Download Summary of the Canadian Consensus Conference on Dementia

The Canadian
Consensus Conference
on Dementia
This article is a summary of the consensus statements
formulated by the conference on dementia for the
assessment and management of dementia in primary care.
by Christopher Patterson, MD, FRCPC
A
Dr. Christopher Patterson, Professor,
Division of Geriatric Medicine,
McMaster University, Hamilton,
Ontario.
s the Canadian population ages,
the prevalence of dementia will
rise dramatically. There are approximately 270,000 people with dementia
currently in Canada; this number is
expected to rise to 778,000 by 2031.1
Manifestations of dementing disorders include not only cognitive
deficits (which make it difficult to
work, drive, manage finances and
make decisions) but also behavioral
complications (e.g., withdrawn or
aggressive behavior, wandering, disinhibition).
Family physicians, who provide
the majority of care for older people,
must be skilled in the diagnosis and
management of dementia. A family
physician with 1,200 patients may
have 12 patients with dementia in their
practice.
These facts underscore the importance of developing clinical practice
guidelines (CPGs) for primary care
physicians. The Canadian Consensus
Conference on Dementia (CCCD)
used a rigorous process to obtain,
select, grade and review evidence.
Background papers were prepared
and circulated to conference participants, all of whom had expertise in
8 • The Canadian Alzheimer Disease Review • September 1999
dementia or a related area. These
papers were discussed and recommendations (consensus statements
upon which the CPGs are based) were
finalized at a conference in Montreal
in February 1998. These recommendations have been published in a supplement to the Canadian Medical
Association Journal.2 A “physicians
guide” to their use has also been published.3 The recommendations are
summarized here, but the reader is
encouraged to read the supplement,
which summarizes the evidence for
these statements. The supplement is
also available at www.cma.ca.
Types of Dementia
Alzheimer’s disease (AD) is by far the
most common cause of dementia in
Canada, accounting for more than 60%
of all cases. Vascular dementia is less
common, and people previously
thought to have vascular dementia
often have co-existent AD. Patients
with frontotemporal dementia usually
show signs of early behavior problems
and language involvement. Dementia
with Lewy bodies is characterized by
early hallucinations and delusions,
extrapyramidal side effects, sensitivity
to neuroleptics and a marked day-today fluctuation in confusion.
Dementia—A Clinical Diagnosis
Although some aspects of cognitive
performance deteriorate with age, cognitive losses that lead to declining
function in occupational, social or dayto-day functioning are associated with
dementia. If mental status testing
uncovers objective evidence of memory loss or decline in other areas, the
ability to perform daily activities
should be assessed.
The most important aspect of establishing a diagnosis of dementia is
obtaining a thorough history from the
patient, and a corroborative history from
caregivers. The history should include a
description of the onset, course and
duration of the problem. Inquiries
should be made about previous psychiatric problems (e.g., depression), risk
factors (e.g., substance abuse, vascular
disease, family history) and neurological symptoms (e.g., new onset
headache). A physical examination
should include a search for systemic
disease, focal neurological signs and a
mental status evaluation. The Mini-
reversible causes are much less common than previously thought,5 emphasis is now on confirming the diagnosis
on the basis of the patient’s history. For
example, AD is typified by a gradual,
insidious loss of memory, usually followed by difficulties with language,
praxis (performing familiar tasks) and
visuospatial disturbances such as
agnosias (failure to recognize familiar
people or surroundings). Behavioral
problems usually appear later in the
course of the disease. The average duration of the disease from onset to death is
about seven years.
Tests for patients who display typical cognitive symptoms or presentation include a complete blood count
and measurement of thyroid stimulating hormone, serum electrolytes,
serum calcium and serum glucose
levels. In atypical cases, laboratory
tests may be indicated.
Neuroimaging, most commonly
computed tomography (CT), can detect
certain causes of dementia such as vascular dementia, tumor, normal pressure
hydrocephalus or subdural hematoma;
it is ineffective in distinguishing AD or
other cortical dementias from normal
Dementia can be detected early if the family physician
maintains a high index of suspicion in elderly patients
and follows up observations of functional decline and
memory loss. Memory complaints should be evaluated.
When caregivers report cognitive decline in a patient, cognitive assessment and careful follow-up are indicated.
Mental State Examination (MMSE)4 is
a good starting point, but other cognitive
domains (e.g., insight, judgment)
should also be assessed. A review of all
prescription and nonprescription medications is essential. This information
will often point to a specific diagnosis.
Laboratory Tests for All Patients
In the past, emphasis has been placed on
investigations to rule out “reversible”
causes of dementia. Because these
aging. CT scans should be restricted to
those people who meet the criteria in
Table 1. Adhering to these “rules”
reduced the number of scans performed
in a memory clinic by two thirds.6
Referrals
Typical characteristics of AD are insidious onset, progressive decline over
seven to 10 years, and a gradual loss of
cognitive and functional abilities.
Physicians are encouraged to seek help
Table 1
CT Scans Are
Recommended for Patients
• younger than 60 years of age,
• who have a rapid unexplained
decline in cognition or function
(over one to two months),
• who have a short duration of
dementia (less than two years),
• who have had a recent and significant
head trauma, unexplained neurologic
symptoms (e.g., new onset of severe
headache or seizures),
• who have a history of cancer (especially in sites and types that metastasize to
the brain) use anticoagulants or have a
history of a bleeding disorder,
• who have a history of urinary incontinence and gait disorder early in the
course of dementia (as may be found
in normal pressure hydrocephalus),
• who have any new localizing sign
(e.g., hemiparesis or a Babinski reflex),
• who have unusual or atypical cognitive symptoms or presentation
(e.g., progressive aphasia),
• or have gait disturbance.
when patients do not follow this typical
pattern (e.g., those who manifest early
behavioral changes or delusions, fluctuating course, early motor changes) or
when management difficulties arise
(Table 2).3
Early Detection
Dementia can be detected early if the
family physician maintains a high index
of suspicion in elderly patients and follows up observations of functional
decline and memory loss. Memory
complaints should be evaluated. When
caregivers report cognitive decline in a
patient, cognitive assessment and careful follow-up are indicated. There is
currently insufficient evidence to recommend screening with short mental
status questionnaires for cognitive
impairment in the absence of symptoms
or in unselected older people.
Genetic Counselling
Genetic counselling is recommended
when there is a strong family history of
The Canadian Alzheimer Disease Review • September 1999 • 9
Figure 1
Diagnosis of Dementia
Complaints of memory loss
Yes
Suspect
dementia
Caregiver confirms
Yes
Yes
Decline in function
Objective evidence of
cognitive decline
Take history of illness from patient and reliable informant. Include:
• onset of symptoms
• duration of symptoms
• evolution of symptoms
• precipitating factors
• family history
Conduct physical examinations
No
No
Subjective
complaints
No
Dementia excluded
as a possible diagnosis.
Symptoms may be the
result of depression or
anxiety. Re-evaluate in
3 to 6 months.
Conduct mental and functional assessment
(e.g., MMSE and FAQ)
Conduct laboratory tests
CBC, TSH, electoytes, calcium, glucose
Conduct other tests as indicated
(CT or MRI in specific cases*)
Eliminate presence of reversible conditions:
• substance abuse
• adverse drug effects
• depression
• metabolic disorders
• systemic illness
Yes
Treat these causes
Are there other
causes for the
symptoms?
No
*
See table of indications
10 • The Canadian Alzheimer Disease Review • September 1999
Diagnosis of dementia
confirmed.
Figure 2
Treatment of Alzheimer’s disease (AD)
Diagnosis of AD
Disclose diagnosis to patient and family
Provide support and education for caregiver and
refer to support organizations
Are there
contributory or treatable causes
of dementia?
Yes
Treat contributory causes
(e.g., hypothyroidism,
reduce sedative drugs)
No
Establish baseline measures
MMSE
Measure of function (e.g., FAQ)
Begin caregiver diary
Initiate treatment with donepezil for informed and
willing patients with no contraindications
Re-assess in 3 months
Repeat baseline measures
Improvement in measures
Yes
Continue treatment
with donepezil
No
Reconsider diagnosis
and/or treatment and
refer to specialist
Re-assess regularly
The Canadian Alzheimer Disease Review • September 1999 • 11
Alzheimer’s disease, particularly when
the onset is below the age of 60.
Risk Factors and
Prevention of Dementia
The risk of dementia may be reduced by
effectively treating vascular risk factors
(e.g., hypertension, diabetes, smoking,
atrial fibrillation).6 Recent evidence
suggests that substandard education
(less than six years), head trauma,
Down syndrome, and family history
may increase the risk of AD. This
opportunity for prevention has been
underused in the past.
Although evidence is currently
insufficient to recommend estrogen
replacement, (NSAIDs) or antioxidants
to prevent dementing disorders, this is
an area of active research. Some authorities encourage the use of vitamin E,
because it is relatively harmless, inexpensive and may be beneficial.
accurately defines driving risk.
Although the risk of crashes increase as
dementia progresses, there is no definite
age or MMSE score before which driving can be confidently assumed to be
safe. Sedative drugs increase the risk of
crashes.8
Caregiver Issues
Solid partnerships between primary
care physicians and caregivers help
families cope with their role.
Caregivers are in a position to monitor
status and symptoms and should be
included in treatment planning.
Physicians can help caregivers by
acknowledging the value of their work,
educating them about the disease and
helping them deal with stress.
Support for caregivers is the most
important aspect of managing a
demented person. Various strategies
and support organizations can greatly
Physicians can help caregivers by acknowledging the
value of their work, educating them about the disease
and helping them deal with stress. Support for caregivers is the most important aspect of managing a
demented person.
Ethical Issues
The wide scope of ethical issues such
as participation in research, decision
making, respecting individuals’ decisions, quality of life, behavior control,
use of restraints, advance directives
and end-of-life decisions have been
dealt with elsewhere.7 The CCCD recommendations deal with only two specific issues: disclosure and driving.
Ethical analysis concludes that, in general, diagnosis should be disclosed to
people with dementia. Disclosure
allows the patient to set out advance
directives and make end-of-life decisions.7 Office assessment of driving
ability is notoriously inaccurate. When
in doubt, a performance-based assessment (including an on-road test) more
help the caregiver. A program of education, case management and support
for the caregiver from the Alzheimer
Society has been shown to delay a
patient’s admission to a long-term care
institution by approximately one year.9
Support programs can also provide
caregivers with information about legal
and financial issues.
Cultural Aspects
In some cultures the concept of
dementia does not exist. Conventional
mental status tests frequently overestimate the cognitive deficits of people from different linguistic and
cultural groups. It is important to
provide services that are culturally
appropriate.
12 • The Canadian Alzheimer Disease Review • September 1999
Table 2
Refer Patients to Other
Health Care Professionals
• if diagnosis is uncertain after the initial
assessment and follow-up,
• if the patient or his or her family want
a second opinion,
• in the presence of significant depression (especially if there is no response
to treatment, treatment problems or
failure with new medications for AD),
• if the need arises for additional help in
patient management (e.g., behavioral
problems) or caregiver support,
• when genetic counselling is indicated,
• when research studies into diagnosis
or treatment are being carried out.
Depression and Dementia
Depression is extremely common in
early stages of AD. Physicians should
consider a diagnosis of depression when
patients experience behavioral symptoms, weight and sleep changes, sadness, crying, suicidal statements or
excessive guilt. Nonpharmacologic
therapy should be initiated if depressive
symptoms are not part of a major affective disorder, severe dysthymia or
severe emotional lability. Medication
should be considered for more severe
depression. Selective serotonin reuptake
inhibiors (SSRIs) and reversible
inhibitors of monoamine oxidase A
(RIMA) antidepressants are generally
preferred over tricyclic antidepressants
(TCAs), which have anticholinergic
effects that can aggravate cognitive
deficits.10 Individuals with AD are particularly sensitive to anticholinergic
agents. Referral to a specialist may be
necessary if the depression is atypical or
refractory.
Behavioral Problems
Behavioral difficulties are common and
are often the most challenging complications of a dementing illness. It is
important to evaluate causes and to
document behavior carefully before
resorting to pharmacologic treatment.11
Environmental modifications (changes
to sound, light, people) are often effective. The value of neuroleptic drugs has
been overestimated in the past, and in
general, a cautious approach is recommended, using low doses, cautious
escalation and careful observation. The
newer atypical neuroleptics may offer
advantages over traditional agents.12 If
symptoms are successfully controlled
with pharmacotherapy, physicians
should regularly evaluate the need for
continuing treatment and reduce or
withdraw the drugs if possible.
Pharmacologic
Management of Dementia
The goal of therapy is to halt or slow
cognitive and functional decline,
improve memory and other cognitive
functions, maintain or improve the ability to perform daily activities, improve
behavioral abnormalities, and improve
mood, contentedness and quality of life
of the patient, which will also improve
the quality of life of the caregiver. None
of the drugs that are currently available
meet all of these criteria, but symptomatic treatment is available.
Donepezil is currently the only medication approved by Health Canada to
treat mild to moderate AD.13,14 Baseline
References
1. Canadian Study of Health and Aging
Working Group: Canadian study of
health and aging: study methods and
prevalence of dementia. CMAJ 1994;
150:899-913.
2. Patterson CJS, Gauthier S, Bergman H,
et al.: The recognititon and
management of dementing disorders:
conclusions from the Canadian
Consensus Conference on Dementia.
CMAJ 1999;160 (Suppl 12).
3. Patterson CJS, Gauthier S, Bergman H,
et al.: Canadian Consensus Conference
on Dementia: a physicians' guide to
using the recommendations. CMAJ
1999; 160:1738-42.
4. Folstein MF, Folstein SE, McHugh PR:
“Mini Mental State”: a practical
method of grading the cognitive state
of patients for the clinician.
J Psychiatry Res 1975; 12:189-98.
5. Clarfield AM: The reversible
assessments should be made before prescribing donepezil, and serial examinations should be conducted to determine
whether the medication is effective. In
addition to the physician’s assessment
(which should include cognitive
(e.g., MMSE4) and functional measures
(e.g., functional assessment questionnaire15)) caregivers of the affected individual should be encouraged to record
their observations in a daily diary and
should be given realistic expectations.
There is currently insufficient evidence to recommend vitamin E or
Ginkgo biloba therapy for patients
with AD.
support of the Canadian Consensus
Conference on Dementia: Bayer
Healthcare Division; Boehringer
Ingelheim Canada Ltd.; Hoechst
Marion
Roussel;
Janssen-Ortho
Pharmaceutical
Inc.;
Novartis
Pharmaceuticals Canada Inc; Pfizer
Canada Inc.; SmithKline Beecham
Pharma; Consortium of Canadian
Centres for Clinical Cognitive
Research; Division of Geriatric
Medicine, McMaster University;
Division of Geriatric Medicine, McGill
University; McGill Centre for Studies in
Aging.
Endorsement
Conclusions
The conference organizers would like to
express their appreciation to the following organizations for providing grants in
The
following
organizations
endorsed consensus recommendations:
Alzheimer Society of Canada;
Canadian Academy of Geriatric
Psychiatry; Canadian Society of
Geriatric Medicine; College of Family
Physicians of Canada; Consortium of
Canadian Centres for Clinical
Cognitive Research (C5R); Canadian
Neurological Society; and the Société
québécoise de gériatrie. Members of
the steering committee included: Drs.
C. Patterson, S. Gauthier, H. Bergman,
C. Cohen, J. Feightner, H. Feldman,
A. Grek, and D. Hogan.
dementias: do they reverse? Ann Intern
Med 1988; 109:476-86.
6. Freter S, Bergman H, Gold S, et al.:
Prevalence of potentially reversible
dementias and actual reversibility in a
memory clinic cohort. CMAJ 1998;
159:657-62.
7. Tough issues: ethical guidelines. Toronto:
Alzheimer Society of Canada, 1997.
8. Hemmelgarn B, Suisa S, Huang A, et al.:
Benzodiazepine use and risk of motor
vehicle crashes. JAMA 1997; 278:27-31.
9. Mittelman MS, Ferris SH, Shulman E, et
al.: A family intervention to delay nursing
home placement of patients with
Alzheimer's disease. A randomized
controlled trial. JAMA 1996; 276:725-31.
10. Wragg RE, Jeste DV: Overview of
depression in Alzheimer's disease.
Am J Psychiatry 1989; 145:577-87.
11. Beck CK, Shue VM: Interventions for
treating disruptive behavior in demented
elderly people. Nurs Clin North Am
1994; 29:143-55.
12. Katz IR, Jeste DV, Mintzer JE, et al.:
Comparison of risperidone and placebo
for psychosis and behavioral disturbances
associated with dementia—a
randomized, double-blind trial.
J Clin Psychiatry 1999; 60:107-15.
13. Rogers SL, Friedhoff LT, the
Donepezil Study Group. The efficacy
and safety of donepezil in patients
with Alzheimer’s disease: results of a
US multicenter, randomized, double
blind, placebo-controlled trial.
Dementia 1996; 7:293-303.
14. Rogers SL, Farlow MR, Doody RS, et al.:
A 24-week, double-blind, placebocontrolled trial of donepezil in patients
with Alzheimer’s disease. Neurology
1998; 50:136-45.
15. Pfeffer RI, Kurosaki TT, Harrah CH:
Measurement of functional activities of
older adults in the community. J Gerontol
1982; 37:323-9.
The foregoing is a brief summary of the
consensus statements formulated by the
Canadian Consensus Conference on
Dementia for the assessment and management of dementia in primary care.
This should be used only as a guide; the
reader is urged to review the full recommendations published in CMAJ2 and
the “physicians guide” to their use.3
Funding Support
The Canadian Alzheimer Disease Review • September 1999 • 13