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
- Evidence provided by one or more well-designed, randomized, controlled clinical trials including overviews (meta-analyses) of such trials.
- Evidence provided by well-designed, observational studies with concurrent controls (e.g., case control or cohort studies).
- 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).
