The Recognition, Assessment and Management of Dementing Disorders: Conclusions from the Canadian Consensus Conference on Dementia

Abstract

To develop evidence based consensus statements on which to build clinical practice guidelines for primary care physicians towards the recognition, assessment and management of dementing disorders; ii) to disseminate and evaluate the impact of these statements and guidelines built on these statements. O p t i o n s : Structured approach to assessment, including recommended laboratory tests, choices for neuroimaging and referral; management of complications (especially behaviour problems and depression) and use of cognitive enhancing agents. Potential outcomes: Consistent and improved clinical care of persons with dementia; cost containment by more selective use of laboratory investigations, neuroimaging and referrals; appropriate use of cognitive enhancing agents. E v i d e n c e : Authors of each background paper were entrusted to: perform a literature search, discover additional relevant material including references cited in retrieved articles; consult with other experts in the field and then synthesize information. Standard rules of evidence were applied. Based upon this evidence, consensus statements were developed by a group of experts, guided by a steering committee of eight individuals from the areas of Neurology, Geriatric Medicine, Psychiatry, Family Développer des énoncés consensuels basés sur les données actuelles de la science sur lesquels on puisse construire des lignes directrices cliniques pour les médecins de première ligne pour l'identification, l'évaluation et la prise en charge des patients déments; ii) diffuser et évaluer l'impact de ces énoncés et des lignes directrices basées sur ces énoncés. O p t i o n s : Une approche structurée pour l'évaluation, incluant les épreuves de laboratoire recommandées, les choix d'examens de neuroimagerie et de référence en spécialité; la prise en charge des complications (spécialement des problèmes de comportement et de dépression) et l'utilisation d'agents qui améliorent la fonction cognitive. Bénéfices potentiels: Des soins améliorés et fiables aux personnes démentes; un contrôle des coûts par une utilisation plus judicieuse des examens de laboratoire, de la neuroimagerie et de la référence en spécialité; une utilisation appropriée des agents qui améliorent la fonction cognitive. É v i d e n c e : Les auteurs de chaque article de fond ont reçu le mandat de faire une recherche de la littérature pour ajouter des informations pertinentes incluant les références citées dans ces articles; consulter d'autres experts dans ce domaine et faire une synthèse de l'information. Ces tâches ont été effectuées conformément aux normes de la preuve. Sur la foi de cette évidence, les énoncés consensuels ont été développés par un groupe d'experts, guidé par un comité de direction de huit individus des domaines de la neurologie, de la gériatrie, de la psychiatrie, de la médecine familiale, de la médecine préventive et des systèmes de santé. Va l e u r s : Des recommandations ont été développées en portant une attention particulière sur le contexte des soins de première ligne ...

Cognitive Pharmacotherapy of Alzheimer's Disease and other Dementias

“…In contrast to the APA Guidelines, they noted that the evidence for the clinical use of Gingko biloba, vitamin E, and selegiline was "inconclusive." Third, in June 1999, the Canadian Consensus Conference on Dementia published the guidelines that were more far-reaching, comprehensive, and comprised several pharmacologic recommendations (89). When present, physicians should treat vascular risk factors, including arterial hypertension, hypercholesterolemia, diabetes mellitus, smoking, use of anticoagulation for atrial fibrillation, and secondary prevention of transient ischemic attacks (TIAs) and stroke.…”

Assessment of Suspected Dementia

“…The 1989 CCCAD 124 had originally suggested that in primary care settings such neuroimaging could be limited to atypical cases delineated using clear guidelines, and these guidelines on referral for neuroimaging were again adopted with modification at the second CCCD conference in 1998. 135 The most commonly used modality -computed tomography (CT) has a clear role in excluding rare reversible causes of dementia such as brain tumor or NPH but it is unclear that CT can distinguish AD or cortical dementias from normal aging. Since excluding treatable pathology is its major indicator, a noncontrast CT is adequate in most cases.…”

“…Four sources of increased stress on neurologists and geriatricians are worth noting: 1) the number of elderly, memory-impaired individuals continue to rise 30 and yet a "wait and see" approach is less acceptable to patients now that symptomatic treatment for AD exists, 2) physicians are being instructed to draw diagnostic distinctions they might previously have ignored (e.g. MCI vs AD), 3) time-consuming assessment of MSE and functional assessment are being encouraged as an essential component of diagnostic assessment without any concomitant financial remuneration for the physician involved, and 4) on one hand, authorities such as the second Canadian Consensus Conference on Dementia 135 insist that the initial assessment of dementia (and its treatment) should take place in a family practice setting, while on the other hand, there are serious pressures afoot that will result in increasing numbers of memory-impaired individuals being referred to neurologists and geriatricians for diagnosis and treatment. In addition to those factors already listed, one would add pressures to obtain neuroimaging more rapidly and new complex provincial government forms required for obtaining donepezil (and ultimately other effective medications) under government/insurance programs.…”

The South West Local Health Integration Network Behavioural Supports Ontario Experience

“…Referred to as responsive behaviours, behavioural and psychological symptoms can include aggression, disruptive behaviours, disinhibition, apathy, depression, anxiety and agitation (Cerejeira et al 2012;Patterson et al 1999;Savva et al 2009). These behaviours are a means of communication and reflect a response to something in the person's environment (Cohen-Mansfield 2000; Kunik et al 2010).…”