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


CONCLUSIONS
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.
Departments of Medicine and Clinical Neurosciences, University of Calgary, Calgary, Alta. dhogan@ucalgary.ca
David B
DB
Hogan
Peter
P
Bailey
Sandra
S
Black
Anne
A
Carswell
Howard
H
Chertkow
Barry
B
Clarke
Carole
C
Cohen
John D
JD
Fisk
Dorothy
D
Forbes
Malcolm
M
Man-Son-Hing
Krista
K
Lanctôt
Debra
D
Morgan
Lilian
L
Thorpe
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000544:Alzheimer Disease / Q000175:diagnosis / Q000628:therapy; D017028:Caregivers / Q000523:psychology / Q000706:statistics & numerical data*; D003131:Combined Modality Therapy; D003704:Dementia / Q000175:diagnosis* / Q000628:therapy*; D019317:Evidence-Based Medicine; D005260:Female; D015577:Geriatric Assessment; D006801:Humans; D008297:Male; D009483:Neuropsychological Tests; D009864:Ontario; D010817:Physician-Patient Relations; D017410:Practice Guidelines as Topic; D011379:Prognosis; D018570:Risk Assessment; D012720:Severity of Illness Index; D016896:Treatment Outcome