Guidelines for Management of Dementia

Guidelines for Management of
DEMENTIA
DR. RAVI SONI, DM-SR III
DEPARTMENT 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

Diagnosis
A. 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

Diagnosis
B. 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

Diagnosis
C. 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

Diagnosis
D. 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.

Diagnosis
E. 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 identified
3. Depression: Behavior management is beneficial
4. Psychosis: no robust evidence identified
5. Repetitive vocalization: no robust evidence identified
6. Sleep disturbance: no robust evidence identified
7. 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.

therapies
 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.

therapies
 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,
Alzheimer’s disease.
dementia with Lewy bodies.
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

 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
 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 confidence
II. Recommended with moderate clinical confidence
III. 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 II
II. Reminiscence therapy, Validation therapy and Sensory
Integration: level III
III. 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]
Guidelines

 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].
Guidelines
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].
APA 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].
APA 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].
APA 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
CATIE-AD

King George's Medical University UP, LucknowKing George's Medical University UP, Lucknow
INDIAINDIA

 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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Guidelines for Management of Dementia