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New Consensus Guidelines on Management of Dementia
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Transcript of New Consensus Guidelines on Management of Dementia
7/17/2019 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
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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
4lan6yeth
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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+
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rd Canadian Consensus Conference on
Diagnosis and /reatment of DementiaCCCD/D
March :1;;! 2009+ Montreal
Specialists & $amily hysicians+
;<0 guidelines+
/ranslation of %esearch to practice+
Clinical scenarios to illustrate how guidelines can
inform practice+
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Criteria for assigning le(els of e(idence
3e(elCriteria
;+ 4(idence o5tained from at least ; properly randomied controlled
trial+
2a+4(idence o5tained from well1designed controlled trials without
randomiation+25+4(idence o5tained from well1designed cohort or case1control
analytic studies! prefera5ly from more than ; centre or
research group+
2c+ 4(idence o5tained from comparisons 5etween times or places
with or without the inter(ention+ Dramatic results in
uncontrolled e=periments are included in this category+
+ "pinions of respected authorities! 5ased on clinical e=perience!
descripti(e studies or reports of e=pert committees+
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Grades of recommendations
Grade Criteria
'+ /here is good e(idence to support this man>u(re+
#+ /here is fair e(idence to support this man>u(re+
C+ /here is insufficient e(idence to recommend for or
against this man>u(re! 5ut recommendations may
5e made on other grounds+
D+ /here is fair e(idence to recommend against this
procedure+
4+ /here is good e(idence to recommend against this
procedure+
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Spectrum of Cogniti(e Decline
Adapted from Chertkow & Murtha, 1998
Super Normal•no deterioration
from young
Age-consistent loss
•average for age
Mild Cognitive Impairment
•1.5 S ! "orma# of age
and edu$ation mat$hed
$ontro#%
Dementia
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Serge Gauthier, 2001
MC
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Not normal, not demented (Does not meet criteria (DSM IV,
ICD 10) or a dementia s!ndrome)
Cognitive decline
• Sel and"or inormant report and impairment on o#$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-/
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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
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/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": #$1%.
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/ypes Bcontinued?
#ronto$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
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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
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/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
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/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
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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
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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
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s this history suggestion of@
Mild cogniti(e impairmentL hite
DementiaL #lac*
)nsure %ed
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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
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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
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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
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CCCD/D %ecommendations
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Should this person and their family 5e referred to
the 'lheimer SocietyL
Fes hite
No #lac*
)nsure %ed
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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@ $irst 3in* program where a(aila5le?P and
/H K;5 1 rimary care physicians should 5e aware of the
resources a(aila5le for the care of those with dementia in their
community Beg@ support groups! adult day program? and to
ma*e appropriate referrals to them+ BG#! 3?
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Should the diagnosis of dementia 5e disclosed to
the person and their familyL
Fes hite
No #lac*
)nsure %ed
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CS *thico$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?
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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?
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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
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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;?
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Could an indi(idualied e=ercise program ha(e animpact on functional performanceL
Fes hite
No #lac*
)nsure %ed
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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;?
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Should a cholinesterase inhi5itor 5e prescri5edL
Fes hite
No #lac*
)nsure %ed
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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?
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Should neuroimaging 5e reuestedL
Fes hite
No #lac*
)nsure %ed
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/ 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?
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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
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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
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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
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Could this man ha(e@
Mild cogniti(e impairmentL hite
Dementia! pro5a5le 'lheimer DiseaseL #lac*
Eascular DementiaL #lue
)nsure %ed
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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
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hat do you thin* the diagnosis is nowL
Mild cogniti(e impairmentL hite
Dementia! pro5a5le 'lheimer DiseaseL #lac*
Eascular DementiaL #lue
)nsure %ed
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CSK<
Clinical mpression
'lheimer Disease A mild
"(er weight
Dia5etes
Still dri(ing
Drin*ing while dri(ing
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CCCD/D %ecommendations
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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;?+
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Should a cholinesterase inhi5itor 5e prescri5edL
Fes hite
No #lac*
)nsure %ed
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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;?
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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?
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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
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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?
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eople with cogniti(e impairment and impairedinstrumental acti(ities of daily li(ing should stop
dri(ing+
Fes hite
No #lac*
)nsure %ed
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/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?
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'n on1road dri(ing assessment is the 5est methodof dri(ing assessment+
Fes hite
No #lac*
)nsure %ed
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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?
7/17/2019 New Consensus Guidelines on Management of Dementia
http://slidepdf.com/reader/full/new-consensus-guidelines-on-management-of-dementia 57/58
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
7/17/2019 New Consensus Guidelines on Management of Dementia
http://slidepdf.com/reader/full/new-consensus-guidelines-on-management-of-dementia 58/58
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+