2008 Dementia Guidelines

1. 2008 Dementia Guidelines CMAJ – 6 articles CCCDTD Michelle Gibson http://www.cmaj.ca/cgi/collection/diagnosis_and_treatment_of_dementia_series http://www.alzheimer.ca/~/media/Files/national/For-HCP/for_hcp_recos_CCCDTD4_en.ashx

2. Overview • Very brief discussion of the high points • Then, a bit more in depth.

3. What I think you need to know • It’s a clinical diagnosis – so H & P, appropriate investigations, focused testing = diagnosis. • Then, you disclose the diagnosis. • Then, you discuss management strategies – mostly non-pharmacological. • Then, you discuss risks and benefits of treatment with meds. • Then, you follow closely like any chronic disease.

4. What I think you need to know • Blood tests to do for everyone: • CBC, electrolytes, TSH, Calcium, glucose, B12 • Who needs imaging, and what kind • Normal aging vs. MCI vs. Common types of Dementia • Approach to in-office cognitive testing • Risks and benefits of cholinesterase inhibitors, memantine, and anti-psychotics • When to refer

5. Approach to diagnosis • The diagnostic process should involve 6 main steps: • taking the patient's history, • interviewing a caregiver or familymember, • physical examination, • brief cognitive tests, • basic laboratorytests, • and structural imaging for patients meeting certain criteria.

6. After your H & P • MMSE is not that sensitive • MoCA might be more helpful • Labs – for everyone • CBC • Electrolytes • TSH • Calcium • Glucose • B12 • (Tests for Brain Changes Can Give the Etiology)

7. Imaging

8. Neuropsychological testing

9. MCI • short- orlong-term memory impairment who have no significant daily functionaldisability, • subjective report of cognitive decline from a formerlevel, • gradual in onset, • present for at least 6 months. • supplemented by objective evidenceof decline in memory and learning on brief or extensive cognitivetesting. • Other cognitive domains remain generally intact.

10. MCI – Progression? • We don’t know • It doesn’t meet criteria for dementia • Monitor closely – high rate of progression • 40%-80% in 5 years meet the criteria for dementia

11. MCI - Treatment • “Fair evidence” to promote engagement in cognitive activity • “Fair evidence” to promote physical activity for older individuals with and without memory loss

12. MCI - Vascular risk factors • Treating hypertension can reduce risk for stroke & thus ?dementia • Generally, benefits outweigh risks, and might help to reduce the risk for dementia • ?Use an ACE or a CCB • No evidence for ASA or statins • ***The presence of cerebrallacunarinfarctsincreases the rate of dementia by a factor of 20

13. MCI - Other medications? • No evidence for cholinesterase inhibitors • Recommend against: • NSAIDS • Estrogen • Ginkgo

14. Dementia

15. Diagnostic criteria - DSM

18. Early Dementia – steps to follow

19. Early Dementia – steps to follow

20. Early Dementia – non-pharm

21. Early Dementia – non-pharm

22. Cholinesterase inhibitors • Use of a cholinesterase inhibitor is a treatment option formost patients with mild Alzheimer disease • An individualized approach is recommended.The decision to initiate therapy should be based on the wishesof the patient (or their proxy) after their evaluation of therelative benefits and risks of therapy.

23. Cholinesterase inhibitors • Contraindications: • Conductionabnormalities other than a right bundle-branch block • In RCTs most patients with serious cardiovascular conditionswere excluded. • Not in guidelines, but • Avoid in severe COPD, CHF, bradycardia, peptic ulcer disease, severe liver or kidney disease

24. Cholinesterase inhibitors • NNT: • 10 patients to get one “cognitive responder” • 12 patients to get one “global responder”

25. Which drug? • Based on tolerability • Donepezil – Aricept • Galantamine – Reminyl • Rivastigmine – Exelon • ?Galantamine for AD/VaD

26. Nice Table

27. What about Memantine? • Memantine is not recommended for patients with mild dementia • It is an option as either monotherapy or adjunctive therapy(with a cholinesterase inhibitor) for the treatment of moderateto severe Alzheimer disease

28. Monitoring • If medications are started – follow-up at 3-6 months • Set target symptoms – more important than MMSE numbers • (Need to do MMSE to get CI’s covered in Ontario – 10-26/30.)

29. Side Effects • M • I • N • D

30. Side Effects • Muscle cramps • Insomnia and incontinence • Nausea/Vomiting • Diarrhea

31. What if they get side effects? • Can try another CI or Memantine • Can drop down to a lower dose • Suggest waiting 4 weeks if side effects are significant • Can just stop!

32. When to stop? • The patient and/or their proxy decision-maker decides to stop; • The patient refuses to take the medication; • The patient is sufficiently non-adherent with the medication that continued prescription of it would be useless, and it is not possible to establish a system for the administration of the medication to rectify the problem; • There is no response to therapy after a reasonable trial; • The patient experiences intolerable side effects; • The comorbidities of the patient make continued use of the agent either unacceptably risky or futile (e.g., terminally ill); or, • The patient's dementia progresses to a stage where there is no significant benefit from continued therapy. (Grade B, Level III)

33. BPSD • Always try non-pharmacological approaches first • Treat underlying conditions • Depression: SSRIs • Dementia: Cholinesterase inhibitors and/or memantine

36. When to refer? • Continuing uncertainty about the diagnosis after initial assessment and follow-up • Request by the patient or the family for another opinion • Presence of significant depression, especially if there is no response to treatment • Treatment problems/failure with specific medications for AD;

37. When to refer • Need for additional help in patient management (e.g., behavioural problems, functional impairments) or caregiver support; • Genetic counseling when indicated; and, • If the patient and/or family express interest in either diagnostic or therapeutic research studies that are being carried out by the recipient of the consult request.

38. What I think you need to know • It’s a clinical diagnosis – so H & P, appropriate investigations, focused testing. • Then, you disclose the diagnosis. • Then, you discuss management strategies – mostly non-pharmacological. • Then, you discuss risks and benefits of treatment with meds. • Then, you follow closely like any chronic disease.

39. What I think you need to know • Blood tests to do for everyone: • CBC, electrolytes, TSH, Calcium, glucose, B12 • Imaging criteria • Normal aging vs. MCI vs. Dementia • Approach to cognitive testing • Risks and benefits of cholinesterase inhibitors, memantine, and anti-psychotics • When to refer