The American Psychiatric Association (APA) has released a practice guideline on the treatment of dementia titled “Practice Guideline for the Treatment of Patients with Alzheimer's Disease and Other Dementias of Late Life.” The guideline is published as a May 1997 supplement to the American Journal of Psychiatry. The emphasis of the guideline is on behavioral symptoms and their treatment. It was developed by the APA Work Group on Alzheimer's Disease and Related Dementias.
The 39-page guideline has six sections: a summary of recommendations, a section on disease definition, natural history and epidemiology, a section on treatment principles and alternatives, a section on the development of a treatment plan, a section on factors that modify the treatment plan and a section on research directions. Copies of the complete guideline are available from the American Psychiatric Press, Inc., 1400 K St., N.W., Washington D.C. 20005; telephone: 800-368-5777 (order number 2310). The cost is $22.50.
The recommendations are designated by one of three categories of endorsement: “I” signifies a recommendation with substantial clinical confidence, “II” signifies a recommendation with moderate clinical confidence and “III” signifies a recommendation that may be made on the basis of individual circumstances. (The three designations are used in this report.) The following information is from the summary of recommendations, which gives an overview of the recommendations.
The practice guideline states that ongoing assessment should include periodic monitoring of the development and evolution of cognitive and noncognitive psychiatric symptoms [I]. Follow-up should be every four to six months [II] and should include evaluation of the potential for suicide and violence; recommendations regarding adequate supervision, prevention of falls and limits on the hazards of wandering; vigilance regarding neglect or abuse; and restrictions on driving and use of other dangerous equipment [I].
While not subjected to randomized clinical trials, behavioral treatments are supported by case studies and are in widespread clinical use [II]. Common sense supports the use of stimulation therapies, such as recreational therapy and art therapy [II]. Supportive psychotherapy is used by some clinicians to address issues of loss in the early stages of dementia and has modest research support for improvement of mood and behavior [III]. Cognition-oriented treatments, such as reality orientation, are unlikely to be of benefit and have been associated with frustration in some patients [III].
Treatment of Cognitive Symptoms
The guideline states that tacrine (Cognex) or donepezil (Aricept) may be given to patients with mild to moderate Alzheimer's disease [I]. Tacrine has been shown to lead to modest improvement in cognition in a substantial minority of patients, but up to 30 percent cannot tolerate the drug because of nausea and vomiting or liver enzyme elevations [I]. Donepezil has also shown to result in modest improvements in a substantial minority of patients, and, as with tacrine, it appears to have a tendency to cause nausea and vomiting [II]. Because donepezil is not associated with a risk of hepatic toxicity, it may prove preferable as a first-line treatment [III].
Vitamin E may also be considered in patients with moderate Alzheimer's disease to prevent further decline [I]. A significant delay in poor outcome during a two-year period was noted in a large trial of vitamin E [I].
Selegiline (Eldepryl) may also be considered in patients with moderate Alzheimer's disease to prevent further decline [II]. A significant delay in poor outcome during a two-year period was demonstrated in a large study [I].
Ergot mesylates (Hydergine) cannot be recommended for treatment of cognitive symptoms but may be offered to patients with vascular dementia and may be continued in those who experience benefit [III]. It has no significant side effects [I].
Treatment of Psychosis and Agitation
It is critical to consider the safety of the patient and those around him or her [I]. The next step is careful evaluation for a general medical, psychiatric or psychosocial problem that may underlie the disturbance [I]. If attention to these issues does not solve the problem and the symptoms do not cause undue stress to the patient or others, they are best treated with reassurance and distraction [I].
While antipsychotic agents have been shown to provide modest improvement in behavioral symptoms in general [I], research and anecdotal evidence suggest that this improvement is greater for psychosis than for other symptoms [II].
Benzodiazepines are most useful for treating anxiety, including on an as-needed basis [I] to patients who have infrequent episodes of agitation or who need to be sedated for a procedure [II].
Patients with depression should be evaluated for suicidal potential [I]. Patients with severe or persistent depressed mood should be treated with antidepressant medications [II]. Selective serotonin reuptake inhibitors are probably the first-line agents, although one of the tricyclic antidepressants or newer agents, such as bupropion (Wellbutrin) or venlafaxine (Effexor), may be more appropriate in some patients [II]. Agents with significant anticholinergic properties should be avoided [I].
Treatment of Sleep Disturbance
Pharmacologic intervention for a sleep disturbance should be considered only when other interventions have failed [I]. If the sleep disturbance does not coexist with other problems, possibly effective agents include zolpi-dem (Ambien) and trazodone (Trazodone, Desyrel) [II], but there are few data on the efficacy of specific agents in patients with dementia. Benzodiazepines and chloral hydrate are not recommended [II]. Diphenhydramine is generally not recommended because of its anticholinergic properties [II].
Issues for Long-Term Care
A structured education program for staff of a long-term care facility may decrease the use of antipsychotic medications [II]. Physical restraints should be used only when patients pose an imminent risk of physical harm to themselves or others and only until definitive treatment is provided or when other measures have been exhausted [I]. When restraints are used, the indications and alternatives should be carefully documented [I].