• Doody RS, Stevens JC, Beck C, Dubinsky RM, Kaye JA, Gwyther L, Mohs RC, Thal LJ, Whitehouse PJ, DeKosky ST, Cummings JL. Practice parameter: management of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001 May 8;56(9):1154-66. [175 references]

This is the current release of the guideline.

According to the guideline developer, this guideline has been reviewed and is still considered to be current as of October 2003. This review involved new literature searches of electronic databases followed by expert committee review of new evidence that has emerged since the original publication date.

• Dementia
• Alzheimer’s disease

Management
Treatment

Family Practice
Geriatrics
Internal Medicine
Neurology
Pharmacology
Psychiatry

Advanced Practice Nurses
Health Care Providers
Nurses
Pharmacists
Physician Assistants
Physicians

• To define and investigate key issues in the management of dementia
• To make literature-based treatment recommendations for the management of dementia

Elderly patients with dementia or Alzheimer’s disease

Pharmacologic Treatment of Alzheimer’s Disease

1. Cholinesterase inhibitors, such as tacrine, donepezil, rivastigmine, and galantamine
2. Precursors and agonists to improve cholinergic transmission and a number of other cognitive-enhancing drugs (considered but not recommended)
3. Vitamin E (alpha-tocopherol)
4. Selegiline
5. Estrogen (e.g., Premarin®), other antioxidants, and anti-inflammatories (e.g., diclofenac, indomethacin, prednisone) are considered but not recommended.

Pharmacotherapy in Mixed Populations or Patients with Mixed Dementias

1. Gingko biloba

Pharmacotherapy in Ischemic Vascular Dementia

1. Oxiracetam, cyclandelate, flunarizine, and pentoxifylline are considered but not recommended.

Pharmacotherapy for Noncognitive Symptoms (behavioral symptoms, depression)

1. Antipsychotics, such as risperidone, haloperidol, thioridazine, olanzepine, quetiapine
2. Antihistamines, (e.g., diphenhydramine), benzodiazepines, (e.g., oxazepam), chelating agents (e.g., desferroxamine) and anticonvulsants (e.g, carbemazepine) are considered but not recommended
3. Antidepressants, such as selected tricyclic antidepressants (clomipramine, maprotiline); monoamine oxidase (MAO) inhibitors; and selective serotonin reuptake inhibitors (fluoxetine, fluvoxamine, citalopram, paroxetine)

Educational Interventions

1. Short-term educational programs for caregivers of dementia patients
2. Intensive long-term education and support services for caregivers
3. Education of staff at long-term facilities

Non-pharmacologic Interventions

1. Interventions to improve functional performance, such as behavior modification, scheduled toileting, prompted voiding to reduce urinary incontinence; measures to increase functional independence; low lighting levels, music, simulated nature sounds to improve eating behaviors; intensive multimodality group training to improve activities of daily living are considered but not recommended.
2. Non-pharmacologic interventions for problem behaviors, such as music, walking and other forms of light exercise, simulated presence therapy, massage, pet therapy, cognitive remediation, bright light, white noise, and other psychosocial programs are considered but not recommended.
3. Care environment alterations, such as special care units in long-term facilities are considered but not recommended.
4. Interventions for caregivers, such as support groups and training programs

• Effectiveness of pharmacotherapy for cognitive symptoms on outcomes of patients with dementia as compared to no therapy
• Effectiveness of pharmacotherapy for noncognitive symptoms on outcomes of patients with dementia as compared to no therapy
• Effectiveness of educational interventions on outcomes in patients and/or caregivers of patients with dementia as compared to no interventions
• Effectiveness of nonpharmacologic interventions other than educational interventions on outcomes in patients and/or caregivers of patients with dementia as compared to no interventions

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases

Literature review process Search terms. Alzheimer’s disease, vascular or multi-infarct dementia, dementia with associated parkinsonian disorder (diffuse Lewy body disease, dementia with Lewy bodies, Parkinson’s disease with dementia), progressive supranuclear palsy, frontotemporal dementia (including Pick’s disease), and senile dementia. Additional search terms were question-specific:

• Question 1: Cholinesterase inhibitors, antioxidants, hormones, anti-inflammatory agents/drugs, cholinergic agents/drugs, nootropics (class of compounds structurally related to piracetam), metabolic enhancers, neurotrophic agents/drugs, (complementary) alternative medicines, treatment, and pharmacotherapy.
• Question 2: Hypnotics, antidepressants, anxiolytics, tranquilizers, sleep medications, selective serotonin reuptake inhibitors (SSRI), treatment and sleep, treatment and depression, treatment and anxiety, treatment and agitation, treatment and disinhibition, treatment and affective disorders, management, treatment and maintain (trunc), and treatment and discontinue (trunc).
• Questions 3 and 4: Counseling, education and caregiver, education and patient, environment, behavior (trunc) manag (trunc), behavior (trunc) and modif (trunc), advance directive, rehabilitation, and terminal care.

The key and index words for the special issue of cooperation between specialists were the following: treatment and multidisciplinary, treatment and team, treatment and community, neurologist (trunc), primary care, respite care, services, providers, transfer of care, long-term care, and family advocacy. Special issues related to economic models used the following key and index words: health care systems, health maintenance organization, preferred provider organization, medicaid, medicare, insurance, managed care, economic (trunc), and quality of care. Special issues related to determining capacity to consent used were the following: competency, decision-making, patient refusal of therapy/treatment, physician patient relations, patient rights, patient involvement, and informed consent.

Databases. For questions 1 and 2 the following databases were searched: MEDLINE, Embase, Current Contents, Psych Abstracts, and Cochrane databases. For questions 3 and 4: MEDLINE, Embase, Current Contents, Psychology Info, Cochrane, and CINAHL.

Inclusion/exclusion criteria and process. Studies selected included the following: randomized, controlled studies in all languages and other types of studies limited to English; human subjects with N greater than 20, regardless of outcome measured; and review articles published between January 1998 and November 1999. The nonpharmacologic intervention questions allowed smaller N for supporting studies to reflect the activity in the field. Members of the work group reviewed all search results and the bibliographies of the review articles to identify any articles that they thought were missing; these articles were submitted to the same inclusion/exclusion criteria. The initial search was conducted in October 1998; additional articles were added until July 2000.

Number and disposition of articles, data extraction, and classification of evidence. The search strategy identified 2,548 articles. A total of 380 met the predefined inclusion/exclusion criteria and were reviewed by at least two individuals. Selected items from each article were entered into a standardized data extraction form, and each article was assigned a class of evidence based upon a priori definitions, which determined whether or not study results were ultimately translated into Standards, Guidelines, or Practice Options.

380

Weighting According to a Rating Scheme (Scheme Given)

Classification of Evidence

1. Evidence provided by one or more well-designed, randomized, controlled clinical trials, including overviews (meta-analyses) of such trials.
2. Evidence provided by well-designed, observational studies with concurrent controls (e.g., case control or cohort studies).
3. Evidence provided by expert opinion, case series, case reports, and studies with historical controls.

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

For all extracted articles, evidence tables were developed according to search question. These tables indicate the author and year of the study, level of evidence, main purpose of the study, population, intervention, out-come measures, and results.

Not stated

Levels of Recommendations

Standard. Principle for patient management that reflects a high degree of clinical certainty (usually this requires Class I evidence that directly addresses the clinical questions, or overwhelming Class II evidence when circumstances preclude randomized clinical trials).

Guideline. Recommendation for patient management that reflects moderate clinical certainty (usually this requires Class II evidence or a strong consensus of Class III evidence).

Practice Option. Strategy for patient management for which the clinical utility is uncertain (inconclusive or conflicting evidence or opinion).

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

After the Quality Standards Subcommittee’s review and approval, the document was circulated to the members of the full Dementia Practice Parameter Work Group (committee members drafting the early detection and diagnosis of dementia sections), members of the American Academy of Neurology, Member Review Network, appropriate sections of the American Academy of Neurology, United States and international dementia experts, and selected patient advocacy and physician organizations.

Classification of evidence ratings, I-III, and the levels of recommendations (Standard, Guideline, Practice Option) are defined at the end of the "Major Recommendations" field.

Pharmacologic Treatment of Alzheimer's Disease

• Cholinesterase inhibitors should be considered in patients with mild to moderate Alzheimer's disease (Standard), although studies suggest a small average degree of benefit.
• Vitamin E (1000 I.U. PO BID) should be considered in an attempt to slow progression of Alzheimer's disease (Guideline).
• Selegiline (5 mg PO BID) is supported by one study, but has a less favorable risk-benefit ratio (Practice Option).
• There is insufficient evidence to support the use of other antioxidants, anti-inflammatories, or other putative disease-modifying agents specifically to treat Alzheimer's disease because of the risk of significant side effects in the absence of demonstrated benefits (Practice Option).
• Estrogen should not be prescribed to treat Alzheimer's disease (Standard).

Mixed Populations or Patients with Mixed Dementias

• Some patients with unspecified dementia may benefit from ginkgo biloba, but evidence-based efficacy data are lacking (Practice Option).

Ischemic Vascular Dementia

• There are no adequately controlled trials demonstrating pharmacologic efficacy for any agent in ischemic vascular (multi-infarct) dementia.

Treatment of Behavioral Disturbances

• Antipsychotics should be used to treat agitation or psychosis in patients with dementia where environmental manipulation fails (Standard). Atypical agents may be better tolerated compared with traditional agents (Guideline).
• Selected tricyclics, monamine oxidase-B (MAO-B inhibitors), and selective serotonin reuptake inhibitors (SSRI) should be considered in the treatment of depression in individuals with dementia with side effect profiles guiding the choice of agent (Guideline).

Educational Interventions

• Short-term programs directed toward educating family caregivers about Alzheimer's disease should be offered to improve caregiver satisfaction (Guideline).
• Intensive long-term education and support services (when available) should be offered to caregivers of patients with Alzheimer's disease to delay time to nursing home placement (Guideline).
• Staff of long-term care facilities should receive education about Alzheimer's disease to reduce the use of unnecessary antipsychotics (Guideline).

Interventions to Improve Functional Performance

• Behavior modification, scheduled toileting, and prompted voiding should be used to reduce urinary incontinence (Standard).
• Graded assistance, practice, and positive reinforcement should be used to increase functional independence (Guideline).
• Low lighting levels, music, and simulated nature sounds may improve eating behaviors for persons with dementia, and intensive multimodality group training may improve activities of daily living, but these approaches lack conclusive supporting data (Practice Options).

Nonpharmacologic Interventions for Problem Behaviors

• Persons with dementia may experience decreased problem behaviors with the following interventions: music, particularly during meals and bathing (Guideline); walking or other forms of light exercise (Guideline).
• Although evidence is suggestive only, some patients may benefit from the following (Practice Options):
  • Simulated presence therapy, such as the use of videotaped or audiotaped family
  • Massage
  • Comprehensive psychosocial care programs
  • Pet therapy
  • Commands issued at the patient’s comprehension level
  • Bright light, white noise
  • Cognitive remediation

Care Environment Alterations

• Although definitive data are lacking, the following environments may be considered for patients with dementia (Practice Options):
  • Special care units (SCU) within long-term care facilities
  • Homelike physical setting with small groups of patients as opposed to traditional nursing homes
  • Short-term, planned hospitalization of 1 to 3 weeks with or without blended inpatient and outpatient care
  • Provision of exterior space, remodeling corridors to simulate natural or home settings, and changes in the bathing environment

Interventions for Caregivers

• The following interventions may benefit caregivers of persons with dementia and may delay long-term placement (Guidelines):
  • Comprehensive, psychoeducational caregiver training
  • Support groups
• Additional patient and caregiver benefits may be obtained by use of computer networks to provide education and support to caregivers (Practice Option), telephone support programs (Practice Option), and adult day care for patients and other respite services (Practice Option).

Definitions:

Classification of Evidence

1. Evidence provided by one or more well-designed, randomized, controlled clinical trials including overviews (meta-analyses) of such trials.
2. Evidence provided by well-designed, observational studies with concurrent controls (e.g., case control or cohort studies).
3. Evidence provided by expert opinion, case series, case reports, and studies with historical controls.

Levels of Recommendations

Standard. Principle for patient management that reflects a high degree of clinical certainty (usually this requires Class I evidence that directly addresses the clinical questions, or overwhelming Class II evidence when circumstances preclude randomized clinical trials).

Guideline. Recommendation for patient management that reflects moderate clinical certainty (usually this requires Class II evidence or a strong consensus of Class III evidence).

Practice Option. Strategy for patient management for which the clinical utility is uncertain (inconclusive or conflicting evidence or opinion).

None provided

The recommendations are based on a review of the literature. The type of supporting evidence is identified and graded for each recommendation on the management of dementia.

Appropriate pharmacologic and non-pharmacologic management of dementia

Not stated

This statement is provided as an educational service of the American Academy of Neurology. It is based on an assessment of current scientific and clinical information. It is not intended to include all possible proper methods of care for a particular neurologic problem or all legitimate criteria for choosing to use specific procedures. Neither is it intended to exclude any reasonable alternative methodologies. The American Academy of Neurology recognizes that specific patient care decisions are the prerogative of the patient and the physician caring for the patient, based on all the circumstances involved.

An implementation strategy was not provided.

Getting Better
Living with Illness

Effectiveness
Patient-centeredness

• Doody RS, Stevens JC, Beck C, Dubinsky RM, Kaye JA, Gwyther L, Mohs RC, Thal LJ, Whitehouse PJ, DeKosky ST, Cummings JL. Practice parameter: management of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001 May 8;56(9):1154-66. [175 references]

Not applicable: Guideline was not adapted from another source.

2001 May (reviewed 2003)

American Academy of Neurology - Medical Specialty Society

American Academy of Neurology (AAN)

Quality Standards Subcommittee

Authors: R.S. Doody, MD, PhD; J.C. Stevens, MD; C. Beck, RN, PhD; R.M. Dubinsky, MD; J.A. Kaye, MD; L. Gwyther, MSW; R.C. Mohs, PhD; L.J. Thal, MD; P.J. Whitehouse, MD, PhD; S.T. DeKosky, MD; and J.L. Cummings, MD

Committee members disclosed any real or potential conflicts of interest.

American Association of Neuroscience Nurses - Professional Association
American Geriatrics Society - Medical Specialty Society

This is the current release of the guideline.

According to the guideline developer, this guideline has been reviewed and is still considered to be current as of October 2003. This review involved new literature searches of electronic databases followed by expert committee review of new evidence that has emerged since the original publication date.

This NGC summary was completed by ECRI on February 12, 2002. The information was verified by the guideline developer on September 5, 2003. This summary was updated by ECRI on April 1, 2005, following the U.S. Food and Drug Administration advisory on Reminyl (galantamine). This summary was most recently updated by ECRI on April 15, 2005 following the public health advisory concerning an unapproved "off-label" use of atypical antipsychotic drugs in elderly patients with dementia. This summary was updated by ECRI on August 15, 2005, following the U.S. Food and Drug Administration advisory on antidepressant medications. This summary was updated by ECRI on May 31, 2006 following the U.S. Food and Drug Administration advisory on Paxil (paroxetine hydrochloride). This summary was updated by ECRI Institute on October 2, 2007, following the U.S. Food and Drug Administration (FDA) advisory on Haloperidol. This summary was updated by ECRI Institute on November 2, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs. This summary was updated by ECRI Institute on July 25, 2008, following the U.S. Food and Drug Administration advisory on Antipsychotics.

This NGC summary is based on the original guideline, which is copyrighted by the American Academy of Neurology.