Each recommendation is rated based on the level of the evidence and the grades of recommendation. Definitions of the grades of the recommendations (A, B, C, D, Good Practice Points [GPP]) and level of the evidence (1++ – 4) are presented at the end of the "Major Recommendations" field.
Screening and Assessment of Dementia
C - There is currently insufficient evidence for routine screening for dementia in older adults. Individuals who should be evaluated for dementia include those with progressive cognitive or behavioural complaints suggestive of dementia, as well as patients who arouse the physician's or caregiver's suspicion of cognitive impairment despite absence of complaints. (Grade C, Level 2+)
GPP - Assessment of dementia should be done via a comprehensive evaluation. This approach will aim to diagnose dementia early, assess for complications of dementia and establish the cause of the dementia. (GPP)
B - In individuals with suspected cognitive impairment, diagnosis can be made using the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria for dementia with history from a reliable informant. This can be supplemented by an objective approach with cognitive tests (Elderly Cognitive Assessment Questionnaire/Abbreviated Mental Test/Chinese Mini Mental State Examination [ECAQ/AMT/CMMSE]) and/or neuropsychological assessment. (Grade B, Level 2++)
B - The complications of dementia can be broadly divided into behavioural and psychological symptoms, functional problems and social problems. These should be evaluated in all patients with dementia as these issues are the major causes of stress on the caregiver and assessment would enable the clinician to target subsequent management effectively. (Grade B, Level 2++)
D - The aim of determining dementia aetiology is to rule out potentially reversible causes of dementia and selecting appropriate treatment strategies for the irreversible dementias. This is done via clinical history and physical examination, followed by laboratory investigations and neuroimaging (Larson et al., 1986; Clarfield, 1988; Walstra et al., 1997; Siu, 1991). (Grade D, Level 4)
B - A number of well-validated clinical criteria for the two most common types of dementia (Alzheimer's disease and Vascular dementia) have been developed over the years. These can be used in the specialized dementia clinics for the definition of Alzheimer's disease and vascular dementia. (Grade B, Level 2++)
Pharmacological Management of Dementia
GPP - Pharmacotherapy should be part of a multi-pronged strategy to dementia management that encompasses a well-established diagnosis, education of patient and caregiver, non-pharmacological measures and comprehensive caregiver psychosocial intervention. (GPP)
B - Although high dose vitamin E (2000 IU per day) may have a modest effect in delaying disease progression in moderately severe Alzheimer's disease, doses of vitamin E in excess of 400 IU a day should be avoided for the treatment of Alzheimer's disease until there is further data on its safety, especially in patients with cardiovascular disease. (Grade B, Level 1+)
A - Anti-inflammatory agents (such as non-steroidal anti-inflammatory agents and cyclo-oxygenase 2 inhibitors) are not recommended for the prevention of cognitive decline in Alzheimer's disease (Aisen et al., 2003; Reines et al., 2004). (Grade A, Level 1++)
B - Prednisolone is not recommended for the prevention of cognitive decline in Alzheimer's disease (Aisen et al., 2000). (Grade B, Level 1+)
A - Oestrogen is not recommended for the prevention of cognitive decline in women with dementia. (Grade A, Level 1++)
A - Acetylcholinesterase inhibitors should be considered for the management of all patients with mild to moderate Alzheimer's disease. (Grade A, Level 1++)
B - Acetylcholinesterase inhibitors can be considered for the management of moderate to severe Alzheimer's disease. (Grade B, Level 1+)
A - Acetylcholinesterase inhibitors have been shown to be of clinical benefit and may be considered for use in the management of mild to moderate vascular dementia. (Grade A, Level 1+)
B - Acetylcholinesterase inhibitors can be considered for the management of dementia with Lewy bodies and Parkinson's disease dementia. (Grade B, Level 1+)
B - All three available acetylcholinesterase inhibitors (donepezil, rivastigmine and galantamine) can be considered for the pharmacological management of dementia, since there is no definite evidence to support a difference in clinical efficacy between them. (Grade B, Level 1+)
A - Where tolerated, acetylcholinesterase inhibitors should be titrated to recommended doses (5 to 10 mg/day donepezil; 6 to 12 mg/day rivastigmine; 16 to 24 mg/day galantamine), which have been shown to confer greater benefit compared with lower doses. (Grade A, Level 1++)
B - N-methyl D-aspartate (NMDA) antagonists such as memantine can be considered for the management of moderate to severe Alzheimer's disease, either alone or in combination with acetylcholinesterase inhibitors. (Grade B, Level 1+)
B - N-methyl D-aspartate antagonists such as memantine may be a treatment option for mild to moderate Alzheimer's disease, if acetylcholinesterase inhibitor therapy is contra-indicated, not tolerated or if there is disease progression despite an adequate trial of acetylcholinesterase inhibitor. (Grade B, Level 1+)
A - N-methyl D-aspartate antagonists have been shown to be of clinical benefit and may be considered for use in the management of mild to moderate vascular dementia. (Grade A, Level 1+)
B - Practitioners who prescribe ginkgo for the treatment of dementia should be aware of the unestablished benefit, variability of active ingredient among preparations, and potential for drug interactions. (Grade B, Level 1+)
A - Selegiline is not recommended for the treatment of core or associated symptoms in Alzheimer's disease. (Birks & Flicker, 2003) (Grade A, Level 1++)
GPP - Appropriate treatment of vascular risk factors is recommended for all patients. However, it should be noted that whilst promising observational data exists, it remains to be shown in a randomised controlled clinical trial if any prevention strategy such as blood pressure reduction or antiplatelet treatment for the secondary prevention of stroke, will reduce the incidence of vascular dementia. (GPP)
GPP - The decision to initiate costly symptomatic dementia treatment, such as acetylcholinesterase inhibitors or N-methyl D-aspartate antagonists, should always be made in consultation with the patient and family after careful consideration of the expected magnitude of benefit, side effects, comorbidities and costs of treatment. (GPP)
GPP - Patients who are started on acetylcholinesterase inhibitors or N-methyl D-aspartate antagonists should be carefully monitored for side effects and response to treatment. (GPP)
Management of Behavioural and Psychological Symptoms of Dementia (BPSD)
GPP - Non-pharmacological methods to manage behavioural and psychological symptoms of dementia should be instituted, prior to consideration of pharmacological measures. (GPP)
GPP - Antidepressants may be used for the treatment of comorbid depression in dementia provided their use has been evaluated carefully for each patient. (GPP)
A - Conventional and atypical antipsychotics may be used with caution, given their side effect profile, to treat neuropsychiatric symptoms of dementia. (Grade A, Level 1+)
B - Trazodone may be considered for patients with depressive symptoms and dementia associated agitation. (Grade B, Level 1+)
A - Routine use of mood stabilizers, such as carbamazepine and sodium valproate, is not recommended for treatment of behavioural symptoms associated with dementia. (Grade A, Level 1+)
GPP - An individualized approach to managing behavioural problems in dementia patients is required. (GPP)
GPP - Cholinesterase inhibitor therapy may be considered in treatment of patients with behavioural problems if antipsychotics are inappropriate. (GPP)
GPP - The decision to start antipsychotic therapy to control behavioural problems in dementia patients should be made in consultation with the patient and family, after careful consideration of the benefit, adverse-effects and co-morbidities. (GPP)
B - For patients with dementia with Lewy Body and behavioural problems, acetylcholinesterase inhibitors should be considered first for management of the behavioural problems. (Grade B, Level 1+)
GPP - In all patients started on antipsychotic medication, they should be monitored carefully for side effects and response to treatment. In patients who are stable, antipsychotic withdrawal should be considered. (GPP)
Social and Caregiver Management of Dementia and Community Resources
A - Caregiver interventions via a multifaceted approach should be considered in the total management of the person with dementia. (Grade A, Level 1+)
GPP - Where appropriate, respite care can be offered to relieve the burden of caregiving on the family caregiver. (GPP)
GPP - Referral to community resources to meet the care needs of the person with dementia and his/her carer should always be considered. (GPP)
Definitions:
Levels of Evidence
1++ High quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of bias.
1+ Well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias.
1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias.
2++ High quality systematic reviews of case-control or cohort or studies.
High quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal.
2+ Well conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal.
2- Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal.
3 Non-analytic studies (e.g., case reports, case series)
4 Expert opinion.
Grades of Recommendation
A. At least one meta-analysis, systematic review, or randomized controlled trial (RCT) rated as 1++, and directly applicable to the target population; or
A body of evidence, consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B. A body of evidence, including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C. A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D. Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
GPP (good practice points) Recommended best practice based on the clinical experience of the guideline development group.
