GPAC: Guidelines and Protocols Advisory Committee

Cognitive Impairment in the Elderly - Recognition, Diagnosis and Management

Effective Date: July 15, 2007

Summary | Flow Sheet | Patient Guide | Full Guideline in PDF

Recommendations and Topics

Scope

Summary Recommendation: Care Objectives

1. Recognition

Table 1: Clinical Features of Dementia, Depression and Delirium

2. Diagnosis

Table 2: Differential Diagnosis of Dementia

3. Diagnosis Disclosure

4. Practice Management

5. Driving

6. Self-Neglect, Neglect and Abuse

7. General Care and Support

8. Co-Morbid Conditions

9. Pharmacotherapy

Table 3: Starting dose and titration schedule of AChEIs

Table 4: Starting dose and titration schedule of memantine

10. Behavioural and Psychological Symptoms of Dementia (BPSD)

11. End-of-Life Care

12. Caregiver Support

13. Community Care, Mental Health and Specialty Services Resources

Rationale

List of Abbreviations

Resources

References

Sponsors

Appendices

Scope

This guideline summarizes current recommendations for recognition, diagnosis and longitudinal management of cognitive impairment and dementia in the elderly. Where the guideline refers to "people affected by dementia", this indicates not only the person with dementia but also the people in their "network of support".

Summary Recommendation: Care Objectives

The primary care objectives are to encourage early recognition and assessment of cognitive impairment and to support general practitioners in the development of a comprehensive care plan that includes the identification of community resources for the people affected by dementia. A summary is provided for this guideline and can be used as a worksheet in the physician's office.

Part I: Recognition and Diagnosis

Recommendation 1: Recognition

1. General population screening in asymptomatic individuals is not recommended at this time.
2. Cognitive impairment should be suspected when there is a history that suggests a decline in occupational, social or day-to-day functional status. This might be directly observed or reported by the patient, concerned family members, friends and/or caregivers.

   Symptoms of Cognitive Impairment

   • Asks the same question repeatedly
   • Cannot remember recent events
   • Cannot prepare any part of a meal or may forget that they have eaten
   • Forgets simple words, or forgets what certain objects are called
   • Gets lost in own neighbourhood and does not know how to get home
   • Dresses inappropriately (e.g. may wear summer clothing on a winter day)
   • Has trouble figuring out a bill, or cannot understand concepts such as birthdays
   • Repeatedly forgets where things were left; puts things in inappropriate places
   • Has mood swings for no apparent reason and especially without prior psychiatric history
   • Has dramatic personality changes; may become suspicious, withdrawn, apathetic, fearful, or inappropriately intrusive, overly familiar or disinhibited
   • Becomes very passive and requires prompting to become involved

   Adapted from the Alzheimer Society of Canada: www.alzheimer.ca

3. At presentation, differentiate, treat, and rule out remediable and/or contributory cause(s) of cognitive impairment such as thyroid disorders, hypercalcemia, alcohol dependence, etc. (Canadian Consensus Guideline). Dementia, delirium, depression and adverse drug effects are the main conditions to consider in the differential diagnosis of cognitive impairment (See Table 1).
4. Complete a comprehensive review of medication history (type, dosage and compliance for both prescription and over-the-counter). Any medication may be implicated.

Table 1: Clinical Features of Dementia, Depression and Delirium^a

(printable PDF)

Recommendation 2: Diagnosis

When delirium and depression have been treated and/or ruled out and cognitive impairment is still present, suspect dementia or mild cognitive impairment (MCI) as the underlying cause. It may be necessary to complete the diagnostic evaluation over a few visits.

1. History - Recognizing Signs of Dementia

In the diagnostic work-up of patients with suspected mild cognitive impairment or dementia, it is important to consider collateral information from family and caregivers.

Course of cognitive decline: Gradual and progressive (usually Alzheimer's disease [AD]); sudden or stepwise (stroke, or possibly VaD); rapid (consider prion disease)

Presence of day-to-day or intra-day fluctuations: Marked fluctuation in cognition or alertness may be a hallmark of Dementia with Lewy Bodies (DLB)

Presence of amnesia (impaired memory): Ask for examples of the patient's forgetfulness or disorientation

Presence of deficits in executive functions: Problem-solving, sequencing, multi-tasking, conceptualizing, mental flexibility, abstract thinking, etc.

Presence of language deficits: Difficulty finding words, loss of speech fluency, word substitutions, problems with verbal comprehension, etc.

Presence of agnosia (impairment of recognition of faces or objects): Not common as a presenting feature of dementia

Presence of apraxia (impairment of performing programmed motor tasks): Examples: playing an instrument, tying shoelaces or a tie, sewing or knitting

Presence of delusions: Examples: paranoid delusions such as irrational suspiciousness, concerns of infidelity, etc.

Presence of hallucinations: Vivid hallucinations are suggestive of DLB

Gait abnormalities: Arise later in AD; earlier in VaD, DLB and normal pressure hydrocephalus (NPH)

Urinary incontinence: If urinary and gait problems occur early in the course of cognitive impairment, consider NPH

Impaired instrumental activities of daily living: A prerequisite for the diagnosis of dementia Examples: can no longer perform job satisfactorily, unable to manage finances, trouble driving, cannot play bridge or keep score in golf, cannot cook from a recipe, unable to use public transit, etc.

Impaired basic activities of daily living: Declining ability to dress, toilet, groom, or attend to hygiene or nutrition

Other behavioural issues: Lack of initiative, apathy, irritability, anger, and social disengagement or behavioural disinhibition (inappropriately intrusive or over familiar)

2. Physical Exam

a. Identify medical conditions contributing to cognitive decline, and;
b. Identify neurologic abnormalities including localizing signs, extrapyramidal signs and ataxia.

3. Laboratory Tests

The following tests are recommended in the initial work up of suspected MCI or dementia:

• Complete blood count
• Serum electrolytes
• Serum calcium
• Serum glucose
• Thyroid Stimulating Hormone (TSH)
• B12*

*Observational studies suggest elevated total homocysteine levels are a risk factor for dementia and impaired cognitive function.^1,2 These effects may be mediated by impaired function of the B vitamins involved in homocysteine metabolism (B12, folate and B6). Current data from systematic reviews of randomized double blind trials, however, do not provide evidence of improvement in cognition or dementia with B12 treatment.³

Other tests may be added as indicated by clinical suspicion (e.g. Serological Test for Syphilis [STS], HIV, renal function tests, liver function test).

4. Neuroimaging^4,5

Neuroimaging (CT or MRI of head) is not routinely indicated but may be useful when:

• The patient is less than 60 years old
• The onset has been abrupt or the course of progression rapid
• There is a history of significant recent head injury
• The presentation is atypical or the diagnosis is uncertain
• There is a history of cancer
• There are new localizing neurological signs or symptoms
• Vascular dementia is suspected
• The patient is on anticoagulants or has a bleeding disorder
• There is a history of urinary incontinence and early presentation of gait disorder

5. Cognitive Testing

• Diagnostic criteria require that there should be objective evidence of a memory deficit to support the diagnosis.
• Perform an objective test of cognition such as the Standardized Mini Mental State Examination (SMMSE). While the normal range for SMMSE scores is 24-30, performance on this test must be interpreted along with the other information gathered such as sensory impairment, education attainment, language and cultural issues. Cognitive status indicated by the SMMSE is an important benchmark for following the course of cognitive impairment (Appendix C).
• Supplementary test to consider: Clock Drawing Test (Appendix D).

6. Working Diagnosis

Arriving at a specific dementia sub-type diagnosis will aid in treatment planning and counselling. Broader use of DSM-IV TR category of 'dementia due to multiple etiologies' is encouraged, with specification of the diseases contributing to the dementia routinely spelled out (Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia, 2006).⁵

The major clinical pathological subtypes of dementia are outlined in the list that follows, although mixed forms of dementia are common (e.g. Alzheimer's and VaD). Less common types of dementias, such as Traumatic Brain Injury (TBI), should be considered in the clinical context.

Table 2: Differential Diagnosis of Dementia

(printable PDF)

7. Mild Cognitive Impairment (MCI)

• A diagnosis of MCI is made when other causes of impaired cognition (e.g. anxiety, depression, delirium or substance abuse) have been excluded and the patient does not meet the criteria for a diagnosis of dementia either because they lack a second sphere of cognitive impairment or because their deficits are not significantly affecting their daily living.
• In cases where there is a suspicion of cognitive impairment or concern about the patient's cognitive status, and the SMMSE score is in the "normal range" (24-30), the MoCA⁶ is recommended [Appendix E] (Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia, 2006).⁵
• Patients with MCI may progress to dementia at a rate of 16% per year.⁷ Once identified, patients with MCI should be re-examined periodically (e.g. every 6 months) so that treatment and counselling can be offered and incident dementia can be identified.

8. Staging

Some clinicians stage AD using the Global Deterioration Scale (See Appendix F).

Recommendation 3: Diagnosis Disclosure

1. The disclosure of a diagnosis of dementia should be done as soon as possible, but can cause significant stress. The timing and extent of disclosure should be individualized and is best carried out over a few visits supported by referral to other support resources (see Patient/Caregiver Guide).
• In general, there are only a few exclusions to disclosure, including probable catastrophic reaction, severe depression or severe dementia
• Disclosure is facilitated through an initial open-ended approach, e.g. asking: "What do you think the change in your memory and thinking is due to?"
2. In setting up the visit for disclosure, consider patient privacy and ask whether the caregiver can be in attendance (the answer will be yes in most situations).
3. At the initial disclosure visit highlight:
• Dementia with dementia sub-type as a clinical diagnosis
• Anticipated prognosis
• Indicate that you will follow-up and provide ongoing support
• Provide the Patient/Caregiver Guide, discuss other support resources as appropriate
• Provide a schedule of visits and book the next visit
4. At follow-up visits discuss (at least every 6 months):
• Information needs and concerns
• Advance planning with respect to finances and patient preferences
• Safety planning
• Availability of education and support resources
5. Disclosure when mild cognitive impairment is diagnosed needs to be carefully considered. Monitoring until progression in the cognitive deficit is demonstrated may be reasonable, but disclosure of the diagnosis with information about the risk of progression to dementia may allow the person to better understand their situation and participate in monitoring for further cognitive decline or associated functional changes or depression.

Part II: Management of Dementia

Recommendation 4: Practice Management

1. Organizational interventions within a chronic disease management (CDM) approach that facilitate proactive care and support are integral to improving care for people with dementia. Physicians are encouraged to:
• Establish a disease register and recall patients for review in a timely manner
• Periodically reassess patients at planned visits dedicated solely to the care of dementia
• Organize and focus by use of a clinical action plan addressing dementia and co-morbid conditions (see optional Cognitive Impairment in the Elderly Flow Sheet, Appendix G)
• Establish a relationship with the person with dementia, family/caregivers and involve them as much as possible in setting goals and making decisions related to care and support
2. Consider referral to secondary services for the assessment of dementia in appropriate cases such as:
• Diagnostic uncertainty or atypical features
• Management issues that are difficult to resolve
• Risk of harm to self or others
• Request of family or caregivers
3. Involve allied health professionals in the care of the patient when indicated (e.g. Home and Community Care case managers, mental health teams, etc.).

Recommendation 5: Driving

1. After early cognitive deficits are first diagnosed, consider entering into a discussion with the affected patient about eventual driving cessation. Assist the affected driver to make the necessary lifestyle changes early and to cease driving by choice rather than by compulsion. Encourage patient to register with HandyDart, HandyPASS and TaxiSavers (see Resources section).
2. An individual's competence for driving should be assessed using both cognitive and non-cognitive criteria (e.g. other medical conditions and special sensory defects), and include collateral history about the individual's driving habits from observers. On cognitive testing, deficits in attention, visuospatial abilities and judgment may be predictors of driving risk. When doubt exists about a patient's driving competence, physicians should recommend a performance-based evaluation such as a re-exam road test by the Insurance Corporation of British Columbia (ICBC) or a driver fitness review through the Office of the Superintendent of Motor Vehicles.
3. In accordance with the BC Motor Vehicle Act, physicians are required to document patients under their care who have a condition incompatible with safe driving and to instruct these patients to stop driving. If the physician learns that the patient continues to drive despite this instruction, the physician is required to notify the Superintendent of Motor Vehicles (Motor Vehicle Act section 230, subsections 1-3).
4. Notwithstanding these minimum requirements, physicians may opt to notify the Superintendent of Motor Vehicles of any patient with a condition incompatible with safe driving.
5. When approached by friends or family members of individuals who may be driving unsafely due to a medical condition, but who do not attend a physician, those members of the public can be told to notify the Superintendent of Motor Vehicles of their concerns.

Recommendation 6: Self-Neglect, Neglect and Abuse

1. Physicians need to be aware of the potential risks for self-neglect, neglect and abuse by caregivers and others (financial or psychological abuse)
2. Refer to Home and Community Care or geriatric outreach teams (where they exist) in the health authorities. Also, Community Living BC has been designated under guardianship legislation to investigate situations of potential self-neglect, neglect and abuse
3. For more information from the Public Guardian and Trustee of BC, see the publication, Protecting Adults from Abuse, Neglect and Self-Neglect online at: www.trustee.bc.ca/reports_publications/

Recommendation 7: General Care and Support

Support patient functioning at the maximum level of independence appropriate for his/her cognitive and physical capabilities. For patients with early dementia who are still living in the community, it is important to identify the following issues and refer to support resources as appropriate:

1. Nutrition
• If the patient is living alone and is responsible for his or her own food preparation, weigh the patient regularly to monitor for weight loss
• Consider the use of meal support such as Meals on Wheels or pre-prepared frozen foods
2. Kitchen safety
• Enquire about kitchen mishaps such as fires or burned pots
• Consider having the stove disabled when the patient can no longer use it safely, especially if the patient is living in an apartment building
• The kitchen area should have a functioning smoke detector
• A family member or caregiver should ideally monitor the refrigerator for food safety
3. Medication management
• Strategies to improve medication safety and adherence should be explored such as the use of blister packaging or Dossette trays and caregiver supervision of medications
• Consider referral to Home and Community Care for medication monitoring
4. Hygiene
• Consider a bathing assistant or bath program (contact Home and Community Care)
5. Wandering
• The patient should always carry identification when out alone
• Consider an ID bracelet through the Safely Home® - Alzheimer Wandering Registry
  Web site: www.alzheimer.ca/english/safelyhome/about.htm
6. Socialization
• Patients with dementia living alone in the community may become socially withdrawn
• Consider referral to an adult day centre (contact Home and Community Care)
7. Legal issues
• As early as possible in the course of dementia, engage the patient in a discussion of advance planning issues
• Encourage the patient to have an up-to-date will, a financial representative, a health care proxy and some form of advance medical directive
• A Representation Agreement permits the patient to appoint both a financial representative and a health representative (guide available at www.trustee.bc.ca). A Power of Attorney (with an enduring clause) is the recommended legal document to appoint a financial representative
8. Other safety issues
• Consider other safety hazards, such as unsafe smoking, firearms in the home, etc.
• Lifeline or 911 stickers on the telephone

Recommendation 8: Co-Morbid Conditions

Address co-morbid conditions to prevent further unnecessary impairment of cognition in demented individuals. The underlying dementia has implications for management of other conditions, particularly with respect to tolerability and adherence to medication.

1. Cardiovascular disease
• Address vascular risk factors, including arterial hypertension, hypercholesterolemia, diabetes mellitus, smoking, obesity, use of anticoagulation for atrial fibrillation and primary/secondary prevention of transient ischemic attacks (TIAs) and stroke
2. Depression
• Mood symptoms are common in mild to moderate AD, but prevalence in advanced dementia is uncertain because recognition is more difficult
• Depression coincident with dementia may not present as depressed mood, but with lack of interest, which along with other depression symptoms such as apathy, anhedonia, insomnia and agitation must be distinguished from the dementia itself
• A high index of suspicion is required to detect depression in demented patients
• A therapeutic trial of an antidepressant may be required to diagnose depression
• Management includes: antidepressant, most often an SSRI, along with behavioural intervention, education and support for the caregivers
• For additional information, see GPAC guideline, Major Depression Disorder - Diagnosis and Management
3. Delirium
• People with dementia are more susceptible to delirium. Although the agitated type of delirium with hallucinations is more easily recognized, hypoactive delirium presenting with inattentiveness and somnolence is more common and difficult to recognize
• Approach delirium as a medical emergency due to the significant conditions that may cause the delirium, such as infections or CHF
• Review and optimize all medications as they commonly contribute to delirium

Recommendation 9: Pharmacotherapy

Acetylcholinesterase Inhibitors (AChEIs)

AChEIs include donepezil (Aricept^®), galantamine (Reminyl^®) and rivastigmine (Exelon^®). They are currently approved by Health Canada for the symptomatic treatment of mild to moderate dementia of the Alzheimer's type (AD). There is insufficient evidence to recommend them for MCI.⁵

• Earlier studies have demonstrated small to modest efficacy of AChEIs in cognitive and global outcome measures, while recent studies have included maintenance of activities of daily living and reduction of caregiver burden as outcomes. In a meta-analysis of studies with global outcomes (subjective assessment by clinician and/or caregiver of change overall), the number needed to treat (NNT) is 12 (3-6 months) for one additional patient to experience stabilization or improvement on global response.⁸ In the literature, there is little definitive evidence for duration of efficacy beyond two years.
• While some evidence suggests a role for AChEIs in the treatment of symptoms associated with severe AD and in other types dementias (VaD and DLB), ^9,10 the clinical meaningfulness of randomized controlled trial outcome measures is controversial and donepezil is the only AChEI currently approved by Health Canada for these indications.
• 8% more patients experience adverse events on AChEIs compared to placebo (number needed to harm [NNH] =12)

• Sleep disturbances (nightmares/abnormal dreams) and muscle/leg cramps may also be observed with donepezil. Slow titration of all three medications may reduce adverse events
• Attrition associated with AChEI treatment groups in clinical trials is greater (approximately 29%) due to adverse events than that of placebo groups (18%)^{8, 12}

Deciding on a trial of AChEIs:

• Do the patient/caregivers have enough clinical information to understand their present condition and prognosis, and have they been able to participate in the development of goals and realistic expectations for treatment?
• Is the patient a suitable candidate (consider the presence of serious co-morbidity and reduced life expectancy with dementia)?
• Is the patient likely able to take medications as prescribed (considering current supports and level of function)?

If a trial of AChEIs is initiated:

• Develop and implement a follow-up plan
• Caregivers may be asked to keep a written record of personal impressions, comment on adverse drug reactions, sleep disturbances etc., to support assessment
• After initiation of the medication, the initial visit schedule will be determined by the titration schedule (i.e. every 2-6 weeks until dose reached)
• A review for side effects should be carried out within the first 3 months, usually at the titration visit(s)
• Every 6 months, monitor for changes from baseline in stabilization or deterioration of cognition, function, behaviour and global assessment of change
• Use patient-specific information to inform reassessment of continued drug therapy
• Current literature is controversial with respect to adverse effects from discontinuing treatment

Table 3. Starting dose and titration schedule of AChEIs

(printable PDF)

Drug*	Starting Dose	Titration Period	Dose Increase Per Titration	Usual Effective Max Dose
donepezil	5 mg daily**	4-6 wks	5 mg daily	10 mg daily
rivastigmine	1.5 mg b.i.d.	2-4 wks	1.5 mg b.i.d.	3-6 mg b.i.d.
galantamine	8 mg ER daily	4-6 wks	8 mg ER daily	16 mg ER daily-24 mg ER daily

Potential Drug Interactions

Toxicity of donepezil and galantamine may be INCREASED by the concomitant use of cytochrome P450 inhibitors (e.g., paroxetine, erythromycin, prednisone, grapefruit juice and nefazodone). Effectiveness of donepezil and galantamine may be DECREASED by the concomitant use of cytochrome P450 inducers (e.g., carbamazepine, phenytoin and rifampin). Rivastigmine is mainly metabolized through hydrolysis; therefore cytochrome P450 drug interactions are not expected.

*AChEI cost approximately $5.00/day Adapted from Hsiung, G., Loy-English, I. BCMJ 2004;46(7):338-343
**Consider 2.5 mg daily in very frail patients

Strategies to Reduce Side Effects of AChEIs

1. Take AChEI with meals (specifically indicated for rivastigmine)
2. Use a longer titration period, temporarily reduce the dose or plan skipped doses
3. If above measures are ineffective, take anti-emetics for limited periods during the titration period e.g. domperidone (avoid OTC anti-emetics with their anti-cholinergic effects that can worsen cognition and/or cause delirium)
4. Avoid sleep disturbances with donepezil by morning dose administration
5. Consider another AChEI if the first is not tolerated (taper first agent over 1-2 weeks and start new agent at lowest possible dose). An alternate AChEI may be offered for issues of tolerability and adverse effects. There is insufficient evidence to recommend switching AChEIs due to ineffectiveness

Memantine (Ebixa^®): Health Canada has granted memantine a Notice of Compliance with Conditions as monotherapy or as adjunctive therapy with cholinesterase inhibitors for the symptomatic treatment of patients with moderate to severe Alzheimer's Disease. The product monograph advises against the use of memantine in patients with renal disease, cardiovascular disease and seizure disorders. Adverse effects of memantine may include: fatigue, pain, dizziness, constipation, anxiety and hallucinations.

Table 4. Starting dose and titration schedule of memantine

(printable PDF)

Drug	Starting Dose	Titration Period	Dose Increase Per Titration	Usual Effective Max Dose
memantine	5 mg	4 wks	5 mg	10 mg b.i.d.

Potential Drug Interactions

Major drug interactions associated with memantine include drugs which increase the pH in urine (e.g. carbonic anhydrase inhibitors). Exercise caution when prescribing memantine with other drugs which undergo renal tubular secretion. Dofetilide is considered a very severe risk, due to the potential for causing arrhythmias. The effects of dopamine agents will be increased when co-administrated with memantine.

Other Agents: Use of Ginkgo Biloba, Vitamin E, anti-inflammatory drugs (such as NSAIDs), estrogen and statins is not recommended. There is insufficient evidence of treatment efficacy and/or concerns have been raised about possible increased risk of negative health impacts.

Recommendation 10: Behavioural and Psychological Symptoms of Dementia (BPSD)

a. Symptoms

• Psychosis (hallucinations or delusions)
• Depression
• Anxiety
• Sleep disturbances
• Behavioural problems of aggression or agitation

b. Assessment

Upon symptom onset, establish an understanding of the origins of behaviours before developing a management strategy.

• Assess and treat medical conditions (consider the influence of pain, dysuria, dyspnea, abdominal discomfort and pruritus)
• Review and optimize current medications
• Assess and treat concurrent psychiatric conditions

c. Management

Treatment goals should include:

• Decreasing or removing the symptom(s) entirely while preserving maximal function
• Reducing caregiver burden

Potential Interventions

1. Environmental and behavioural modifications are recommended as first line management.
   • Identify and minimize environmental and behavioural precipitants (use record keeping by caregivers to identify potential triggers such as physical treatments, meal time, bathing and company)
2. Psychosocial interventions are recommended.
   • Offer psychosocial support and education for caregivers
   • Suggest activities such as music therapy, pet therapy, walking or other forms of light exercise
3. Pharmacotherapeutic interventions for BPSD:
   • Treat depression or anxiety with antidepressants
   • Treat sleep disorders when necessary with trazodone 25-75 mg at the hour of sleep
     (*Benzodiazepines are not recommended due to their high potential for adverse events such as confusion and falls)
   • Treat psychosis (hallucination or delusions) with antipsychotic medications only when the patient is particularly disturbed by these symptoms
   • Treat aggression or agitation with:
     • Cholinesterase inhibitors, or
     • Trazodone 25-50 mg does up to 200 mg a day, or
     • Antipsychotics: typical (Loxapine) or atypical (risperidone, olanzapine or quetiapine) only after environmental and psychosocial interventions have been considered, except in urgent situations

Exercise caution when prescribing antipsychotic medications.
All antipsychotics have side effects and a risk-benefit assessment
needs to be carefully adjudicated in each case.

Antipsychotic medications are only recommended when:

• Alternate therapies are inadequate on their own
• There is an unidentifiable risk of harm to the patient and others
• Symptoms are severe enough to cause suffering and distress

When using antipsychotics, initiate a careful trial of a low dose antipsychotic and slow upward titration (e.g. risperidone 0.125 mg in very frail patients with slow upward titration to 1.5 - 2 mg maximum a day). In patients with DLB and PDD, consider sensitivity to medication (e.g. increased risk of extrapyramidial side effects when using antipsychotics). Monitor the effects closely and review to determine whether a maintenance dose may be needed (it may be possible to discontinue maintenance dose over time).

• Atypical antipsychotics include: risperidone, quetiapine and olanzapine. Risperidone has been favoured as the most efficacious for agitation in dementia, but with modest outcomes. It is the only atypical antipsychotic approved for the short-term treatment of aggression or psychosis in patients with severe dementia.
• Atypical antipsychotics have been associated with severe adverse events such as increased risk of falls, cerebrovascular events* (stroke and transient ischemic attacks), and increased mortality in the elderly^†. While recent population based observational studies have shown that there is a similar risk of stroke, cerebrovascular events and drug-induced movement disorders with typical antipsychotics as with atypicals, reviews of randomized controlled trials indicate that atypical antipsychotics, at lower doses are associated with fewer extrapyramidal side effects and less somnolence than typical antipsychotics in the treatment of BPSD.^13-15

d. Follow-up

Once symptoms are controlled, regularly evaluate the need for continuing treatment (ongoing review for adverse events and effectiveness) and consider withdrawal of medication with close monitoring for re-emergence of symptoms.

Recommendation 11: End-of-Life Care

1. Review patient/family expectations for quality of life and intensity of care and support
2. Discuss initiation or revision of advance care planning with patient and family
3. Clarify specific care decisions pertaining to:
• Pain (commonly occurs in this phase of the life course). A high index of suspicion is necessary with agitation or other behavioural changes; may need a closely monitored therapeutic trial
• Nutrition and hydration
• Treatment of recurrent infections
• Provision for increased services at home
• Indications for transfer to hospital or to a higher level of care

Recommendation 12: Caregiver Support

Caregivers need to be well supported. Determine your capability to provide ongoing, regular support, and/or refer out to other agencies (See Recommendation 13 for working with community and health care services).

• Ask about the caregiver's needs, coping strategies, support system and burden
• Educate patients and caregivers about the disease and how to cope, including advance care planning (consider cultural context for understanding and acceptance of dementia; see Patient & Caregiver Guide)
• Coordination, communication and planning during transition between care environments
• Respite for caregivers including adult day centre referral for patient etc.

Recommendation 13: Community Care, Mental Health and Specialty Services Resources

1. Timely referral to the Alzheimer Society of BC (ASBC). The ASBC assists people with all types of dementia and their caregiver's particularly:
• People with early stage dementia
• Caregivers for people with dementia at any stage
  Note: Disclosure of the diagnosis or suspected diagnosis of dementia should occur before referral to ASBC
2. Ask the opinion of a dementia specialist (geriatrician, neurologist, psychiatrist) when diagnosis or management is problematic
3. Refer to Home and Community Care services in each of the Health Authorities for long-term case management, home support, home safety assessment, respite care, adult day care or transitions to alternate living situations
4. Refer to Community Mental Health Services for significant and complex mental health conditions affecting the health and care of the patient and caregiver

Rationale

Alzheimer's disease (AD) and related dementias are progressive, irreversible degenerative brain diseases that lead to a decline in memory and other cognitive functions sufficient to affect daily life in an alert person. AD is the most common type of dementia representing approximately 67% of all cases nationally. Examples of related dementias include: vascular dementia (VaD), mixed dementia (AD and VaD together), dementia with Lewy Bodies (DLB), fronto-temporal dementia, and Creutzfeldt-Jakob disease.¹⁶

It is estimated that AD and related dementias affect 8% of Canadians over the age of 65. Nationally, this translates to approximately 420,000 people. Pending a validated dementia registry in British Columbia, it is estimated that between 51,000 and 64,000 people are currently affected, approximately 41,000 of whom are female. Dementia prevalence is positively correlated with age. Historically, 2.4% of people age 65 to 74, 11.1% of people age 75 to 84, and 34.5% of those 85 years and older in Canada have some form of dementia. Ostbye and Crosse (1994) estimated the total annual net cost of dementia in Canada (health care and paid/unpaid caregiving) to be $3.9 billion.¹⁷ Based on this study, the Alzheimer Society of Canada recently updated this figure to $5.5 billion to reflect 2003 dollars.¹⁸

The current and projected burden of AD and related dementias has led the National Advisory Council on Aging and the Alzheimer Society of Canada to call for the development and implementation of a national strategy dealing with dementia. Their position paper outlines 30 recommendations which include increased research into the causes, prevention and treatment of progressive cognitive impairment, increased allocation of resources for long term care facilities, caregiver support and home care, increased physician training and education in AD and related dementias.

List of Abbreviations

Resources

DriveSafe
The BC Medical Association's Guide for Physicians in Determining Fitness to Drive a Motor Vehicle (with updates) can be accessed online at: www.drivesafe.com. This site contains a number of links to resources for physicians such as:

• British Columbia: Report a Medical Condition Affecting Fitness and Ability to Drive, MV2351, updated November 2003;
• AMA Physician's Guide to Assessing and Counselling Older Drivers

Drive ABLE Assessment Centres Inc.
For an assessment centre in your region, please call 1-877-433-1494 or go to: www.driveable.com or www.candrive.ca.

HandyDART is a door-to-door, share ride, custom transportation service. This service is for people who are unable to use the regular transit service some or all of the time due to mobility issues associated with a permanent or temporary physical or cognitive disability:
www.busonline.ca/regions/vic/accessible/handydart-plan-trip.cfm

TaxiSavers provides greater convenience for one-time trips when handyDART cannot accommodate your travel needs:
www.busonline.ca/regions/vic/accessible/taxi-saver-plan-trip.cfm

Community Living BC has been designated under guardianship legislation to investigate situations of potential self neglect, neglect and abuse: www.communityliving.bc.ca

Alzheimer Society of BC assists people with all types of dementia and their caregivers 1-800-667-3742 or go to: www.alzheimerbc.org

Alzheimer's Drug Therapy Initiative
All questions, clinical and administrative, can be directed to Health Insurance BC at 1-800-663-7100 or go to: www.health.gov.bc.ca/pharme/adti

References

1. Wright CB, Lee HS, Paik MC, et al. Total homocysteine and cognition in a tri-ethnic cohort: the Northern Manhattan Study. Neurology 2004;63:254-60.
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3. Malouf R, Areosa Sastre A. Vitamin B12 for cognition. Cochrane Database of Systematic Reviews 2003;(3):CD004326.
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Appendices

Appendix A: The Confusion Assessment Method (CAM) Diagnostic Algorithm

Appendix B: Geriatric Depression Scale (GDS)

Appendix C: Standardized Mini-Mental State Exam (SMMSE)

Appendix D: Clock Drawing Test

Appendix E: Montreal Cognitive Assessment (MoCA)

Appendix F: Global Deterioration Scale

Appendix G: Cognitive Impairment in the Elderly Flow Sheet (Optional)

Sponsors

This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission.

Revised Date: January 30, 2008

This guideline is based on scientific evidence current as of the effective date.

Disclaimer

The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.

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