APA Releases Updated Guidelines for Treating Patients With Dementia

Marlene Busko
December 14, 2007 — The American Psychiatric Association (APA) has released a second edition of practice guidelines to assist psychiatrists caring for patients with Alzheimer's disease and other dementias. These guidelines update the original ones issued in 1997, and include stronger clinical evidence and useful insights.
The guidelines are published as a supplement to the December issue of the American Journal of Psychiatry.
"Stronger Evidence, Worth Reading"
"I think that we have been able to strengthen many of the recommendations that were made, because there have been a number of confirming studies," Peter V. Rabins, MD, of Johns Hopkins University School of Medicine, in Baltimore, Maryland, and chair of the guideline's work group, told Medscape Psychiatry. "There's really nothing new. It's just that the evidence is stronger."
"The bottom line is that there isn't really that much new," echoed David Knopman, MD, of the Mayo Clinic, in Rochester, Minnesota, and a member of the American Academy of Neurology, in a comment to Medscape Psychiatry. "I didn't see, nor would I expect to see, any earthshaking proposed changes in practice." It is a well-written document, he added. "It would be well worth the time to read through it, as it does touch on a number of issues regarding diagnosis and treatment in a thoughtful and well-written manner."
New Developments in Past Decade
In the 10 years since the initial guidelines were issued, new drugs have become available, and some of the evidence backing earlier recommendations has been strengthened, said Dr. Rabins.
"First, on the positive side, we now have 3 cholinesterase inhibitors approved by the Food and Drug Administration for the treatment of Alzheimer's disease, as well as memantine (Namenda, Forest Pharmaceuticals, Inc.), a drug from a new class," he elaborated.
Second, there is better evidence that nonpharmacologic intervention targeting the patient's emotional well being is beneficial. Third, there is stronger evidence that pharmacologic treatment of depression in patients with Alzheimer's disease is clearly better than placebo. Fourth, new evidence shows that providing caregivers with education and emotional support benefits them and the patient, he added.
"On the less positive side, we've withdrawn the recommendation for using vitamin E as a treatment for Alzheimer's disease, primarily because there have been no new studies to support its benefit, and health risks have been associated with high doses," he continued.
Also, in the past 2 years it has become clear that all antipsychotic drugs — both typical and atypical ones — confer an increased mortality risk on people with dementia.
Important Change: Limit Antipsychotics
For patients who have neuropsychiatric symptoms, such as agitation, delusion, hallucinations, and aggression, there is stronger evidence that nondrug treatment should be tried first, and that real efforts should be made to limit the use of antipsychotics in all settings — at home and in the long-term-care setting. "That is the most important way the guidelines will change practice," he noted.
"I think that real efforts need to be made to make sure that when antipsychotics are prescribed, they are both necessary and effective; when they are not effective, they should be discontinued," he added.
Formulating and Implementing a Treatment Plan
The 55-page guidelines include an executive summary in which recommendations are coded according to 3 levels of degree of clinical evidence. This section summarizes treatment recommendations for cognitive symptoms, psychosis, agitation, depression, and sleep disturbances, and also discusses psychotherapies, psychiatric management, treatments for elderly patients, and special issues for long-term care.
The section that follows this is an extensive guide for developing and implementing a stage-specific treatment plan for the individual patient. The last section details specific clinical features influencing the treatment plan.
Between January 2003 and December 2006, Dr. Rabins received speaking fees from AstraZeneca, Janssen, Eli Lilly and Company, Forest Pharmaceuticals, Inc., and Wyeth Pharmaceuticals. Financial disclosures for the other members of the work group are listed in the practice guideline. The Executive Committee on Practice Guidelines has reviewed the guidelines and found no evidence of influence from these relationships.