This is the current release of the guideline.

The strength of evidence (high, moderate, low, insufficient evidence to determine benefits or risks) and strength of recommendations (strong, weak, I recommendation) are defined at the end of the "Major Recommendations."

Recommendation 1: Clinicians should base the decision to initiate a trial of therapy with a cholinesterase inhibitor or memantine on individualized assessment. (Grade: weak recommendation, moderate-quality evidence.)

The decision to initiate therapy should be based on evaluation of benefits and risks associated with an individual patient. In particular, in more advanced dementia, family or other decision makers may not view stabilization or slowing of decline as a desirable goal if quality of life is judged to be poor. All of the drugs have known adverse events, and the decision to manage patients with dementia should balance harms against modest or even no benefit. Although the evidence shows statistically significant benefits of treatment with some cholinesterase inhibitors and memantine for all kinds of dementia, these benefits, on average, are not clinically significant for cognition and are modest for global assessments. However, limited evidence suggests, but does not demonstrate conclusively, that a subgroup of patients achieves clinically important improvements. Currently, there is no way to predict which patients might have a clinically important response. Therefore, the evidence does not support prescribing these medications for every patient with dementia.

Evidence is insufficient to determine the optimal duration of therapy. A beneficial effect, if any, would generally be observed within 3 months on the basis of duration of trials. This effect could be an improvement or stabilization. In addition, no evidence demonstrates when it is appropriate to stop the treatment if the patient becomes unresponsive or shows decline in various domains of dementia. However, if slowing decline is no longer a goal, treatment with memantine or a cholinesterase inhibitor is no longer appropriate.

Recommendation 2: Clinicians should base the choice of pharmacologic agents on tolerability, adverse effect profile, ease of use, and cost of medication. The evidence is insufficient to compare the effectiveness of different pharmacologic agents for the treatment of dementia. (Grade: weak recommendation, low-quality evidence.)

Because few trials compare one drug with another, evidence about effectiveness is insufficient to support the choice of specific drugs for the treatment of dementia. Therefore, tolerability, adverse effect profile, ease of use, and cost of medication are reasonable criteria to help select a treatment. For example, when the benefits and harms related to a drug are being evaluated, the severe side effects associated with tacrine make it an unreasonable choice.

Cholinesterase inhibitors are approved for treatment of mild to moderate dementia, and memantine is approved by the U.S. Food and Drug Administration (FDA) for the treatment of moderate to severe Alzheimer disease. Patients with mild vascular dementia have shown mild benefit from memantine. However, memantine use in mild Alzheimer disease has not been well studied. Major contraindications of cholinesterase inhibitors and memantine include, but are not limited to, uncontrolled asthma, angle-closure glaucoma, the sick sinus syndrome, and left bundle-branch block.

See the original guideline document for recommendations for further research.

Definitions:

This guideline grades the evidence and recommendations by using the American College of Physicians' clinical practice guidelines grading system adopted from the classification developed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) workgroup.

*Adopted from the classification developed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) workgroup.

None provided

The type of supporting evidence is identified and graded for each recommendation.

Not applicable: The guideline was not adapted from another source.

2008 Mar

American Academy of Family Physicians - Medical Specialty Society
American College of Physicians - Medical Specialty Society

American College of Physicians
American Academy of Family Physicians

Joint American College of Physicians/American Academy of Family Physicians Panel on Dementia

Clinical Efficacy Assessment Subcommittee and the Commission on Science of the American Academy of Family Physicians

Authors: Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; J. Thomas Cross Jr., MD, MPH; Mary Ann Forciea, MD; Robert Hopkins Jr., MD; Paul Shekelle, MD, PhD; Alan Adelman, MD; David Mehr, MD, MS; Kenneth Schellhase, MD, MPH; Doug Campos-Outcalt, MD, MPA; Pasqualina Santaguida, PhD; Douglas K. Owens, MD, MS

Subcommittee Members: Douglas K. Owens, MD, MS (Chair); Donald E. Casey Jr., MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Paul Dallas, MD; Nancy C. Dolan, MD; Mary Ann Forciea, MD; Lakshmi Halasyamani, MD; Robert H. Hopkins Jr., MD; and Paul Shekelle, MD, PhD. Commission on Science of the American Academy of Family Physicians: Eric M. Wall, MD, MPH; Jonathan E. Rodnick, MD; Kenneth G. Schellhase, MD, MPH; Steven W. Strode, MD, MEd, MPH; Kurtis S. Elward, MD, MPH; James W. Mold, MD, MPH; Jonathan L. Temte, MD, PhD; Frederick M. Chen, MD, MPH; Thomas F. Koinis, MD; Donya A. Powers, MD; James M. Gill, MD, MPH; Kevin Peterson, MD, MPH; Robert C. Marshall, MD, MPH; Herbert F. Young, MD, MA; Bellinda K. Schoof, MHA, CPHQ

Honoraria: P. Santaguida (American College of Physicians). Grants received: V. Snow (Centers for Disease Control and Prevention, Novo Nordisk, Bristol-Myers Squibb, Robert Wood Johnson Foundation, Boehringer-Ingelheim, Endo Pharmaceuticals)

This is the current release of the guideline.

This NGC summary was completed by ECRI on April 18, 2008. The information was verified by the guideline developer on May 9, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.