Canadian Consensus Conference on Dementia, February 27-28, 1998: Conference Highlights [*].

The Canadian Consensus Conference on Dementia was comprised of a group of experts, guided by a steering committee from the areas of neurology, geriatric medicine, psychiatry, family medicine, preventive health care, and health care systems. The goals of this conference were as follows:

* To develop evidence-based consensus statements on which to base clinical practice guidelines for primary care physicians for the recognition, assessment, and management of dementing disorders.

* To widely distribute these recommendations to primary care physicians.

* To evaluate the impact of these recommendations and guidelines based on these statements.

The entire text of this conference was published as a supplement to the Canadian Medical Association Journal: The recognition, assessment and management of dementing disorders: conclusions from the Canadian Consensus Conference on Dementia. Patterson CJ, Gauthier S, Bergman H, et al. CMAJ 1999: 160 (12 Suppl).

Diagnosis and Natural History of Dementia

* Alzheimer's disease (AD) is characterized by gradual onset, continuing decline of memory and at least one additional cognitive domain impairment unexplained by other neurologic or systemic disorders. AD accounts for about 60% of the cases of dementia in Canada.

* Vascular dementia (VaD) exists as a number of syndromes usually associated with cerebrovascular disease. These are generally characterized by abrupt onset, stepwise decline, impaired executive function, gait disorder and emotional lability, with clinical or neuroimaging evidence of cerebrovascular disease. A temporal relationship between a vascular insult and cognitive change should be found. VaD and AD frequently coexist in a condition called mixed dementia.

* Frontotemporal dementia (FTD) is distinguished by an insidious onset and slow progression of behavioral changes, such as loss of social awareness, disinhibition, mental rigidity, inflexibility, hyperorality, perseverative behavior, distractibility, loss of insight and declining hygiene, and prominent language changes that occur with reduction in verbal output.

* Dementia with Lewy Bodies is a progressive cognitive decline with fluctuating symptoms, reoccurring visual hallucinations, and spontaneous extrapyramidal signs. The diagnosis is accompanied by repeated falls, hypersensitivity to neuroleptics, delusions, nonvisual hallucinations and syncope, or transient losses of consciousness.

Recommendations were developed to help physicians assess and care for patients with dementia.

Assessment * Dementia is a clinical diagnosis requiring a detailed history and physical examination, including office-based psychometric tests, such as the Mini Mental State Examination (MMSE) and scales that look at functional autonomy, such as the Functional Assessment Questionnaire.

* For most patients who have a clinical presentation consistent with AD with typical cognitive symptoms or presentation, only the following basic set of laboratory tests should be ordered: complete blood count; measurement of thyroid stimulating hormone, serum electrolytes, serum calcium and serum glucose levels. Other tests, including vitamin [B.sub.12] blood levels, may be recommended depending on the findings during history taking and physical examination.

* Extensive investigations for potential reversibility are no longer justified unless there are features in the presentation that would suggest an alternative diagnosis such as delirium or a particular reversible cause.

* Neuroimaging, particularly computed tomography (CT), plays a role in detecting certain causes of dementia such as VaD, tumor, normal pressure hydrocephalus or subdural hematoma. It is less effective in distinguishing AD or other cortical dementias from normal aging.

* A cranial CT scan is recommended if one or more of the following criteria are present: age less than 60 years; rapid unexplained decline in cognition or function; short duration of dementia ([less than] 2 years); recent and significant head trauma; unexplained neurologic symptoms (onset of severe headache or seizures); history of cancer (especially in sites and types that metastasize to the brain); use of anticoagulants or history of a bleeding disorder; history of urinary incontinence and gait disorder early in the course of dementia; any new localizing sign (hemiparesis or a Babinski reflex); unusual or atypical cognitive symptoms or presentation; or gait disturbance.

* Many ancillary tests are being investigated for their usefulness in diagnosing specific dementias. Examples include: brain imaging (eg, magnetic resonance imaging, hippocampal volumes, functional imaging [positron emission tomography, single photon emission, computed tomography]); cognitive assessments; neurophysiologic tests; electroencephalography (EEG); sleep EEG; measurement of cognitive evoked potentials (P300); and genetic and neurochemical tests.

Referral of Patients with Dementia

* Due to the difficulties in allocating sufficient time for an informant interview and cognitive assessment of the patient, the use of nonmedical personnel or multiple office visits may be necessary.

* Patients who do not follow a typical pattern (those who manifest early behavioral changes or delusions, fluctuating course, early motor changes) may be considered for referral.

* Most patients with dementia can be assessed and managed adequately by their primary care physicians.

Screening and Case-finding

* With the burden of dementia for older people and their caregivers, it is important for the clinician to maintain a high index of suspicion for dementia and to follow up concerns and observations of functional decline and memory loss. Memory complaints should be evaluated and the patient followed up to assess progression.

* In the absence of symptoms of dementia, there is insufficient evidence to recommend for or against screening for cognitive impairment.

* Short mental status questionnaires are insufficiently sensitive or specific for use in screening. For example, Folstein's MMSE, the most commonly used short test of cognitive function, has an average sensitivity of 83% and an average specificity of 82% for detecting dementia. If this test were applied to a population of sixty-five 74-year-old individuals, the false positive rate of dementia would be 93%.

Genetics

* First-degree relatives of AD patients have a two- to fourfold increase in their personal risk for the disease.

* The presence of apoE4 genotype is associated with an increased risk of AD.

* The sensitivity (approximately 50%) and specificity (about 75%) for the presence of the apoE4 genotype in diagnosing AD is insufficiently high to guide diagnosis or accurately quantify genetic risk.

* Screening asymptomatic people for genetic risk factors such as apoE4 is not recommended at this time.

* Asymptomatic people concerned about inheriting AD can be referred to a genetic clinic if the family history is suggestive of autosomal dominant inheritance.

Prevention

* Prevention of dementia may become a reality as the etiologic factors for dementing disorders become more clearly identified.

* If the onset of dementia could be delayed by five years, the population prevalence could be reduced by one half. If delayed by 10 years, prevalence could decline by 75%.

* When clinical conditions that can lead to cognitive impairment are identified by clinical and laboratory assessment, appropriate treatment should be initiated, such as thyroid or vitamin [B.sub.12] replacement, and alcohol abstinence programs.

* The risk of dementia may be reduced by treating vascular risk factors, such as arterial hypertension, hypercholesterolemia, diabetes mellitus, and smoking, and by using prophylactic anticoagulation for chronic atrial fibrillation.

* Treating transient ischemic attacks and stroke may lower the risk of vascular dementia by the secondary prevention measures mentioned above and with anticoagulants, antiplatelets, and carotid endarterectomy.

* Epidemiologic studies have shown an association between AD and a lack of formal education (less than six years).

* Postmenopausal hormone replacement therapy may reduce the incidence of AD; however, current evidence does not support recommending estrogens solely for this purpose.

* The use of nonsteroidal anti-inflammatory drugs cannot be recommended for the treatment of prevention of AD.

* Head injuries have been suggested to increase the subsequent incidence of AD, therefore encouraging the use of seatbelts and bicycle helmets would be helpful in the primary prevention of dementia.

Ethical Issues

* The loss of insight, the declining capacity to make reasonable decisions and the risk to others have to be carefully balanced against preservation of autonomy.

* The participants recommend Tough Issues, published by the Alzheimer Society of Canada, as a helpful resource for caregivers and physicians who need to make decisions for dementia patients.

Disclosure of Diagnosis

* While each case should be considered individually, generally, the diagnosis of a dementing condition should be disclosed to the patient and family. This disclosure should include a discussion of prognosis, diagnostic uncertainty, advance planning, treatment options, support groups and future plans.

* Exceptions to disclosure to a patient would be severe dementia where understanding the diagnosis is unlikely, when a phobia about the condition is likely, or when a patient is severely depressed.

Driving and Dementia

* Clinicians should consider risks associated with driving when caring for patients with cognitive impairment.

* Performance-based evaluations of driving competence are preferable for accurate assessment, especially in uncertain cases.

* Focused medical assessments are recommended in addition to a general medical evaluation.

* Driving difficulties may indicate other cognitive/functional problems that need to be addressed.

* Clinicians should encourage AD patients and their caregivers to plan early for eventual cessation of driving privileges and offer continuing support for those who lose their ability to drive.

* Physicians should notify licensing bodies of their concern regarding competency to drive.

Caregiving

* Absence of a caregiver is a major predictor of earlier institutionalization of people with dementia as well as higher perceived caregiver burden.

* Up to 50% of caregivers experience significant psychiatric symptoms during caregiving.

* Clinicians should work with caregivers and families until the death of the patient.

* Clinicians should educate patients and families of the disease and how to cope with its manifestations.

* Caregiver coping strategies should be evaluated as well as psychiatric and health problems and stress reduction strategies.

* The caregiver's social support system should be assessed.

* Clinicians should refer caregivers to appropriate community services for dementia care.

* Physicians should discuss legal and financial issues with caregivers and families if required.

Cultural Issues

* Physicians need to be aware of the cultural impact on families' recognition and acceptance of dementia in a family member, and that more in-depth discussion about symptoms and the meaning of aging may be necessary.

* Physicians should be aware that measures of cognitive abilities could often overestimate cognitive impairment in many cultural and linguistic groups.

* The care and management of patients from specific cultural groups should take into account the risk of isolation, the importance of culturally appropriate services and special issues that occur in providing caregiver support.

Depression

* The prevalence of major depressive disorders in patients with dementia varies between 6% and 20%.

* Physicians should consider diagnosing depression when weeks of symptoms characteristic of depression, such as behavioral symptoms, weight and sleep changes, sadness, crying, suicidal statements, or excessive guilt are present.

* When depressive illness is refractory, the patient could be referred to a specialist, such as a geropsychiatrist.

* Depressive symptoms that are not part of a major affective disorder, severe dysthymia, or severe emotional lability, should be initially treated nonpharmacologically.

* A trial of antidepressants or mood stabilizers may be considered in patients with disturbing emotional lability or pathological laughing and crying.

Management of Behavioral Disturbances

* Behavioral and psychological problems occur in about 90% of all patients with dementia.

* Behavioral problems tend to occur later in patients with AD or VaD, however, they occur more frequently and earlier in ETD and Lewy Body Dementias.

* Assessment of behavioral problems should include a review of potential triggers, such as pain, intercurrent illness, and medications.

* Nonpharmacologic interventions are generally recommended first, such as light therapy, music, or pets.

* There is little evidence from randomized controlled trials that psychotropic medications are effective in demented patients.

* Neuroleptic agents seem to be modestly effective.

* Traditional neuroleptic agents have a high incidence of extrapyramidal side effects including Parkinsonism and tardive dyskinesia.

* Atypical neuroleptics, such as risperidone, olanzapine and quetiapine may offer advantages.

* Neuroleptics with marked anticholinergic effects such as chlorpromazine and thioridazine should be avoided.

* Several antidepressants, such as trazodone and the selective serotonin reuptake inhibitors have been recommended but trials are inconclusive.

* Benzodiazepines should be used cautiously in low doses.

* No medication controls wandering.

* An appropriate time of observation of the patient should occur before changing a therapeutic approach.

Pharmacotherapy

* Cognition-enhancing drugs may be used to try to halt or slow the course of dementia with respect to measurable cognitive and functional decline leading to institutionalization. They may improve memory and other cognitive functions, self-care abilities, behavioral abnormalities, and improve moods and quality of life for patients and caregivers.

* Donepezil is approved to treat mild to moderate AD.

* There is currently (March 1998) insufficient evidence to support the use of vitamin E for the treatment or prevention of AD.

* There is currently (March 1998) insufficient evidence to support using Ginkgo biloba to treat or prevent AD.

* Physicians should reevaluate patients every three months once pharmacotherapy begins.

* Records should be kept so that stabilization, improvement, or persisting deterioration in patients treated with anti-dementia drugs can be determined and so that continued treatment can be evaluated.

* Physicians should ask caregivers to keep a written record of personal impressions and historical data on the patient's daily performance.

* Physicians should be instructed through continuing medical education on the administration and interpretation of measures of functional activities and cognitive abilities.

Five Case Scenarios

In the same issue of the Canadian Medical Association Journal, five different scenarios were presented. Along with each example, recommendations for approach and management were discussed. This article highlights some of the conclusions of the conference and offers details of how physicians can incorporate these recommendations into their practices.

*The full text of this article is published in CMAJ: Canadian Consensus Conference on Dementia: a physician's guide to using the recommendations. Patterson CJ, Gauthier S, Bergman H, et al. CMAJ 1999;160:1738-42.

The following scenarios were presented:

Scenario 1: Early Dementia

A 78-year-old widow lives alone and expresses no complaints. Her daughter says that her mother is more forgetful, her behavior is repetitive, and that she displays instances of self-neglect.

Scenario 2: Early Behavioral Change

A 67-year-old man's behavior has changed over recent months. He is verbally and physically aggressive toward his wife. Although once considered polite he is now disinhibited, frequently insulting family members and visitors. His driving abilities have deteriorated. There is no history of psychiatric disturbance, headaches, or other neurological symptoms. The patient feels he has no problem.

Scenario 3: Early Hallucinations

An 83-year-old patient lives in a retirement home with his wife. He is in good physical health, even though he has a history of prostate carcinoma and became confused after transurethral radical prostatectomy done three years previously. He has visual hallucinations that occur almost daily. He accuses his wife of being unfaithful and feels the local newspaper is critical of his religious beliefs.

Scenario 4: Preventing Dementia

A 47-year-old woman previously treated for anxiety and depression is worried she is at risk for Alzheimer's disease since her 76-year-old mother has been diagnosed with the disease. She wants to be alerted to any means of prevention.

Scenario 5: Advanced Alzheimer's Disease

The patient described in scenario one is now 83 years old and living in a long-term care facility. She is totally disoriented as to time and place, and has no recognition of her daughter or other individuals. This lady is dependent in all basic daily activities and has urinary but not bowel incontinence. She is resistive to care and verbally abusive to staff and other residents.

(*.)Prepared by Elaine McLellan-Holm.