New Consensus Guidelines on Management of Dementia

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New Consensus Guidelines onManagement of Dementia

7 May 2008

Symposium on the Changes & Challenges in Geriatric Careaterloo! "ntario

Michael #orrie! M# Ch#! $%CC

'ging #rain and Memory Clinic

Di(ision of Geriatric Medicine! )"

ar*wood Site! St+ ,oseph-s .ealth Care



Disclosure Statement

%esearch Support Clinical /rials $unding

C.% urdue1harma

'lheimer Society Canada Neotherapeutics

hysician Ser(ices ncorporated .M%

3awson .ealth %esearch nstitute harmacia

#oehringer1ngelheim

Consultant and CM4 rograms Sanofi1Synthela5o

fier Myriad harmaceuticals

,anssen1"rtho "N" harma )S'

No(artis Neurochem

3und5ec* 4lan

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"5ecti(es

)sing case scenarios! re(iew and discuss rele(ant

guidelines from the

rd

Canadian Consensus Conferenceon Diagnosis and /reatment of Dementia! March 2009+



rd Canadian Consensus Conference on

Diagnosis and /reatment of DementiaCCCD/D

March :1;;! 2009+ Montreal

Specialists & $amily hysicians+

;<0 guidelines+

/ranslation of %esearch to practice+

Clinical scenarios to illustrate how guidelines can

inform practice+



Criteria for assigning le(els of e(idence

3e(elCriteria

;+ 4(idence o5tained from at least ; properly randomied controlled

trial+

2a+4(idence o5tained from well1designed controlled trials without

randomiation+25+4(idence o5tained from well1designed cohort or case1control

analytic studies! prefera5ly from more than ; centre or

research group+

2c+ 4(idence o5tained from comparisons 5etween times or places

with or without the inter(ention+ Dramatic results in

uncontrolled e=periments are included in this category+

+ "pinions of respected authorities! 5ased on clinical e=perience!

descripti(e studies or reports of e=pert committees+



Grades of recommendations

Grade Criteria

'+ /here is good e(idence to support this man>u(re+

#+ /here is fair e(idence to support this man>u(re+

C+ /here is insufficient e(idence to recommend for or

against this man>u(re! 5ut recommendations may

5e made on other grounds+

D+ /here is fair e(idence to recommend against this

procedure+

4+ /here is good e(idence to recommend against this

procedure+



Spectrum of Cogniti(e Decline

Adapted from Chertkow & Murtha, 1998

Super Normal•no deterioration

from young

Age-consistent loss

•average for age

Mild Cognitive Impairment

•1.5 S ! "orma# of age

and edu$ation mat$hed

$ontro#%

Dementia



Serge Gauthier, 2001

MC



Not normal, not demented (Does not meet criteria (DSM IV,

ICD 10) or a dementia s!ndrome)

Cognitive decline

• Sel and"or inormant report and impairment on o#$ective

cognitive tas%s

and"or

• &vidence o decline over time on o#$ective cognitive tas%s

'reserved #asic activities o dail! living " minimal impairmentin comple instrumental unctions

ecommendations or t*e +eneral Criteria or Mild

Cognitive Impairment Consensus eport 00.

'in(#ad ), *a#mer +, +ivipe#to M et a#. Mild cognitive impairment – beyond controversies,

towards a consensus report of the International Working Group on Mild Cognitive Impairment.

ourna# of nterna# Medi$ine -/0-52-/3-/



Diagnostic Criteria for Dementia of the

Alzheimer’s Type (DSM IV)

;? /he de(elopment of multiple cogniti(e deficits manifested 5y 5oth;? memory impairment! and 2? one or more of the following

cogniti(e distur5ances@

A 3anguage distur5ance B'phasia?

A mpaired a5ility to carry out motor 5eha(iours despite intact

motor function B'pra=ia? A $ailure to recognie or identify o5ects B'gnosia?

A Distur5ance in planning! organiing! seuencing! a5stracting

B4=ecuti(e $unctioning?

2? Cognitive deficits case significant impairment in social or

occpational fnctioning

? Gradual onset and continual decline

<? Cogniti(e deficits are not due to a? other CNS conditions! 5? other

Systemic conditions *nown to cause dementia! c? su5stance

induced dementia! d? delirium! and e? another primary

psychiatric disorder



/ypes of Dementia

Alzheimer’s (AD)

A Gradual on1set of memory and functional loss

Vasclar Dementia (VaD)

A Step wise decline of memory and functional loss

A "ften occurring months or so after a stro*e

Mi!ed Dementia (AD " VaD)

A Now the most common form of dementia

A hen 'D and EaD Bcere5ro(ascular disease? co1e=ist

Reference: Patterson C, et al. The recognition, assessment and management of dementing disorders:

Conclusions from the Canadian Consensus Conference in Dementia. Can J Neurol Sci. 2001;28(u!!l. 1": #$1%.



/ypes Bcontinued?

#ronto$temporal Dementia (#TD) A /he mirror image of 'D with pronounced 5eha(iour

pro5lems initially and memory pro5lems later

%e&y 'ody Dementia (%'D) A .allucinations B(isual?

A ar*inson1li*e symptoms A $luctuations in le(el of consciousness





M4M"%F %ead list of words! su5ect

must repeat them+ Do 2

trials+&'C )*)T C+RC+ D'- RD



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Dementia %is* $actors

'ge

$amily history

Eascular ris* factors

.igh 5lood pressureDia5etesSmo*ing"5esity.igh Cholesterol

'trial $i5rillation

3ow education .ead inury6concussion



/he Dou5ling %ule B/hin* 2? $or Dementia %is*

9H I ;J

9H I 2J

70 I <J

7H I 8J

80 I ;9J

8H I 2J

/ Ris Doules eer3 4

3ears



/he Dou5ling %ule B/hin* 2? $or Dementia %is*

9H I ;J

9H I 2J

70 I <J

7H I 8J

80 I ;9J

8H I 2J

/ Ris Doules eer3 4

3ears

/ 5ut each additional ris

factor a!!ro6imatel3 doules

the ris

/ Positie famil3 histor3

doules the ris



CS K2

7H year old woman! retired secretary! grade ;2 education

1 Sudden confusion with slurred speech for ; hour!

H years ago 1 $orgetting names! years

1 gradually worse+

1 $alls = B2 trips? in last ;2 months

1 gait slower and less certain Bcane?! 9 months



CS K2

Collateral .istory A spouse and daughter

1 gradual progression since onset+ 1 stopped dri(ing ; month ago+ Getting disoriented & ran a redlight

1 purchasing se(eral unneeded grocery items! ; year

1 coo*ing uality changed

1 forgetting medications

ast .istory

1 .igh 5lood pressure! ;H years! on meds

1 Dia5etes! ;0 years! on meds 1 4le(ated cholesterol! H years! on meds

1 'trial $i5rillation! years! on meds

6S A no alcohol! no smo*ing

1 less energy+ No initiati(e+ DepressedL ; year



s this history suggestion of@

Mild cogniti(e impairmentL hite

DementiaL #lac*

)nsure %ed



CS K2

4=amination 1 eight ;90 l5s! .eight H-2! # ;906:0 sitting and standing

1 MMS4 2H60 06 delayed recall! date! place

1 M"C' ;760! 06H delayed recall! modified /rails #! cu5e!cloc*! a5straction 062! fluency! serial 7-s! date! day

1 Geriatric Depression Scale <6;H

1 Cornell for depression ;068

1 Dia5etes .# ';C +078

1 Gait slightly wide15ased! unpredicta5le steps to right!impro(ed with cane+ nee pain sit to stand

1 nee refle=es 5ris*! more on the right A #a5ins*i fle=or right& left

1 hip fle=ion strength <6H right & left



Clinically! is the dementia li*ely due to@

'lheimer disease B'D?L hite

Eascular dementia BEaD?L #lac*

Mi=ed 'D6EaDL #lue

)nsure %ed



CS K2

Clinical mpression

;+ Dementia A Mild+ Mi=ed B'D EaD?+2+ 4arly "' *nees

+ Ouadriceps wea*ness

<+ Eascular ris* factors

H+ Depressi(e symptoms



CCCD/D %ecommendations



Should this person and their family 5e referred to

the 'lheimer SocietyL

Fes hite

No #lac*

)nsure %ed



CSK2 %ecommendations

/H K;a 1 'll patients with dementia and their families who consent

should 5e referred to the local chapter of the 'lheimer Society

Beg@ $irst 3in* program where a(aila5le?P and

/H K;5 1 rimary care physicians should 5e aware of the

resources a(aila5le for the care of those with dementia in their

community Beg@ support groups! adult day program? and to

ma*e appropriate referrals to them+ BG#! 3?



Should the diagnosis of dementia 5e disclosed to

the person and their familyL

Fes hite

No #lac*

)nsure %ed



CS *thico$legal recommendations

/H K9a A 'lthough each case should 5e considered indi(idually! in

general! the diagnosis of dementia should 5e disclosed to the

patient and family+ /his process should include a discussion ofprognosis! diagnostic uncertainty! ad(ance planning! dri(ing

issues! treatment options! support groups! and future plans+ BG#!

3?

/H K95 A rimary care physicians should 5e aware of the

pertinent laws in their urisdiction a5out informed consent! the

assessment of capacity! the identification of a surrogate decision1

ma*er! and the responsi5ilities of physicians in these matters+

BG#! 3?

/H K9c A hile patients with 'D Bdementia? retain capacity! they

should 5e encouraged to update their will and to enact 5oth an

ad(ance directi(e and an enduring power of attorney+ BG#! 3?



CSK2 %ecommendations

"ther therapeutic inter(entions

/7 K2 n(estigations for (ascular ris* factors+ t is recommended

that (ascular ris* factors are identified in all patients with (ascular

cogniti(e impairment+ BGC! 3?

/7 K /reating hypertension+ /here is some e(idence that

treating hypertension may pre(ent further cogniti(e decline

associated with cere5ro(ascular disease+ /here is no compelling

e(idence that one class of agent is superior to anotherP calciumchannel 5loc*ers or 'C41inhi5itors may 5e considered BGrade #!

3e(el ?+ /reatment for hypertension should 5e implemented for

other reasons! including the pre(ention of recurrent stro*e+ BG'!

3?



n a person with mild dementia! will cogniti(e

training6reha5 impro(e and6or maintain cogniti(eand or function performanceL

Fes hite

No #lac*

)nsure %ed



CS K2 %ecommendations A non1pharmacologicaltherapy in Mild 'D

/H K7a A /here is insufficient e(idence to come to any firm

conclusions a5out the effecti(eness of cogniti(e training6cogniti(ereha5ilitation in impro(ement and6or maintaining cogniti(e and6orfunctional performance in persons with mild to moderatedementia+ BGC! 3;?



Could an indi(idualied e=ercise program ha(e animpact on functional performanceL

Fes hite

No #lac*

)nsure %ed



CS K2 %ecommendations A non1pharmacological

therapy in Mild 'D

/H K7d 1 /here is good e(idence to indicate that

indi(idualied e=ercise programs ha(e an impacton functional performance in persons with mild to

moderate dementia+ BG'! 3;?



Should a cholinesterase inhi5itor 5e prescri5edL

Fes hite

No #lac*

)nsure %ed



CSK2 %ecommendations A )se of

cholinesterase inhi5itors

/7 K7 1 )se of cholinesterase inhi5itors in dementia dueto com5ined 'lheimer-s and Cere5ro(ascular

Disease@ /here is fair e(idence of 5enefits of smallmagnitude for Galantamine in cogniti(e! functional!5eha(ioural and glo5al measures in 'D with CED+Galantamine can 5e considered a treatment option

for mi=ed 'lheimer-s with Cere5ro(ascular Disease+BG#! 3?



Should neuroimaging 5e reuestedL

Fes hite

No #lac*

)nsure %ed



/ Structural neuroimaging K2 1 /here is fair

e(idence to support use of structural

neuroimaging to rule in concomitant cere5ro(ascular disease that can affect patient

management+ BG#! 32?



CS K2

lan

'lheimer Society referral Caregi(er education

Control6monitor (ascular ris* factors+ #!cholesterol eight loss 4=ercise program .ead C/6M% scan

Symptomatic treatment of dementia Depressi(e symptoms A non drug approaches

1 medicationsL



CS K<

781year1old retired truc* dri(er6grade ;0 education

Qa 5it forgetful! ust old age ; year

1 Collateral h=+ ife+

1 %epeating stories and uestions A yrs

1 Ga(e up woodwor*ing A 2 yrs Qnot interested

1 Not as handy a5out house A ; yr

1 Difficulty reassem5ling lawn mower A 2 mths ago

1 More irrita5le! easily angered at other dri(ers A ; yr 1 %olling stops A ; yr

1 3ate to pic* up grandson from school = 1 2 mths



CSK<

ast .istory1 2 yrs ago! confused after prostate surgery1 Dia5etes A diet only A H yrs

6S

1 'lcohol A 21< 5eers at the 3egion ; = 6wee*1dri(es1 Smo*er A <0 p* yrs! stopped at age 90

Medication A 'cetaminophen ; gram =6day Bsometimes forgets it?

4=amination1 eight 220 l5s! .eight H-:1 # ;06801 "steoarthritis in hips and *nees1 Normal neurological e=am



Could this man ha(e@


Dementia! pro5a5le 'lheimer DiseaseL #lac*

Eascular DementiaL #lue

)nsure %ed



CSK<

MMS4 260 B;6 recall! 6H world! day! date! place?

MoC' ;960 B06H recall! trails! hands on cloc*!

fluency! a5straction! date! 7-s?Geriatric Depression Scale 06;H

Cornell 268 irrita5ility

$asting glucose ;2! N7

.5 ';C 0+07<! N0+09



hat do you thin* the diagnosis is nowL


Dementia! pro5a5le 'lheimer DiseaseL #lac*

Eascular DementiaL #lue

)nsure %ed



CSK<

Clinical mpression

'lheimer Disease A mild

"(er weight

Dia5etes

Still dri(ing

Drin*ing while dri(ing



CCCD/D %ecommendations



CSK< %ecommendations

/H K;5 A rimary care physicians should 5e aware of the

resources a(aila5le for the care of those with dementia in their

community Beg! support groups! adult day programs? and to ma*e

appropriate referrals to them+ BG#! 3?

/ K 1 QMild 'lheimer-s disease can 5e diagnosed with a highdegree of specificity! when the presenting clinical picture is one of

memory impairment BG#! 3;?

/H K7d 1 /here is good e(idence to indicate that indi(idualiede=ercise programs ha(e an impact on functional performance in

persons with mild to moderate dementia BG'! 3;?+



Should a cholinesterase inhi5itor 5e prescri5edL

Fes hite

No #lac*

)nsure %ed



CSK< %ecommendations A on cholinesterase inhi5itors

/H K;<a 1 'll three cholinesterase inhi5itors a(aila5le in Canadaare modestly efficacious for mild to moderate 'D+ /hey are all(ia5le treatment option for most patients with mild to moderate

'D+ BG'! 3?

/H K;<5 A hile all three cholinesterase inhi5itors a(aila5le inCanada ha(e efficacy for mild to moderate 'D! eui(alency hasnot 5een esta5lished in direct comparisons+ Selection of whichagent to 5e used will 5e 5ased on ad(erse effect profile! ease ofuse! familiarity! and 5enefits a5out the importance of the

differences 5etween the agents in their pharmaco*inetics andother mechanisms of action+ BG#! 3;?



CSK< %ecommendations

Neuropsychology testing

/ Neuropsych K9 1 /he diagnosis and differentialdiagnosis of dementia is currently a clinically integrati(e

one+ Neuropsychological testing alone cannot 5e used forthis purpose and should 5e used selecti(ely in clinicalsettings BG#! 3?



Should people and their families 5e counselled a5out

e(entually gi(ing up dri(ingL

Fes hite

No #lac*

)nsure %ed

Does an a5normal score on the MMS4 mean a person

should not dri(eL

Fes hite

No #lac*

)nsure %ed



CSK< Dri(ing %ecommendations

/H K2Ha A Clinicians should counsel persons with a

progressi(e dementia Band their families? that gi(ing updri(ing will 5e an ine(ita5le conseuence of theirdisease+ Strategies to ease this transition should occurearly in the clinical course of the disease+ BG#! 32?

/H K2H5 1 No single 5rief cogniti(e test Be+g+ MMS4? orcom5ination of 5rief cogniti(e tests has sufficientsensiti(ity or specificity to 5e used as a sole determinantof dri(ing a5ility+ '5normalities on cogniti(e tests such asthe MMS4! cloc* drawing and /rails # should result infurther in1depth testing of dri(ing a5ility+ BG#! 32?



eople with cogniti(e impairment and impairedinstrumental acti(ities of daily li(ing should stop

dri(ing+

Fes hite

No #lac*

)nsure %ed



/H K2Hc 1 Dri(ing is contraindicated in persons

who! for cogniti(e reasons! ha(e an ina5ility to

independently perform multiple instrumentalacti(ities of daily li(ing Be+g+ medication

management! 5an*ing! shopping! telephone use

coo*ing? or any of the 5asic acti(ities of daily li(ing

Be+g+ toileting! dressing?+ BG#! 3?

/H K2Hd 1 /he dri(ing a5ility of persons with earlier

stages of dementia should 5e tested on an

indi(idual 5asis BG#! 3?



'n on1road dri(ing assessment is the 5est methodof dri(ing assessment+

Fes hite

No #lac*

)nsure %ed



CSK< Dri(ing %ecommendations

/H K2He 1 ' health professional15ased comprehensi(e off and on1road dri(ing e(aluation is the fairest method of indi(idual testingBG#! 3?

/H K2Hf 1 n places where comprehensi(e off and on1road dri(inge(aluations are not a(aila5le! clinicians must rely on their own

udgment+ BG#! 3?

/H K2Hg 1 $or persons deemed safe to dri(e! reassessment oftheir a5ility to dri(e should ta*e place e(ery 91;2 months+ BG#! 3?

/H K2Hh 1 Compensatory strategies are not appropriate for thosedeemed unsafe to dri(e+ BG#! 3?



CSK< lan

;+ $irst lin* 'lheimer Society6CC'C

2+ Nutritional counselling

+ eight loss

<+ 4=ercise

H+ "ral meds for dia5etesL

9+ Dri(ing testing A Dri(e'#34

7+ 3ipid profile

8+ 4C 'S' 8;mg



Summary

;+ dentify Mild Cogniti(e mpairment early 5y

listening to concerns a5out memory loss Bpatient andcaregi(er?+

2+ $ollow memory impairment with a sensiti(e measureMoC'+

+ 'ddress (ascular ris* factors and depressi(e symptoms+

<+ /reat symptoms of dementia Be=cept $/D? with

cholinesterase inhi5itors+

H+ #egin discussion a5out dri(ing early and assessment withon1road assessment+

Documents

New Consensus Guidelines on Management of Dementia