Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The strength of recommendation grading (A-D) and level of evidence (1++, 1+, 1, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Diagnosis
History Taking and Differential Diagnosis
B - Diagnostic and Statistical Manual, 4th edition (DSM-IV) or National Institute of Neurologic, Communicative Disorders and Stroke-Alzheimer's disease and related Disorders Association (NINCDS-ADRDA) criteria should be used for the diagnosis of Alzheimer's disease.
B - The Hachinski Ischaemic Scale or National Institute of Neurological Disorders and Stroke
Association Internationale pour la Recherche et l'Enseignement en Neurosciences (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.
Initial Cognitive Testing
B - In individuals with suspected cognitive impairment, the Mini-Mental State Examination (MMSE) should be used in the diagnosis of dementia.
Screening for Comorbid Conditions
B - As part of the assessment for suspected dementia, the presence of comorbid depression should be considered.
The Use of Imaging
C - Structural imaging should ideally form part of the diagnostic workup of patients with suspected dementia.
C - Single photon emission controlled tomography (SPECT) may be used in combination with computed tomography (CT) to aid the differential diagnosis of dementia when the diagnosis is in doubt.
The Role of Cerebrospinal Fluid and Electroencephalography
B - Cerebrospinal fluid (CSF) and Electroencephalography (EEG) examinations are not recommended as routine investigations for dementia.
Neuropsychological Testing
B - Neuropsychological testing should be used in the diagnosis of dementia, especially in patients where dementia is not clinically obvious.
Non-Pharmacological Interventions
Behaviour Management
B - Behaviour management may be used to reduce depression in people with dementia.
Caregiver Intervention Programmes
B - Caregivers should receive comprehensive training on interventions that are effective for people with dementia.
Cognitive Stimulation
B - Cognitive stimulation should be offered to individuals with dementia.
Reality Orientation Therapy
D - Reality orientation therapy should be used by a skilled practitioner, on an individualised basis, with people who are disorientated in time, place and person.
Recreational Activities
B - Recreational activities should be introduced to people with dementia to enhance quality of life and well-being.
Pharmacological Interventions
Cholinesterase Inhibitors
Donepezil
B - Donepezil, at daily doses of 5 mg and above, can be used to treat cognitive decline in people with Alzheimer's disease.
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
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.
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.
Rivastigmine
B - Rivastigmine, at daily doses of 6 mg and above, can be used to treat cognitive decline in people with Alzheimer's disease.
B - Rivastigmine, at daily doses of 6 mg and above, can be used to treat cognitive decline in people with dementia with Lewy bodies.
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.
Antidepressants
D - Antidepressants can be used for the treatment of comorbid depression in dementia providing their use is evaluated carefully for each patient.
Antipsychotics
A - If necessary, conventional antipsychotics may be used with caution, given their side effect profile, to treat the associated symptoms of dementia.
Clinically Ineffective Interventions
Anti-Inflammatories
A - Anti-inflammatories are not recommended for treatment of cognitive decline in people with Alzheimer's disease.
B - Hydroxychloroquine is not recommended for the treatment of associated symptoms in people with dementia.
A - Prednisolone is not recommended for the treatment of associated symptoms in people with Alzheimer's disease.
Oestrogen
B - Oestrogen is not recommended for the treatment of associated symptoms in women with dementia.
Selegiline
A - Selegiline is not recommended for the treatment of core or associated symptoms in people with Alzheimer's disease.
Interventions Lacking Evidence of Clinical Effectiveness
Anticonvulsants
A - Valproate is not recommended for the treatment of behavioural symptoms associated with dementia.
Information for Discussion with Patients and Carers
Supportive Information for Patients and Carers
C - Patients and carers should be offered information tailored to the patient's perceived needs.
Disclosure of Diagnosis
C - Healthcare professionals should be aware that many people with dementia can understand their diagnosis, receive information and be involved in decision making.
C - Healthcare professionals should be aware that some people with dementia may not wish to know their diagnosis.
D - Healthcare professionals should be aware that in some situations disclosure of a diagnosis of dementia may be inappropriate.
Definitions:
Grades of Recommendations
Grade A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), or 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
Grade 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+
Grade 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++
Grade D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort 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