• Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with dementia. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2006 Feb. 53 p. (SIGN publication; no. 86). [183 references]

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, 4^th 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

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with dementia. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2006 Feb. 53 p. (SIGN publication; no. 86). [183 references]

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

1998 Feb (revised 2006 Feb)

Scottish Intercollegiate Guidelines Network - National Government Agency [Non-U.S.]

Scottish Executive Health Department

Not stated

Guideline Development Group: Dr Peter Connelly (Chair) Consultant Old Age Psychiatrist, Murray Royal Hospital, Perth; Dr Carole Archibald, Associate Consultant/Trainer, Dementia Services Development Centre, University of Stirling; Dr Simon Backett, Consultant Old Age Psychiatrist, St John's Hospital, Livingston; Miss Jenni Brockie, Information Officer, SIGN; Dr Andrew Carnon, Consultant in Public Health Medicine, Dumfries and Galloway NHS Board; Dr Gisu Cooper, General Practitioner, Leith Walk Surgery, Edinburgh; Mrs Christina Cooper, Dementia Advocate, TODAY Group, Stratheden Hospital, Cupar; Ms Ann Fraser, Senior Physiotherapist, Royal Victoria Hospital, Edinburgh; Ms Eva Frigola Capell, Clinical Psychologist, Spain (SIGN Visiting Fellow); Dr John Greene Consultant Neurologist, Southern General Hospital, Glasgow; Professor Donald Hadley, Consultant Neuroradiologist, Southern General Hospital, Glasgow; Dr Roberta James, Programme Manager, SIGN; Ms Gail Kilbane, Service Manager, Alzheimer's Scotland, Action on Dementia, Kirkcaldy; Ms Caroline Lawrie, Charge Nurse, Bangour Village Hospital, Broxburn; Ms Margo Mason, Senior Occupational Therapist, Royal Victoria Hospital, Edinburgh; Mr Sandy McAfee, Consultant Clinical Psychologist, St John's Hospital, Livingston; Dr Gary Morrison, Consultant Psychiatrist, Crichton Royal Hospital, Dumfries; Ms Julie Penn, Memory Clinic Support Worker, Alzheimer's Scotland, Action on Dementia, Kirkcaldy; Dr Dan Rutherford, General Practitioner, Fife; Ms Sandra Stark, Nursing and Quality Consultant, Ardoch Consulting, Doune

Declarations of interests were made by all members of the guideline development group. Further details are available from the Scottish Intercollegiate Guidelines Network (SIGN) Executive.

This summary was completed by ECRI on February 6, 2002. The information was verified by the guideline developer as of April 9, 2002. This summary was updated by ECRI on April 7, 2006. The updated information was verified by the guideline developer on May 1, 2006. 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 9, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs. This summary was updated by ECRI Institute on January 10, 2008, following the U.S. Food and Drug Administration advisory on Carbamazepine. This summary was updated by ECRI Institute on July 25, 2008, following the U.S. Food and Drug Administration advisory on Antipsychotics.