DESK REVIEWS | 04.06.04. What areas are covered by standards, guidelines, and protocols?

DESK REVIEW | 04.06.04. What areas are covered by standards, guidelines, and protocols?

The guidelines describe risk factors, criteria, and methods for diagnosis, as well as the pharmacological and non-pharmacological management of dementia. They present some differences between Alzheimer’s dementia and vascular dementia. There are no guidelines of other types of dementia (for example, frontotemporal).

a) Alzheimer’s disease

Modifiable risk factors are identified: Depression, Physical inactivity, Hypertension, Obesity, Smoking, Low educational attainment, and Diabetes. And the non-modifiable: advanced age, first-degree family history, autosomal dominant gene presence of apolipoprotein allele E4.

b) Vascular dementia

It is mentioned that cardiovascular risk factors contribute to the development of vascular dementia, and these are classified as modifiable and non-modifiable.

Not modifiable: Age, sex, ethnic group (black, Hispanic, and Asian race), family history.

Modifiable: Hypertension, diabetes mellitus, hyperlipidemia, atrial fibrillation, smoking, obesity, carotid disease, homocysteinaemia.

a) Alzheimer’s disease

Various actions are recommended to improve the accuracy of the diagnosis, such as the following:

  1. Obtain a medical and family history of the individual, including a neuropsychiatric history and a history of changes in cognition and behaviour.
  2. Review of medications used that could affect cognition
  3. Ask family members and others close to you individually for changes in thinking or behaviour.
  4. Cognitive tests, neurological exam, and physical tests.
  5. Serological and neuroimaging tests (primarily to rule out other causes).

b) Vascular dementia

Patients at high risk for vascular cognitive impairment should be considered those who present the following risk factors: hypertension, age over 65, hyperlipidemia, diabetes mellitus, clinical evidence of cerebral vascular event, findings in neurodiagnostic images of cerebral vascular event and/or leukoencephalopathy, damage to other target organs (eye, kidney, heart), and patients with cognitive or functional changes that are clinically evident or reported during the completion of the clinical history.

General examinations are recommended in patients with suspected dementia, to exclude potentially reversible causes of dementia and for screening for comorbidities. As well as neuroimaging studies for the detection of vascular components.

It is recommended to differentiate between vascular dementia, Alzheimer’s disease or the co-existence of the two entities, using the Hachinski ischemia scale, in order to better identify treatment and prevention.

a) Alzheimer’s disease

Acetylcholinesterase inhibitor (ACE) therapy such as donepezil, rivastigmine and galantamine are described as drug treatment interventions. As well as the evaluation of the response to the global treatment of behavioural and psychological symptoms of dementia.

Non-pharmacological interventions are indicated: Structured Activities, Behavioural Therapy, Environmental Modifications, Social Contact, Sensory Stimulation and Relaxation.

The active participation of the caregiver is essential for the efficacy of non-pharmacological intervention programmes in patients with dementia.

Among the main comorbidities are depression and the recommendation of the use of antidepressants, preferably sertraline and citalopram.

b) Vascular dementia

Treatment for cardiovascular risk factors is recommended to prevent new events (secondary prevention) rather than to improve cognitive function[1].

The pharmacological treatment of behavioural and psychological symptoms of dementia will be used only in the presence of specific syndromes or that impact the patient’s quality of life or safety.

It is recommended that a multidisciplinary team should be formed for the comprehensive care of the patient. The intervention of personnel trained in geriatrics, psychiatry, neurology, nutrition, social work, physical, occupational and language therapy is suggested, depending on the case and institutional capacity. Rehabilitation strategies adapted to the mental and functional limitations, as well as the remaining cognitive skills of the individual, should be implemented and the needs and goals of patients and caregivers identified. Structured exercise programs, as well as recreational activities, are recommended to maintain functionality and mobility; improve quality of life and self-perception of well-being. However, there is no mention of carer support strategies.

[1] The recommendations are: maintain blood pressure less than 150/90 mmHg (in older adults), with diastolic pressure greater than 60-65 mmHg, adequate glycaemic control, lifestyle interventions, physical exercise, smoking cessation and when appropriate, treatment with platelet antiaggregant, statins and antihypertensive therapy.

For the patients with any kind of dementia, it is recommended to assess the progression of cognitive impairment at least every 3 months, given that a wide range of psychological and behavioural manifestations are presented in each patient. Therefore, it is recommended to recognise promptly the needs of the patient and family to refer the corresponding health personnel (geriatrician, neurologist, psychiatrist, neuropsychologist, nutritionist, occupational and physical therapist) to the second and third levels of care within an appropriate time frame.

No, the guideline does not mention this.

It is not mentioned in the clinical practice guidelines.

It is not mentioned in the clinical practice guidelines.

It is not mentioned in the clinical practice guidelines.

It is not mentioned in the clinical practice guidelines.