DESK REVIEWS | 04.06. Clinical guidelines, standards, and protocols for dementia

DESK REVIEW | 04.06. Clinical guidelines, standards, and protocols for dementia

Yes. There is a “Clinical Protocol of Therapeutic Guidelines” (Protocolo Clínico de Diretrizes Terapêuticas – PCDT) about Alzheimer’s Disease”. It guides health professionals and the population on the diagnosis and treatment of Alzheimer’s Disease (Brazilian Ministry of Health, 2017c). There is also a “Technical-Scientific Opinion” (Parecer Técnico-Científico) about the prevention of Alzheimer’s Disease (Valle, 2013), the “recommendations for diagnosing Alzheimer’s disease in Brazil” (Nitrini et al., 2005), and “recommendations in Alzheimer” (Brucki & Schultz, 2011).

References:

Brazilian Ministry of Health. (2017c). PCDT Alzheimer. Brazilian Ministry of Health.

Brucki, S. M. D., & Schultz, R. (2011). Manual de recomendações da ABN em Alzheimer-2011. 5. https://neurologiahu.ufsc.br/files/2012/08/Manual-de-recomendações-da-ABN-em-Alzheimer-2011.pdf

Nitrini, R., Caramelli, P., Damasceno, B. P., Brucki, S. M. D., & Anghinah, R. (2005). Diagnóstico de Doença de Alzheimer no Brasil. Avaliação cognitiva e funcional. Arq Neuropsiquiatr, 8.

Valle, E. A. (2013). Parecer Técnico-Científico: Prevenção da demência.

The Indian Psychiatric Society (IPS) published Clinical Practice Guidelines (CPGs) for the management of dementia in 2007 and revised this in 2018 (Grover and Avasthi, 2017). In addition, the Diagnostic and Statistical Manual of Mental Disorders-5th edition (DSM-5) and the International Classification of Diseases-11th revision (ICD-11) guidelines for dementia are followed by healthcare professionals in India.

References:

Grover, S., and Avasthi, A. (2017). Indian Psychiatric Society Survey on Clinical Practice Guidelines. Indian Journal of Psychiatry, 59(5), 10. https://doi.org/10.4103/0019-5545.196971

 

There is a clinical guide-book on dementia, which has been published by the Association of Neurologists in Indonesia (Perhimpunan Dokter Spesialis Saraf Indonesia (PERDOSSI)) in 2015. The book contains guidelines, protocols, and recommendations for all types of healthcare facilities (PERDOSSI, 2015).

References:

PERDOSSI. (2015). Panduan Praktik Klinik: Diagnosis dan Penatalaksanaan Demensia. PERDOSSI.

There are currently no national or sub-national online accessible documents on standards, guidelines or protocols specific to dementia in Kenya. The national government has published clinical guidelines for management and referral of the following mental disorders: psychosis, alcohol withdrawal syndrome, substance use, anxiety, PTSD, psychosexual disorders, depression, bipolar disorder, schizophrenia, sleep disorders, and suicides (Crouch, 2009; Management & Guidelines, 2009). None of these documents mention dementia explicitly at primary care or hospital level.

References:

Crouch, M. (2009). Clinical Management and Referral Guidelines Volume II: Clinical Guidelines for Management and Referral of Common Conditions at Levels 2–3: Primary Care. Ministry of Medical Services and Ministry of Public Health and Sanitation. Nairobi, Kenya. 282–289. http://publications.universalhealth2030.org/uploads/clinical_guidelines_vol_ii_final.pdf

Management & Guidelines (2009). Levels 4–6 – Hospitals i.

Three clinical practice guidelines have been developed in Mexico in relation to dementia and cognitive impairment:

  1. Diagnosis and Treatment of Alzheimer’s Disease. Evidence and Recommendations Guide: Clinical Practice Guide. Updated in 2017 (CENETEC, 2017).
  2. Clinical Practice Guide Diagnosis and treatment of vascular dementia in adults in the three levels of care, updated in 2017 (Secretaría de Salud, 2017).
  3. Guide to Clinical Practice, Diagnosis and Treatment of Cognitive Impairment in the Elderly in the First Level of Care, Mexico, updated in 2012 (Secretaría de Salud, 2012).
References:

CENETEC. (2017). Diagnóstico y Tratamiento de la Enfermedad de Alzheimer. Guía de Evidencias y Recomendaciones: Guía de Práctica Clínica. Guia de Practica Clinica. http://www.cenetec-difusion.com/CMGPC/IMSS-393-10/RR.pdf

Secretaría de Salud. (2012). Guía de Práctica y Tratamiento del Deterioro Cognostivo en el Adulto Mayor en el Primer Nivel de Atención. In CENETEC (Vol. 1).

Secretaría de Salud. (2017). Guía de Práctica Clínica Diagnóstico y Tratamiento de demencia vascular en el adulto en los tres niveles de atención.

The South African Society of Psychiatrists (SASOP) has developed guidelines for treatment of a range of psychiatric disorders and has dedicated a chapter on Dementia. This document refers to the country’s private healthcare settings and provides guidelines for (a) the diagnosis, clinical characteristics, and course of the disease; (b) the assessment and differential diagnosis; as well as (c) treatment goals with clinical guidelines for the pharmacological and non-pharmacological treatment of dementia (Emsley et al., 2013, p.141-152). Many who rely on public healthcare do not have access to many of the pharmacological treatments recommended by these guidelines (Emsley et al., 2013) as the public sector is characterised by constrained and limited resources and lack of specialist treatments and approaches particular to dementia.

In the public sector, there are also Standard Treatment Guidelines available from the National Department of Health that provide guidelines for the treatment of dementia and focuses primarily on pharmacological/medicine treatment (National Department of Health, 2020).

South Africa has a National Strategic plan for nurse education, training and practice (DOH, 2016), and approved competencies for nursing to provide care throughout the lifespan. However, these are not dementia-specific and support generic models for care at hospitals and other facilities.

References:

DOH. (2016). The National Strategic Plan for Nurse Education, Training and Practice.

Emsley, R., & Seedat, S. (2013). The South African Society of Psychiatrists (SASOP) treatment guidelines for psychiatric disorders. South African Journal of Psychiatry, 19(3), 127–196. https://doi.org/10.4102/sajpsychiatry.v19i3.942

National Department of Health. (2020). Primary healthcare Standard Treatment Guidelines And Essential Medicines List (7th ed). Available from: https://www.knowledgehub.org.za/elibrary/primary-healthcare-standard-treatment-guidelines-and-essential-medicines-list-7th-edition

The existing one is national.

The PERDOSSI guideline is used as a reference by all neurologists practicing in Indonesia, thus, it can be considered a national guideline. To date (27 February 2020), no national guideline on dementia has been issued by the government.

The guidelines are developed by the Ministry of Health, through the National Centre of Technological Excellence in Health (CENETEC), which is a government dependence body whose objective is to provide information based on the best available evidence for appropriate decision-making on health technologies in health services in Mexico, through advice, coordination of sectoral efforts and the generation, integration and dissemination of information.

These guidelines are developed by the SASOP, to be utilised nationally by practicing psychiatrists within the private sector only.

The Clinical Protocol of Therapeutic Guidelines was approved by the government, it was developed by the Ministry of Health.

The PERDOSSI guideline was not issued by the government, but nationally accepted as it was issued by a professional organisation operating under the country’s legal framework.

The guidelines are developed, approved, and disseminated by the Ministry of Health, and are supported by the main institutions that are part of the national health system, such as IMSS, ISSSTE, PEMEX, DIF, as well as other health institutions at the national level.

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.

Yes, see p.150 of Emsley et al., (2013).

 References:

Emsley, R., & Seedat, S. (2013). The South African Society of Psychiatrists (SASOP) treatment guidelines for psychiatric disorders. South African Journal of Psychiatry, 19(3), 127–196. https://doi.org/10.4102/sajpsychiatry.v19i3.942

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.

Yes, see p.143 of Emsley et al., (2013).

References:

Emsley, R., & Seedat, S. (2013). The South African Society of Psychiatrists (SASOP) treatment guidelines for psychiatric disorders. South African Journal of Psychiatry, 19(3), 127–196. https://doi.org/10.4102/sajpsychiatry.v19i3.942

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.

Yes, see p.145-150 of Emsley et al., (2013) for pharmacological and non-pharmacological treatments.

References:

Emsley, R., & Seedat, S. (2013). The South African Society of Psychiatrists (SASOP) treatment guidelines for psychiatric disorders. South African Journal of Psychiatry, 19(3), 127–196. https://doi.org/10.4102/sajpsychiatry.v19i3.942

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.

The SASOP guideline briefly mentions accommodation and level of supervision required after diagnosis and refers the reader to seek support from primary care facilities, social clubs, senior centres, day-care and respite-care centres, as well as the NGO sector (Emsley et al., 2013). However, there is no mention in the SASOP guideline of information regarding questions 04.06.04.05-04.06.04.08 below. The Department of Health Standard treatment guidelines at hospital level mentions family counselling and support in a one-line statement under general measures and provide guideline for medication in palliative care generally (not dementia-specific) (DOH, 2018; Maartens et al., 2015).

References:

DOH. (2018). Standard Treatment Guidelines And Essential Medicines List for South Africa: Primary healthcare level. https://doi.org/10.1017/CBO9781107415324.004

Emsley, R., & Seedat, S. (2013). The South African Society of Psychiatrists (SASOP) treatment guidelines for psychiatric disorders. South African Journal of Psychiatry, 19(3), 127–196. https://doi.org/10.4102/sajpsychiatry.v19i3.942

Maartens, G., Benson, F., Blockman, M., Clark, C., Bamford, L., Bera, R., Brits, H., & Dheda, M. (2015). Standard Treatment Guidelines and Essential Medicines List for South Africa: Hospital Level. Available from: https://extranet.who.int/ncdccs/Data/ZAF_D1aia_Hospital%20level%20(Adult)%202015.pdf

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.

The “Clinical Protocol of Therapeutic Guidelines about Alzheimer’s Disease” was developed in 2017 by the Ministry of Health (Brazilian Ministry of Health, 2017c).

Prior to this, the Brazilian Academy of Neurology published consensus papers regarding the diagnosis and treatment of Alzheimer’s disease, such as the “recommendations for diagnosing Alzheimer’s disease in Brazil”, developed in 2005, and the “recommendations in Alzheimer” developed in 2011.

References:

Brazilian Ministry of Health. (2017c). PCDT Alzheimer. Brazilian Ministry of Health.

The clinical practice guideline was developed by Indonesia’s Neurologist Association (PERDOSSI) in 2015 (PERDOSSI, 2015).

References:

PERDOSSI. (2015). Panduan Praktik Klinik: Diagnosis dan Penatalaksanaan Demensia. PERDOSSI.

The clinical practice guides are developed mainly in the Ministry of Health, through the National Centre of Technological Excellence in Health (CENETEC). Their updating depends on the identification and evaluation of new evidence, the opinion of experts, as well as the opinion of the team that developed the guide, the perception of users, and the analysis of the context. As there is no defined time to update it, it will rather depend on these points, as well as on the resources, the availability of time, the methodology used, as well as the collaboration of the institutions involved (Secretaría de Salud, 2015a).

References:

Secretaría de Salud. (2015a). Metodología para la integración de Guías de Práctica Clínica en el Sistema Nacional de Salud.

The private sector guidelines discussed above were developed by the South African Society of Psychiatrists (SASOP) and published in 2013.

These guidelines are evidence-based and mainly developed by healthcare professionals (clinicians and managers). Although specialists and members of public may contribute for their development, once finalised, these documents are not widely available to the public. Thus, many people, including doctors (especially those working in the private sector) do not know about the existence of these guidelines.

No information on this in the guideline (PERDOSSI, 2015).

References:

PERDOSSI. (2015). Panduan Praktik Klinik: Diagnosis dan Penatalaksanaan Demensia. PERDOSSI.

 

In general terms, it is proposed that the use of clinical practice guidelines should be a national reference to favour clinical and managerial decision-making based on recommendations supported by the best available evidence, aiming to reduce the variability of clinical practice, as well as the use of unnecessary or ineffective interventions, to facilitate the treatment of patients with the maximum benefit, with a lower risk and an acceptable cost (CENETEC, 2016).

References:

CENETEC. (2016). Dirección de integración de Guías de Práctica Clìnica. CENETEC. http://www.cenetec.salud.gob.mx/contenidos/gpc/dir_gpc.html

 

These guidelines currently refer to the private healthcare setting in South Africa with the expectation that various stakeholders (and hopefully policy makers and administrators) will make use of them. Practitioners are expected to use guidelines with caution and continue to be critical of approaches, maintaining their own level of expertise and keeping abreast of developments of evidence-based approaches within the field (Emsley et al., 2013).

References:

Emsley, R., & Seedat, S. (2013). The South African Society of Psychiatrists (SASOP) treatment guidelines for psychiatric disorders. South African Journal of Psychiatry, 19(3), 127–196. https://doi.org/10.4102/sajpsychiatry.v19i3.942

Yes, but mainly in rural and remote areas.

Mexico has a strong history of use of traditional medicine, based on different needs or services: pregnancy and deliveries, bone-healers, traditional medics. These traditions are a mix of pre-Hispanic indigenous cultures and beliefs, as well as the use of local herbs, remedies, etc., and the practices brought by the Spanish which have been widely documented (Lozoya X & Zolla, 1984). These practices are different between states and regions and their prevalence of use is highly correlated with higher percentage of rural population/localities, some of them presenting a wide diversity of “remedies”. For example, one of the first studies of traditional medicine practices in the State of Chiapas (southeast of the country) documented the use of 206 plants for a huge diversity of ailments and diseases such as stomach ache, burns, cough, wounds, head ache, tuberculosis, diabetes, diuretics, empacho (colloquial for indigestion) or verguenza (literal translation, shame) (Lozoya X & Zolla, 1984). Since these first studies, many more have documented the use of alternative or complementary medicine use in the country. Notwithstanding the fact that most likely some “remedies” are being used to manage or treat symptoms of dementia like memory loss, no information or published studies are identified on the use of these alternative practices to treat or manage dementia.

References:

Lozoya X, & Zolla C. (1984). Medicina Tradicional en México. Boletín de La Oficina Sanitaria Panamericana (OSP), 96(4). https://iris.paho.org/bitstream/handle/10665.2/17007/v96n4p360.pdf?sequence=1&isAllowed=y

South Africa is a multi-cultural country with a myriad of beliefs and practices. The use of traditional medicine and healers is a socially accepted practice amongst some cultures in the country, with the belief that the cause of some conditions/diseases/misfortune (especially mental, emotional and neurological conditions) is social (Mkhonto & Hanssen, 2018). Traditional healers are believed to be able to diagnose and treat conditions caused by social misconduct, spirits, spells and witchcraft where biomedicine is unable to ‘identify’ and treat (Audet et al., 2017). Traditional healers speak the local languages of the person seeking help, they often live within close proximity, they are easily available for consultation and they are believed to spend more time explaining diagnoses, causes and treatments to patients – hence preferred over mainstream biomedical approaches or used in conjunction with bio-medicine (Audet et al., 2017). A review of studies on plants used to treat Alzheimer’s disease in South Africa has found the following plants used to treat memory loss in the form of aqueous or ethanol extracts (Stafford et al., 2008), (see p. 533 for more detail):

  • Malva parviflora (leaves),
  • Boophone disticha (L.f.) Herb. (leaves and bulbs),
  • Albizia adianthifolia (Schumach.) W. Wright (stem bark),
  • Albizia suluensis Gerstner (root bark) and
  • Crinum moorei f. (bulbs) for acetylcholinesterase (AChE) inhibitory activity.
References:

Audet, C. M., Ngobeni, S., Graves, E., & Wagner, R. G. (2017). Mixed methods inquiry into traditional healers’ treatment of mental, neurological and substance abuse disorders in rural South Africa. PLoS ONE, 12(2), 1–14. https://doi.org/10.1371/journal.pone.0188433

Mkhonto, F., & Hanssen, I. (2018). When people with dementia are perceived as witches. Consequences for patients and nurse education in South Africa. Journal of Clinical Nursing, 27(1–2), e169–e176. https://doi.org/10.1111/jocn.13909

Stafford, G. I., Pedersen, M. E., van Staden, J., & Jäger, A. K. (2008). Review on plants with CNS-effects used in traditional South African medicine against mental diseases. Journal of Ethnopharmacology, 119(3), 513–537. https://doi.org/10.1016/j.jep.2008.08.010

Natural medicines are used by the population, although there is no evidence of their effect. Some of them are:  ginkgo biloba, selegiline, vitamin E, and omega 3 (Brazilian Alzheimer’s Association, 2019). Faith healers are not widely used in Brazil for treating and managing dementia, in some cases, sporadic prayer groups may exist for that aim.

References:

Brazilian Alzheimer’s Association. (2019). ABRAZ. ABRAZ. https://abraz.org.br/2020/

As previously mentioned, traditional medicine is widely used. No studies are yet available/published on its particular use for dementia and its related symptoms.

Natural medicines are communicated by “word of mouth” and can be purchased in pharmacies or natural products stores without prescription. Traditional/Faith healers are not common in Brazil, but there are the so called ‘benzedeiras’ (blessers), who were common in the past, and generally prescribe teas or pray for someone who is ill.

Subjectively, the use of traditional medicine and spiritual healers seems to be quite popular among the general public. Pratono & Maharani (2018) report the preference of many older people in the Malang Regency of consulting traditional medicine/healers as opposed to modern healthcare providers, although this work did not specifically focus on dementia. There has been no information on how traditional or alternative medicine for dementia are communicated or how the patients access them. However, other study on traditional medicine for other health problems reported that most patients find the information about it from family (33.3%), friends (25%), religious group (22.2%), mass media (16.7%), and neighbours (2.7%) (Devy & Aji, 2006).

References:

Devy, S. R., & Aji, B. (2006). Faktor Predisposing, Enabling dan Reinforcing pada Pasien di Pengobatan Alternatif Radiesthesi Medik Metode Romo H. Loogman di Purworejo Jawa Tengah. Indonesian Journal of Public Health, 3(2), 35–44.

Pratono, A. H., & Maharani, A. (2018). Long-Term Care in Indonesia: The Role of Integrated Service Post for Elderly. Journal of Aging and Health, 30(10), 1556–1573. https://doi.org/10.1177/0898264318794732