs to reduce unwanted exiting incorporating outdoor areas with therapeutic design features considering making toilets more visible to potentially reduce incontinence eliminating factors that increase stress when bathing.

Multisensory stimulation and combined therapies

This approach uses lighting effects, relaxing music, recorded sounds, massage cushions, tactile surfaces and fragrances to create a multisensory environment.

Aromatherapy: Melissa officinalis (lemon balm) was shown to have a positive effect on agitation.

There is insufficient evidence for the efficacy of aromatherapy in reducing the core and associated symptoms of dementia and more well controlled trials are needed.

In people with dementia who show behavioral disturbance despite the use of psychotropic medication, aromatherapy may influence behavior but cannot be recommended as a direct alternative to antipsychotic drugs, nor for the reduction of specific behavioral problems.

The use of aromatherapy to reduce associated symptoms in people with dementia should be discussed with a qualified aromatherapist who can advise on contraindications.


Light therapy: Evidence from a series of small studies using bright light therapy

shows its effect on cognitive function in patients with dementia is negligible

No consistent benefit of bright light therapy is reported in the domains of sleep or agitation.

Bright light therapy is not recommended for the treatment of cognitive impairment, sleep disturbance or agitation in people with dementia

Music therapy: Evidence from a series of small under powered studies suggests

that exposure to music, tailored to the individual’s taste, can relieve agitation but not aggressive behavior in people with dementia.

Music therapy is easy to implement, but more research is needed to determine whether it is beneficial to the person with dementia.


Multisensory Stimulation: Individuals exposed to multisensory environments showed less

confusion and talked more spontaneously and in normal length sentences.

In people with moderate dementia there was a small improvement in mood, apathy and restlessness for the duration of the session but there was no improvement in psychotic behavior, aggression and irritability

For people with moderate dementia who can tolerate it, multisensory stimulation may be a clinically useful intervention.

Multisensory stimulation is not recommended for relief of neuropsychiatric symptoms in people with moderate to severe dementia.

Evidence from one systematic review does not demonstrate a significant clinical effect in favor of the use of the commercially available sensory resource Snoezelen


Physical activities: Overall the clinical impact of physical activities on core or

associated symptoms of dementia is minimal. For people with dementia, a combination of structured

exercise and conversation may help maintain mobility. Recreational activities:

Activities used range from self expression through drawing, music, arts and crafts, to cooking, games and interacting with pets.

Significant positive effect based on facial expression and body posture

Recreational activities should be introduced to people with dementia to enhance quality of life and well-being.

Individualized activities adapted to maximize the person’s remaining abilities and based on previous interests may be more beneficial to people with dementia than generic activities.


Simulated presence: For nursing home residents simulated presence therapy was

associated with improved alertness but provided no clinical benefits compared to a placebo tape recording.

Simulated presence therapy is not effective for reduction of agitation in nursing home residents with severe dementia.

Validation therapy: Validation therapy is an approach used to communicate with

disorientated elderly people that involves acknowledging and supporting their feelings in whatever time and place is real to them, even if this may not correspond to their “here and now” reality.

A systematic review of two RCTs and a further RCT showed no statistically significant or clinically relevant effects from using validation therapy with people with dementia.

Interventions lacking evidence of clinical effectiveness Memory books Reminiscence therapy.

Pharmacological interventions

Core symptoms: Cognitive decline: all cholinesterase inhibitors and gingko Functional decline: all cholinesterase inhibitors and gingko Social decline: no evidence

Associated symptoms: Agitation: Salvia, Trazodone Aggression: Antipsychotics Depression: Antidepressants Psychosis: Donepezil, Antipsychotics Repetitive vocalization: no evidence Sleep disturbance: no evidence Non-specific behavior disturbance: all cholinesterase

inhibitors, gingko and antidepressants

Pharmacological Interventions

Donepezil: There is a significant body of evidence to support the use of the cholinesterase

inhibitor donepezil in people with mild to moderate Alzheimer’s disease. There is evidence to suggest that its efficacy may extend to the treatment of

people with more severe forms of Alzheimer’s disease. Grade B: Donepezil, at daily doses of 5 mg and above, can be

used to treat cognitive decline in people with Alzheimer’s disease.

Age and severity of Alzheimer’s disease should not be contraindications to the use of donepezil. A systematic review of the use of donepezil in people with vascular dementia

demonstrated some benefit to patients with mild to moderate cognitive impairment examined over a six month period.

Grade B: Donepezil, at daily doses of 5 mg and above, can be used for the management of associated symptoms in people with Alzheimer’s disease.


Galantamine: Galantamine is effective for the maintenance of cognition in

people with mild to moderate Alzheimer’s disease. There is evidence of some cognitive benefit to patients with

mixed Alzheimer’s disease and cerebrovascular disease. Grade B: Galantamine, at daily doses of 16 mg and

above, can be used to treat cognitive decline in people with Alzheimer’s disease and people with mixed dementias. Galantamine should be used with slow escalation to doses of up

to 24 mg. Grade B: Galantamine, at daily doses of 16 mg and

above, can be used for the management of associated symptoms in people with Alzheimer’s disease. Evaluation of the efficacy of Galantamine in people with

moderate to severe dementia needs further research.


Rivastigmine: In people with mild to moderately severe Alzheimer’s disease,

rivastigmine treatment showed significant benefits in cognitive and global function.

There is evidence from one study that the cognitive benefits of rivastigmine treatment were more robust in patients with moderately severe dementia.

Recommendations: Grade B: Rivastigmine, at daily doses of 6 mg and

above, can be used to treat cognitive decline in people with Alzheimer’s disease.

Grade B: Rivastigmine, at daily doses of 6 mg and above, can be used to treat cognitive decline in people with dementia with Lewy bodies.

Grade B: Rivastigmine, at daily doses of 6 mg and above, can be used for the management of associated symptoms in people with Alzheimer’s disease and dementia with Lewy bodies.


Memantine: The efficacy of memantine has been examined in

people with moderate to severe Alzheimer’s disease and mild to moderate vascular dementia. After six months of treatment with 20 mg of memantine

per day, there was a small, although not clinically significant, benefit over a wide range of outcome measures in patients with mild to moderate vascular dementia.

In patients with moderate to severe Alzheimer’s disease there was a non-clinically significant positive effect from use of memantine on activities of daily living at six months.

There is currently insufficient evidence to recommend the use of memantine for the treatment of core or associated symptoms in people with dementia.


Gingko: Products derived from the maidenhair tree, Ginkgo biloba, have

been used in traditional Chinese medicines for centuries. A number of studies demonstrate that using Ginkgo to treat

dementia has a positive benefit on cognition and function. In patients with advanced AD the differences between Ginkgo

and placebo are more pronounced. Patients may need to take Ginkgo for 52 weeks before there is

an improvement in cognition and activities of daily living. Ginkgo causes bleeding when combined with warfarin or aspirin,

raises blood pressure when combined with a thiazide diuretic and possibly causes coma when combined with trazodone.

Further trials are required before a statement can be made about the effective dose of Ginkgo for the treatment of patients with dementia.

People with dementia who wish to use Ginkgo biloba should consult a qualified herbalist for advice and should be made aware of possible interactions with other prescribed drugs.


Salvia: Historically, the herb Salvia officinalis is known for its

soothing, calming effects and for its ability to improve cognition, especially memory. In one small RCT (39 participants), the effect of using Salvia

officinalis to treat agitation in patients with Alzheimer’s disease was small and non-significant

Further trials are required before a statement can be made about the efficacy of Salvia officinalis for the treatment of agitation in people with Alzheimer’s disease.

People with dementia who wish to use Salvia officinalis should consult a qualified herbalist for advice.


Antidepressants: The use of antidepressants for patients with dementia

accompanied by depressive symptoms is widespread, but their effect on depression and cognitive function is uncertain.

Grade D: Antidepressants can be used for the treatment of comorbid depression in dementia providing their use is evaluated carefully for each patient.


Antipsychotics: Grade A: If necessary, conventional antipsychotics may be

used with caution, given their side effect profile, to treat the associated symptoms of dementia.

The atypical antipsychotics, olanzapine and risperidone are useful in the management of psychotic symptoms, aggression and other behavioral problems associated with dementia.

Atypical antipsychotics with reduced sedation and extrapyramidal side effects may be useful in practice, although the risk of serious adverse events such as stroke must be carefully evaluated.

In patients on stable antipsychotic regimens, who are free from behavioral disturbances, withdrawal of antipsychotic treatment may not be associated with relapse.

An individualized approach to managing agitation in people with dementia is required.

Where antipsychotics are inappropriate cholinesterase inhibitors may be considered.

In patients who are stable antipsychotic withdrawal should be considered.


Trazodone: One small RCT of trazodone showed reduction in agitation

when accompanied by depressive symptoms in patients with dementia.

Trazodone may be considered for patients with depressive symptoms and dementia associated agitation.

Clinically Ineffective Interventions: Anti-Inflammatories:

Grade A: Anti-inflammatories are not recommended for treatment of cognitive decline in people with AD.

Grade B: Hydroxychloroquine is not recommended for the treatment of associated symptoms in people with dementia.

Grade A: Prednisolone is not recommended for the treatment of associated symptoms in people with Alzheimer’s disease.


Melatonin: Exogenous melatonin is not effective in reducing sleep

disturbance associated with dementia. Melatonin treatment does not affect total time asleep,

median number of awakenings or sleep efficiency in patients with dementia.

Estrogen: There is evidence to suggest that estrogen is ineffective for

the prevention of cognitive decline in women with dementia. Although one small RCT (16 participants) showed a

favorable effect of estrogen on associated problems in people with dementia,153 two further studies (170 participants) point to ineffectiveness of the treatment.

Grade B: Estrogen is not recommended for the treatment of associated symptoms in women with dementia.

Clinically Ineffective Interventions:

Physostigmine: Compared to placebo, there was no clinical benefit in

treating people with dementia with physostigmine. Physostigmine has a short half-life and significant adverse

reactions. Selegiline:

A large body of evidence revealed no clinically meaningful benefit from the drug selegiline in the treatment of Alzheimer’s disease.

Grade A: Selegiline is not recommended for the treatment of core or associated symptoms in people with Alzheimer’s disease.


Clinically Ineffective Interventions:

Anticonvulsants: No robust evidence was identified to suggest that valproate is

effective in reducing associated symptoms in people with dementia.

Grade A: Valproate is not recommended for the treatment of behavioral symptoms associated with dementia. One small RCT suggested carbamazepine reduced behavioral

problems associated with severe dementia. An open label study of gabapentin showed no statistical

significance in outcome measures on completion of the study. Anticonvulsants may be considered for the symptomatic

treatment of seizures or myoclonus associated with dementia but are not recommended for other symptoms of dementia.


Intervention lacking evidence of clinical effectiveness

Aspirin: A Cochrane systematic review identified no randomized controlled

evidence that aspirin benefits patients with vascular dementia in a similar way. There is a risk that it may increase the frequency of intracranial hemorrhage.

Aspirin is only recommended in people with vascular dementia who have a history of vascular disease.

Benzodiazepines: No systematic reviews or RCTs examining the usefulness of

benzodiazepines in the management of associated symptoms of dementia, including anxiety, were identified.

Lithium: No RCTs of the use of lithium in people with dementia were

identified. Small open studies produced conflicting results probably related to the size of the study.

In the absence of concurrent evidence of bipolar affective disorder lithium is not recommended for the reduction of behavioral problems in dementia.



Other interventions: The following pharmacological interventions

lacked evidence of clinical effectiveness for the treatment of people with dementia: Acetyl-L-carnitine Cerebrolysin Nicergoline Lecithin



Information for discussion with patients and

carers Supportive information for patients and carers:

Grade C: Patients and carers should be offered information tailored to the patient’s perceived needs.

Good communication between healthcare professionals, patients and carers is essential.

Disclosure of the diagnosis: Grade C: Healthcare professionals should be aware that many

people with dementia can understand their diagnosis, receive information and be involved in decision making.

Grade C: Healthcare professionals should be aware that some people with dementia may not wish to know their diagnosis.

Grade D: Healthcare professionals should be aware that in some situations disclosure of a diagnosis of dementia may be inappropriate.

The wishes of the person with dementia should be upheld at all times. The diagnosis of dementia should be given by a healthcare professional

skilled in communication or counselling. Where diagnosis is not disclosed there should be a clear record of the

reasons.

Information at other stages of the patient journey: Information provision at other stages of the patient’s journey of care is generally more focused on

carer needs than that of the patient. In decision making, people with mild dementia are more involved, largely in a collaborative role.

Beyond that carers generally make final decisions. Patients and carers should be provided with information about the services and

interventions available to them at all stages of the patient’s journey of care. Information should be offered to patients and carers in advance of the next stage of the

illness. Methods of disseminating information which may be appropriate for people with dementia

and their carers include: Written information Individual education programs Group education programs Counselling Telemedicine service Communication workshops Cognitive behavior therapy (CBT) Stress management Combinations of the above.

Information for discussion with patients and

carers

Specific recommendations from APA Guidelines

Recommendations codes with varying levels of clinical confidence:

I. Recommended with substantial clinical confidenceII. Recommended with moderate clinical confidenceIII. May be recommended on the basis of individual

circumstances Non-Pharmacological Interventions: Behavioral interventions: level II Stimulus oriented treatments: level II

Such as recreational activity, art therapy, music therapy, and pet therapy, along with other formal and informal means of maximizing pleasurable activities for patients

I. Emotion-oriented treatments: level IIII. Reminiscence therapy, Validation therapy and Sensory

Integration: level IIIIII. Cognition-oriented treatments: level III

such as reality orientation, cognitive retraining, and skills training focused on specific cognitive deficits

2014 APA Guideline watch: Update

Psychosocial Interventions: Available research does not conclusively show which

psychosocial intervention works best for which service setting, specific behavior, disease stage, or caregiver and patient profile

Additional evidence suggests the value of psychosocial interventions to improve or maintain cognition, function, adaptive behavior, and quality of life but does not demonstrate whether any specific psychosocial intervention is more effective than another

Support programs for caregivers and patients with dementia significantly decreased the odds of institutionalization and improved caregiver well-being.

Pharmacological Interventions: APA Guidelines

Treatment of Cognitive Symptoms: Cholinesterase Inhibitors should be offered to patients

with mild to moderate Alzheimer’s disease after a thorough discussion of their potential risks and benefits [I]

They may be helpful for patients with severe Alzheimer’s disease [II]

Cholinesterase inhibitors should be considered for patients with mild to moderate dementia associated with Parkinson’s disease [I] Only rivastigmine has been approved by the FDA for this

indication, but there is no reason to believe the benefit is specific to this cholinesterase inhibitor.

Cholinesterase inhibitors can be considered for patients with dementia with Lewy bodies [II]

No specific recommendations for vascular dementia and MCI, although individual patients may benefit from these drugs. [II]

Treatment of Cognitive Symptoms: Memantine: has been approved by the FDA for use in

patients with moderate and severe Alzheimer’s disease, may provide modest benefits and has few adverse effects; thus, it may be considered for such patients. [I]

There is some evidence of its benefit in mild Alzheimer’s disease [III] and very limited evidence of its benefit in vascular dementia [I]

Vitamin E: not recommended [II] NSAIDS, statin medications and estrogen

supplementations: not recommended [I]

Pharmacological Interventions: APA

Guidelines

Pharmacological Interventions: APA Guidelines for Cognitive symptoms: Update 2014

Evidence does not show clinically meaningful advantages to administering higher doses of donepezil

Higher doses of the rivastigmine patch may be associated with greater benefit.

Three new trials of memantine for mild to moderate Alzheimer’s disease showed no benefit.

New randomized controlled trials show effects that are, at best, slight or of unclear clinical significance when memantine is added to cholinesterase inhibitors.

Additional evidence has clarified the adverse effects of cholinesterase inhibitors when these agents are used on a long-term basis.

Such effects include anorexia, weight loss, falls, hip fractures, syncope, bradycardia, and increased use of cardiac pacemakers.

No new evidence supports the use of other pharmacological agents to prevent or treat cognitive symptoms.

Treatment of Behavioral Symptoms: Antipsychotic medications are recommended for the treatment of

psychosis in patients with dementia [II] and for the treatment of agitation [II]

Antipsychotics have also been shown to provide modest improvement in behavioral symptoms in general [I] They must be used with caution and at the lowest effective dosage [I],

after considering the risks of not treating the psychiatric symptoms [I] Second-generation (atypical) antipsychotics currently have a black

box warning for increased risk of mortality in elderly patients Recent data suggest that first-generation (typical) agents carry at

least a similar risk High-potency agents tend to cause akathisia and parkinsonian

symptoms; low-potency agents tend to cause sedation, confusion, delirium,

postural hypotension, and peripheral anticholinergic effects. The decision of which antipsychotic to use is based on the

relationship between the side-effect profile and the characteristics of the individual patient [I]


Benzodiazepines occasionally have a role in treating patients with prominent anxiety [III]

As-needed basis for patients with infrequent episodes of agitation or for those who require sedation for a procedure such as a tooth extraction or a diagnostic examination [II]

Adverse effects of benzodiazepines include sedation, worsening cognition, delirium, increased risk of falls, and worsening of breathing disorders.

Lorazepam and oxazepam, which have no active metabolites, are preferable to agents with a longer half-life such as diazepam or clonazepam [III]

There is minimal evidence for the efficacy of anticonvulsants, lithium, and beta-blockers for the treatment of psychosis or agitation in dementia

They are generally not recommended except for patients for whom other treatments have failed [III]

The antidepressant trazodone and the selective serotonin reuptake inhibitors (SSRIs) are also not well studied for symptoms other than depression but may be appropriate for nonpsychotic patients with agitation, especially for patients with mild agitation or prior sensitivity to antipsychotic medications [III].


Treatment of Behavioral Symptoms:

Treatment of Depression: Depressed mood may respond to improvements in the patient’s living

situation or to stimulation-oriented treatments [II] Clinical consensus supports a trial of an antidepressant to treat clinically

significant, persistent depressed mood [II]. The choice among agents is based on the side-effect profile of specific

medications and the characteristics of the individual patient [I]. SSRIs may be preferred because they appear to be better tolerated than

other antidepressants [II]. Bupropion, venlafaxine, and mirtazapine may also be effective [II]. Agents with substantial anticholinergic effects (e.g., amitriptyline,

imipramine) should be avoided [I]. Despite the lack of research data, clinical experience suggests that unilateral

electroconvulsive therapy (ECT) may be effective for patients who do not respond to pharmacological agents [II].

Treatments for apathy are not well supported, but psychostimulants, bupropion, bromocriptine, and amantadine may be helpful [III].

Psychostimulants are also sometimes useful in the treatment of depression in patients with significant general medical illness [III].


Guidelines

Treatment of sleep disturbances: Interventions include maintaining daytime activities and

giving careful attention to sleep hygiene [II]. Pharmacological intervention could be considered when other

approaches have failed [II]. If a patient also requires medication for another psychiatric

condition, an agent with sedating properties, given at bedtime, could be selected [I].

Primarily for the treatment of sleep disturbance, medications with possible effectiveness include trazodone, zolpidem, or zaleplon [III]

Benzodiazepines are not recommended for other than brief use because of risks of daytime sedation, tolerance, rebound insomnia, worsening cognition, falls, disinhibition, and delirium [II]

Diphenhydramine is not recommended because of its anticholinergic properties [II].

Antipsychotic medications should not be used solely for the purpose of treating sleep disturbances [I].


Guidelines

Special issues for long term care: Appropriate use of antipsychotic medications can relieve

symptoms and reduce distress and can increase safety for patients, other residents, and staff [I]

Good clinical practice requires careful consideration and documentation of the indications and available alternatives, both initially and on a regular ongoing basis [I].

A dose decrease or discontinuation should be considered periodically for all patients who receive antipsychotic medications [I].

A structured education program for staff may help to both manage patients’ behavior and decrease the use of these medications in nursing homes [II].

Physical restraints are rarely indicated and should be used only for patients who pose an imminent risk of physical harm to themselves or others [I].

Reasons for the use of physical restraints should be carefully documented [I].

The need for restraints can be decreased by environmental changes that decrease the risk of falls or wandering and by careful assessment and treatment of possible causes of agitation [II].


Guidelines

Behavioral symptoms: New evidence indicates that antipsychotics provide weak benefits for

the treatment of psychosis and agitation in patients with dementia. New evidence from a single trial suggests benefits for citalopram in

the treatment of agitation in patients with Alzheimer’s disease, but treatment may be constrained by cognitive and cardiac side effects.

New evidence indicates that for many patients with Alzheimer’s disease, antipsychotics can be tapered and discontinued without significant signs of withdrawal or return of behavioral symptoms.

New studies indicate that cholinesterase inhibitors and memantine have no clinically significant effects on disruptive behaviors.

Depression: There continues to be mixed evidence for the efficacy of

antidepressants to treat depression in patients with dementia. Apathy:

New evidence shows inconsistent effects of psychostimulants in treating severe apathy in patients with dementia.

Pharmacological Interventions: APA Guidelines for Behavioral symptoms: Update 2014

Specific highlights from NICE guidelines:

If a genetic cause for dementia is not suspected, including late-onset dementia, genotyping should not be undertaken for clinical purposes.

People who are assessed for the possibility of dementia should be asked if they wish to know the diagnosis and with whom this should be shared.

Formal neuropsychological testing should form part of the assessment in cases of mild or questionable dementia.

A midstream urine test should always be carried out if delirium is a possibility.

Cerebrospinal fluid examination should not be performed as a routine investigation for dementia.

Clinical presentation should determine whether investigations such as chest X-ray or electrocardiogram are needed.

Magnetic resonance imaging (MRI) is the preferred modality to assist with early diagnosis and detect subcortical vascular changes, although computed tomography (CT) scanning could be used.

Electroencephalography should not be used as a routine investigation in people with dementia.

Electroencephalography should be considered if a diagnosis of delirium, frontotemporal dementia or Creutzfeldt–Jakob disease is suspected, or in the assessment of associated seizure disorder in those with dementia.

Mixed Dementia: such cases should be managed according to the condition that is thought to be the predominant cause of dementia.

Memantine is recommended as an option for managing Alzheimer’s disease for people with:

Moderate Alzheimer’s disease who are intolerant of or have a contraindication to AChE inhibitors or

Severe Alzheimer’s disease.


Treatment should be continued only when it is considered to be having a worthwhile effect on cognitive, global, functional or behavioral symptoms.

Managing risk: Health and social care staff who care for people with dementia

should identify, monitor and address environmental, physical health and psychosocial factors that may increase the likelihood of behavior that challenges, especially violence and aggression, and the risk of harm to self or others. These factors include:

Overcrowding Lack of privacy Lack of activities Inadequate staff attention Poor communication between the person with dementia and staff Conflicts between staff and carers Weak clinical leadership


Principles of pharmacological control of violence, aggression and extreme agitation:

Immediate management should take place in a safe, low-stimulation environment, separate from other service users.

Violent behavior should be managed without the prescription of high doses or combinations of drugs, especially if the person with dementia is elderly or frail. The lowest effective dose should be used.

If IM preparations are needed for behavioral control, lorazepam, haloperidol or olanzapine should be used. Wherever possible, a single agent should be used in

preference to a combination. If rapid tranquillization is needed, a combination of IM

haloperidol and IM lorazepam should be considered. IM diazepam and IM chlorpromazine are not

recommended for the management of behavior that challenges in people with dementia.


Quetiapine in Alzheimer’s Disease

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King George's Medical University UP, Lucknow King George's Medical University UP, Lucknow INDIA INDIA

This Power point presentation is prepared from the data published in the following guidelines for management of Dementia:

1. APA guidelines for management of Alzheimer’s Disease and other dementias [American Psychiatrists Association] [2007 and update 2014]

2. NICE guidelines for management of Dementias [National Institute for Clinical Excellence] [2011]

3. SIGN guidelines for management of Dementias [Scottish Intercollegiate Guidelines Network] [2006]

guidelines for management of dementia

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