Managing Dementia & Agitation
Practice Guideline for the Treatment of Patients with Alzheimer’s Disease and Other Dementias of Late Life
American Psychiatric Association
http://www.psych.org/psych_pract/treatg/pg/pg_dementia_32701.cfm
SUMMARY
The purpose of this guideline is to assist the psychiatrist in caring for a demented patient. It is the product of an expert working group and an extensive working group. It attempts to be inclusive but cannot cover everything. Most of the emphasis is on behavioral symptoms because most of the effective treatments available for dementing disorders are in this realm.
This comprehensive document covers the following areas:
- Disease definition, natural history and epidemiology
- Associated features
- Differential diagnosis
- Prevalence and course
- Specific dementias
- Treatment principles and alternatives
- Determining the site of treatment and frequency of visits
- Psychiatric management, psychotherapy and other psychosocial treatments
- Specific psychotherapies/psychosocial treatments
- Somatic treatments
- Development of a treatment plan
- Mildly impaired patients
- Moderately impaired patients
- Severely and profoundly impaired patients
- Factors modifying treatment decisions
- Comorbid conditions
- Site-specific issues
- Demographic and social factors
- Research directions
- Individuals and organizations that submitted comments
- References
California Workgroup on Guidelines for Alzheimer’s Disease Management
http://www.alzla.org/medical/CAguidepdf.pdf
SUMMARY
This clinical practice guideline represents core care recommendations for the management of Alzheimer’s disease, which are clear, measurable, practical and based on scientific evidence as available. The California Workgroup provided its expert opinion when research evidence was unavailable or when research results were inconsistent. The guideline suggests care management principles and is based on the assumption that a proper diagnosis of AD, using reliable and valid diagnostic techniques has been made. It is intended to serve as a general guide for the ongoing management of people with AD. The impact of language, education level and culture are given serious consideration, as is the impact of functional health literacy.
A bibliography of 311 references and 8 tables enhance the text. The tables cover:
- Considerations when working with ethnically diverse populations
- Age and education adjustments to MMSE scores
- Caregiver assessment
- A model for cultural assessment
- Medical treatment of mild to moderate Alzheimer’s disease
- Support services for AD patients and caregivers
- Non-pharmacological management techniques for behavioral symptoms
- Pharmacological treatment of behavior and mood
Intended audience: Primary care practitioners, including physicians, nurse practitioners, physician assistants, social workers and other professionals providing primary care to AD patients and their families.
Contents of the document include:
- Alzheimer’s Disease and Its Treatment: Critical Features and Issues
- Assessment of
- Daily function
- Cognitive status
- Other medical conditions
- Behavioral symptoms, psychotic symptoms and depression
- Health literacy
- Regular reassessments
- Primary caregiver identification and support system assessment
- Patient decision making capacity and surrogate identification
- Cultural sensitivity
- Development and implementation of a treatment plan
- Use of cholinesterase inhibitors, if clinically indicated, to treat cognitive decline
- Principles for prescribing acetylcholinesterase inhibitors
- Referral to community based services
- Other medical conditions
- Sensory deficits
- Dental dare
- Treatment of behavioral symptoms and mood disorders
- General approach
- Non-pharmacologic treatment approaches
- Pharmacologic interventions for behavioral symptoms
- Common forms of AD-related behavioral symptoms and treatment recommendations
- Wandering
- Depression
- Agitation
- Sleep disorders
Patient and caregiver education
- Communication with patient and family
- Referrals to support services
- Advance planning and end of life care
Reporting requirements
Guidelines for the Support and Management of People with Dementia
New Zealand Guidelines Group
http://www.nzgg.org.nz/guidelines/0045/Guidelines For People With Dementia.pdf
SUMMARY
About the Guideline
- Guideline team
- Documentation
Guideline Information
- Summary of recommendations
- Introduction
- Incidence and prevalence of dementia in New Zealand
- Clinical spectrum of dementia
- Diagnosis
- Cognition enhancing drug treatments in dementia
- Management of dementia
- Community care
- Cultural issues
- Recommendations for research
- Audit of care for persons with dementia in general practice
Appendices
- Mini mental state examination
- Dementia screening tests
- Systematic review of the literature
- Economic costs of dementia
- Evidence for use of CT brain scans and diagnostic works
- Evaluation of training and activity programs
References
Patient information
- Mental status examination
- CES-D major depressive disorder scale
- Even briefer assessment scale for depression
- Disability support services
Evaluation of dementia guideline
Dementia Screening
U.S. Preventive Services Task Force
http://www.ahrq.gov/clinic/uspstf/uspsdeme.htm
SUMMARY
The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening for dementia in older adults.
Rationale: The USPSTF found good evidence that some screening tests have good sensitivity but only fair specificity in detecting cognitive impairment and dementia. There is fair to good evidence that several drug therapies have a beneficial effect on cognitive function (equivalent to delaying the natural progression of Alzheimer’s disease from 2 to 7 months), but the evidence of their beneficial effects on instrumental activities of daily living is mixed, with benefit being small at best. There is insufficient evidence to determine whether the benefits observed in drug trials are generalizable to patients whose disease would be detected by screening in primary care settings. The accuracy of diagnosis, the feasibility of screening and treatment in routine clinical practice and the potential harms of screening (e.g., labeling effects) also are unknown. The Task Force therefore could not determine whether the benefits of screening for dementia outweigh the harms.
The Expert Consensus Guideline Series: Agitation in Older Persons with Dementia
Alexopoulos, GS, Silver JM, Kahn DA, Frances A, Carpenter D
http://www.psychguides.com/gagl.pdf
SUMMARY
The agitation that can occur in association with dementia greatly complicates patient care, poses a risk to the patient’s health and safety, and significantly increases the burden for families and caregivers. Based on a survey of 84 experts in geriatric psychiatry, these guidelines cover assessment of agitation in dementia, overall management strategies, and selection of environmental interventions and medications. Recommendations are given for selecting medications and environmental strategies to manage delirium, psychosis, depression, anxiety, insomnia, “sundowning”, and other types of aggression or anger and pain that occur in the context of dementia. Guidelines are also provided concerning medication dosing, side effects, safety and tolerability; managing inadequate response to medication; and long-term treatment issues. The guidelines include schematic treatment algorithms for selecting general management strategies and choosing medications for specific types of agitation. Also included is “A Guide for Families and Caregivers” that was developed with the assistance of the American Federation for Aging Research, the American Association for Retired Persons and the National Citizens’ Coalition for Nursing Home Reform.
Agitation in Older Persons with Dementia: A Guide for Families and Caregivers
David A. Kahn, M.D., Lisa P. Gwyther, M.S.W., Allen Frances, M.D., Jonathan M. Silver, M.D., George S. Alexopoulos, M.D.
http://www.psychguides.com/gahe-lp.pdf
SUMMARY
This well written Postgraduate Medicine Special Report for those involved in the care of patients with dementia covers the following topics:
- The definition of dementia
- The definition of agitation?
- Causes of agitation in dementia
- Physical and mental problems
- Environmental stresses
- Sleep problems
- Psychiatric syndromes
- Psychosis
- Anger and aggression
- Depression
- Anxiety
- Treatment of agitation
- How soon it should be treated
- How it is treated
- Providing the right environment
- Supervising activities
- Learning how to talk with a person who has dementia
- Getting support and improving coping skills
- Medications
- How specific medications are chosen for a person
- Medication strategies for different types of agitation
- Antipsychotics
- Antidepressants
- Divalproex
- Carbamazepine
- Buspirone
- Trazodone
- Benzodiazepines
A list of resources is included at the end of the article.
