CMAJ • October 7, 2008; 179 (8). doi:10.1503/cmaj.070803.
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Review

Diagnosis and treatment of dementia: 4. Approach to management of mild to moderate dementia

David B. Hogan, MD, Peter Bailey, MD, Sandra Black, MD, Anne Carswell, MSc PhD, Howard Chertkow, MD, Barry Clarke, MD, Carole Cohen, BA MD, John D. Fisk, PhD, Dorothy Forbes, RN PhD, Malcolm Man-Son-Hing, MSc MD, Krista Lanctôt, PhD, Debra Morgan, RN PhD and Lilian Thorpe, MD PhD

From the Departments of Medicine and Clinical Neurosciences (Hogan), University of Calgary, Calgary, Alta.; the Division of Neurology, Department of Medicine (Bailey), the Department of Family Medicine (Clarke) and the Department of Psychiatry (Fisk), Dalhousie University, Halifax, NS; the Department of Medicine (Black), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ont.; the School of Occupational Therapy (Carswell) and the School of Nursing (Forbes), Faculty of Health Sciences, University of Western Ontario, London, Ont.; the Bloomfield Centre for Research in Aging, Lady Davis Institute for Medical Research, and the Division of Geriatric Medicine, Department of Medicine (Chertkow), Sir Mortimer B. Davis–Jewish General Hospital, McGill University, Montréal, Que.; the Department of Neurology and Neurosurgery (Chertkow), McGill University; and Centre de recherche, Institut Universitaire de Gériatrie de Montréal and Université de Montréal (Chertkow), Montréal, Que.; the Departments of Psychiatry (Cohen, Lanctôt) and Pharmacology (Lanctôt), University of Toronto, Toronto, Ont.; the Department of Medicine (Man-Son-Hing), University of Ottawa, Ottawa, Ont.; and the Institute of Agricultural Rural and Environmental Health (Morgan) and the Department of Psychiatry (Thorpe), University of Saskatchewan, Saskatoon, Sask.

Correspondence to: Dr. David B. Hogan, Department of Clinical Neurosciences, Health Sciences Centre, University of Calgary, 3330 Hospital Dr. NW, Calgary AB T2N 4N1; fax 403 283-6151; dhogan{at}ucalgary.ca

Abstract

Background: The management of mild to moderate dementia presents complex and evolving challenges. Practising physicians are often uncertain about the appropriate approaches to issues such as the disclosure of the diagnosis, driving and caregiver support. In this article, we provide practical guidance on management based on recommendations from the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia.

Methods: We developed evidence-based guidelines using systematic literature searches, with specific criteria for the selection and quality assessment of articles, and a clear and transparent decision-making process. We selected articles published from January 1996 to December 2005 that dealt with the management of mild to moderate stages of Alzheimer disease and other forms of dementia. Recommendations based on the literature review were drafted and voted on. Consensus required 80% or more agreement by participants. Subsequent to the conference, we searched for additional articles published from January 2006 to April 2008 using the same major keywords and secondary search terms. We graded the strength of evidence using the criteria of the Canadian Task Force on Preventive Health Care.

Results: We identified 1615 articles, of which 954 were selected for further study. From a synthesis of the evidence in these studies, we made 48 recommendations for the management of mild to moderate dementia (28) and dementia with a cerebrovascular component (8) as well as recommendations for addressing ethical issues (e.g., disclosure of the diagnosis) (12). The updated literature review did not change these recommendations. In brief, patients and their families should be informed of the diagnosis. Although the specifics of managing comorbid conditions might require modification, standards of care and treatment targets would not change because of a mild dementia. The use of medications with anticholinergic effects should be minimized. There should be proactive planning for driving cessation, since this will be required at some point in the course of progressive dementia. The patient's ability to drive should be determined primarily on the basis of his or her functional abilities. An important aspect of care is supporting the patient's primary caregiver.

Interpretation: Much has been learned about the care of patients with mild to moderate dementia and the support of their primary caregivers. There is a pressing need for the development, and dissemination, of collaborative systems of care.


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Can. Med. Assoc. J. 2008 179: 733. [Full Text] [PDF]



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D. B. Hogan MD, P. Bailey MD, S. Black MD, A. Carswell MSc PhD, H. Chertkow MD, B. Clarke MD, C. Cohen BA MD, J. D. Fisk PhD, D. Forbes RN PhD, M. Man-Son-Hing MSc MD, et al.
Diagnosis and treatment of dementia: 5. Nonpharmacologic and pharmacologic therapy for mild to moderate dementia
Can. Med. Assoc. J., November 4, 2008; 179(10): 1019 - 1026.
[Abstract] [Full Text] [PDF]