Clinical practice guidelines for management of dementia

INTRODUCTION Indian Psychiatric Society (IPS) published Clinical Practice Guidelines (CPGs) for management of dementia, in the year 2007. (http://www.indianjpsychiatry.org/cpg2007.asp). The current version of the CPG is an update of the earlier version of CPGs for management of dementia There were three separate CPGs for management of dementia, one each for Reversible Dementias, Alzheimer's Disease and Vascular Dementia, Please note that the present CPG on dementia deals all types of dementia together. The current version of the CPGs for dementia in elderly must be read in conjunction with the previous version of CPGs for dementia. The focus of the present CPG is to provide suggestions and clinical tips to differentiate dementia syndrome from other clinical conditions, identify the subtypes of dementia and then offer suggestions for management. These guidelines only provide a broad framework for assessment, management and follow-up of older people with dementia. While most of the recommendations are evidence based, these guidelines should not be considered as a substitute of professional knowledge and clinical judgment. The recommendations made as part of these guidelines should be tailored to address the clinical needs of the individual patient and the treatment setting. AGING, DEPRESSION AND DEMENTIA Before we examine the management of dementia, let us look at the issues related to the clinical diagnosis of dementia. Mental health problems and disablement are frequent in late life. Dementia and depression are two major mental health problems in late life. It is well known that the prevalence of dementia increases steadily with age. Normal aging itself is associated with age related decline in cognitive functions. Depressive symptoms are more common in later years of life. The differentiation between depressive disorder and a cognitive disorder can be problematic in this age group. There are many symptoms which can be seen in both in depressive disorders as well as in cognitive disorders. Depression can co-exist with mild cognitive impairment (MCI) a condition which is being increasingly recognized as an important entity. MILD COGNITIVE IMPAIRMENT AND DEMENTIA Mild cognitive impairment (MCI) is a controversial entity but remains a useful construct in terms of targeting interventions to prevent dementia. MCI detection relies largely on subjective memory complaint (SMC) as a presenting symptom. However SMC is heterogeneous in its etiology and poorly predicts medium-term dementia risk. The differentiation of early dementia from MCI depends on the level of cognitive impairment and the resultant disability. Cognitive impairment in dementia causes significant impairment in instrumental activities of daily living and this is known to increase with time. Most diagnostic criteria use the resultant disability as an important differentiating feature. However reliance on informant reports can be problematic as that could be influenced by the social context, expectations of the informant and his or her ability to know and the current level of functioning of the older person. DEMENTIA SYNDROME Dementia is a syndrome due to disease of the brain, usually chronic, characterized by a progressive, global deterioration in intellect including memory, learning, orientation, language, comprehension and judgment. It mainly affects older people, after the age of 65 years. Then onwards, the prevalence doubles with every five year increment in age. Dementia is one of the major causes of disability in late-life. People with dementia have difficulty in living independently and have difficulties in social and occupational functioning. The disabilities progress with the severity of dementia Cognitive changes that are part of normal aging process has to be differentiated from the dementia syndrome. This is difficult in early stages of dementia. Age related changes are more frequent in those who are in their eighties and nineties. Propensity to develop transient cognitive problems like delirium increases with age and in the presence of cognitive impairment Evaluation of cognitive symptoms Cognitive symptoms can be due to many conditions and dementia is only one of them. Delineation of the syndrome of dementia and differentiating it from other cognitive disorders is the first task. Other assessments can then follow. The suggested assessments are best carried out as part of the initial evaluation though it might take a few sessions to complete. See table -1.Table 1: Assessment for dementiaThe following assessments will help in making a clinical diagnosis of dementia : See the flow chart below. History of Cognitive Changes History taking is the main tool in eliciting and evaluating the nature and progression of cognitive decline. Choose an informant who knows about the person's current and past personal, social and occupational functioning. A reliable informant should be interviewed separately in person. This will allow discussion of a certain information which may otherwise be difficult in the presence of the patient. While doing the assessments, one has to be mindful of the family's culture, values, primary language, literacy level and also the decision making process. A thorough history should include details like the mode of onset of cognitive decline which affects multiple cognitive domains. The pattern progression, clinical manifestations of cognitive dysfunction, behavioral as well as personality changes will have to be enquired into. Subjects or informants can be asked if the person is forgetful about recent events; especially amnesia for events which happened hours or days back. Does the person forget the fact that he/she had a meal some time after having the meal? Does the person tend to ask the same questions repeatedly even though this was answered many times. Is the person unable to recall where they’ve placed things and often searching for things? A review of current medication is very important. Enquire if is of cognitive symptoms after of a certain the use of all including may be See if the person is on with which can cognitive functions. of of is an important diagnosis of dementia. with dementia could present for the first time with of cognitive and of symptoms should the to the of is a that needs to be early and A diagnosis of dementia be made if the cognitive the of is characterized by a of and a in that develop a of time. The disorder has a to the of the and is evidence from the or that the delirium is a of a or The diagnostic criteria for is AND of of of the with ability to or of by impairment of recall and recent memory, with in or person. one of the following from to or flow of of or the by at one of the which in may with or or of the of and which may as or after onset and of the symptoms the of the evidence from and or of an or disease that can be to be for the clinical manifestations in causes of those with to and or should take not to as Dementia and also not to the diagnosis of it is on dementia. is clinical of the should focus on the in older people are most often in etiology and of the conditions us to provide interventions to them. 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The differentiating are history of cognitive decline which has onset to the of symptoms the presence of significant impairment in multiple cognitive on clinical This is is of from it could be difficult symptoms have onset after the age of years and also in where it is difficult to cognitive due to could also who after many years of with onset or present with cognitive decline and clinical of dementia. an diagnosis of dementia can be made from the diagnosis of the mental health See for some clinical of with in the between Dementia and Mild Cognitive The differentiation between early dementia and mild cognitive impairment can be difficult at but to that is the Mild to to this not have The following criteria may be as a for clinical diagnosis of Mild Cognitive criteria for Mild Cognitive of cognitive decline from a previous level of in one or more cognitive and memory, language, or social of the a or the that has a mild decline in cognitive and A impairment in cognitive by in its clinical The cognitive not with for in activities instrumental activities of daily living as or are but or may be The cognitive not in the of a The cognitive are not by mental disorder major depressive or other behavioral symptoms The diagnostic in MCI is in the of impairment in which is for the diagnosis of dementia. 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