MENTAL HEALTH

Health Evidence Bulletins - Wales
Team Leader: Dr. Lyn Harris

Date of Completion: 4.6.98

DEMENTIA

This document is a supplement to, not a substitute for, professional skills and experience. Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation

The Statements The Evidence
3.1 Prevention and Promotion.
3.1a. The risk factors for vascular dementia are similar to those for stroke and the scope for prevention is therefore the samei.
See Cardiovascular Diseases bulletin in this seriesii.
i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
ii. See inside front cover.
3.1b. Some dementing illnesses such as Huntington’s Disease have a genetic cause and genetic counselling for families at risk should be availablei. i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
3.1c. Public education is an important area in preparing people to deal with issues associated with dementiai. i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
3.1d. The importance of aluminium exposure as a risk factor for Alzheimer's disease is still unknown. While one observational study suggests no significant relationship between aluminium intake (from food, water & medication)i, an earlier randomised trial of treatment with a metal ion binding compound, suggested that there may be a link ii.

i. Forster DP, Newens AJ, Kay DW, Edwardson JA. Risk factors in clinically diagnosed presenile dementia of the Alzheimer type: a case-control study in northern England. Journal of Epidemiology and Community Health 1995; 49: 253-258
(Type IV evidence - case control study)
ii. McLachlan DR, Fraser PE, Dalton AJ. Aluminium and the pathogenesis of Alzheimer’s disease: a summary of the evidence. Ciba Foundation Symposium. 1992. pp.87-98
(Type II evidence - randomised trial of treatment with desferrioxamine)

3.1e. Prolonged postmenopausal hormone replacement therapy (HRT) delays the onset and reduces the incidence of dementiai,ii.
For further information about HRT see the Cardiovascular Diseases, Cancers and Injury Prevention Bulletins in this seriesiii.
i. Tang M-X, Jacobs D, Stern Y et al. Effects of oestrogen during menopause on risk and age of onset of Alzheimers disease. Lancet 1996; 348: 429-432
(Type III evidence - cohort study)
ii. McNagny SE, Green RC. ACP Journal Club 1997; 126(1): 21. Commentary on the above.
iii. See inside front cover.

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3.2 Diagnosis and Assessment
3.2a. Early identification and referral to specialist services is to be encouraged at the stage when there is a possibility of beneficial intervention and multidisciplinary assessment teams should be utilisedi,ii. i. Costa PT, Williams TF, Somerfield M et al. Early identification of Alzheimers disease and related dementias. Quick reference guide for clinicians. Guide Number 19. Rockville: Agency for Health Care Policy and Research, November 1996
(Type V evidence - expert opinion)
ii. Bayer A, Rule J, Furnish S. Chapter 3.22 in Mental Health. A Technical Document produced by the Health Gain Panel of Review. pp. 318-349. Cardiff: Welsh Health Planning Forum, 1995
(Type V evidence - expert opinion)
3.2b. Simple mental state tests are adequate to provide diagnosis in primary care and routine investigation before referral is unwarranted. The probability of dementia was greatly reduced with normal serial 7s, 7-digit span, recall of three items or clock drawing (likelihood ratio, LR, 0.06-0.2). Abnormal clock drawing increased the likelihood of Alzheimer disease as distinguished from other dementias (LR, 3.7, 95% CI, 2.4-5.9) and normal drawing decreased the likelihood (LR, 0.03, CI, 0.01-0.07)i. i. Siu A.L. Screening for dementia and investigating its causes. Annals of Internal Medicine 1991; 115: 122-132
(Type I evidence - systematic review)
3.2c. Ready access to appropriate investigations should be available to patientsi. i. Bayer A, Rule J, Furnish S. Chapter 3.22 in Mental Health. A Technical Document produced by the Health Gain Panel of Review. pp. 318-349. Cardiff: Welsh Health Planning Forum, 1995
(Type V evidence - expert opinion)
3.2d. Reversible dementia is now very rare (<1%) and mostly metabolic, toxic, neurosurgical or psychiatric (depressive) in origin i. i. Weytingh M. D, Bossuyt P.M.M, Van Crevel H. Reversible Dementia. More than 10% or less than 1%. A quantitative review. Journal of Neurology 1995: 242: 466- 471
(Type IV evidence -meta analysis of observational studies)
3.2e. Appropriate training and education should be provided to professionals who care for patients with dementia as this is likely to be beneficiali. i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)

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3.3 Treatment and Care
3.3a. The following strategies are recommended for the care of patients with dementia i:
  • Early treatment of reversible dementia
  • Maintaining the physical health and fitness of patients
  • Appropriate drug treatment of associated psychosis

and ii:

  • Active management of acute illness
  • Local day and sitter support
  • Reminiscence techniques
  • Highly flexible respite care
  • Training in the management of wandering and unsafe behaviour
i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
ii. Bayer A, Rule J, Furnish S. Chapter 3.22 in Mental Health. A Technical Document produced by the Health Gain Panel of Review. pp. 318-349. Cardiff: Welsh Health Planning Forum, 1995
(Type V evidence - expert opinion)
3.3b. Behavioural management is likely to be beneficial i. One small study suggested that occupational therapy was of value for long-term geriatric patients with slight to moderate dementia ii. i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
ii. Bach D, Bach M, Bohmer F, Fruhwald T, Grilc B. Reactivating occupational therapy: a method to improve cognitive performance in geriatric patients. Age and Ageing 1995; 24: 222-226
(Type III evidence - prospective study of 44 patients.)
3.3c. Planning and design of patients' living environment is likely to be helpfuli. i. Bayer A, Rule J, Furnish S. Chapter 3.22 in Mental Health. A Technical Document produced by the Health Gain Panel of Review. pp. 318-349. Cardiff: Welsh Health Planning Forum, 1995
(Type V evidence - expert opinion)
3.3d. In a trial of dementia care in nursing homes, the A.G.E. dementia care program (Activities, Guidelines for psychotropic medications and Educational rounds) reduced the prevalence of behaviour disorders and the use of antipsychotic drugs and restraints i. i. Rovner BW, Steele CD, Shmuely Y, Folstein MF. A randomized trial of dementia care in nursing homes. Journal of the American Geriatric Society 1996; 44: 7-13
(Type II evidence - randomised controlled trial of 89 patients)

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3.3e. Formal reality orientation sessions and validation therapy are of uncertain valuei. i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
3.3f. Physical restraints should not be usedi. i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
3.4 Specific Drug Therapies
3.4a. Neuroleptics have a consistent modest effect in agitated patients. No drug takes precedencei. i. Schneider L S. Pollock V E et al. Meta-analysis of controlled trials of neuroleptic treatment. Journal of the American Geriatric Society 1990; 38 (5): 553-563
(Type I evidence - systematic review)
3.4b. Long term treatment with acetyl.l.carnitine may produce a deceleration in decline of patients with dementia i,ii. i. Spagnoli A, Lucca U, Menasce G. Long term acetyl.l.carnitine treatment in Alzheimer’s disease. Neurology 1991; 41: 1726-1732
(Type I evidence - systematic review)
ii. Kennedy JS, Whitehouse PJ. ACP Journal Club 1992; 116(3): 81. Commentary on the above
3.4c. The use of hydergine has not yet proven to be of benefit in the treatment of Alzheimers dementia but might be of some limited use in vascular dementiai,ii.
A systematic review is in preparationiii.
i. Schneider LS, Colin JT. Overview of trials of hydergine in dementia. Archives of Neurology. 1994; 51: 787-798
(Type I evidence - systematic review)
ii. Guida CV. ACP Journal Club 1995; 122(1): 17. Commentary on the above.
iii. Schneider et al. Efficacy of hydergine for dementia [Protocol]. Cochrane Database of Systematic Reviews, Cochrane Library 1998 Issue 2. Review in preparation
3.4d. There is no convincing evidence at present that nimodipine is a useful treatment for dementia but review is not yet completei. i. Qizilbash N, Lopez Arrieta J, Birks J. Nimodipine in the treatment of primary degenerative, mixed and vascular dementia. Cochrane Database of Systematic Reviews, Cochrane Library 1998 Issue 2
(Type I evidence - systematic review)

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3.4e. At this stage, the evidence does not support the use of piracetam in the treatment of people with dementia or cognitive impairment i. i. Flicker L, Grimley-Evans J. The efficacy of piracetam in patients with dementia or cognitive impairment. Cochrane Database of Systematic Reviews, Cochrane Library 1998 Issue 2
(Type I evidence - systematic review)
3.4f. Although the evidence for a beneficial effect of selegiline on patients with Alzheimer's disease is promising there is not yet enough evidence to recommend its use routinely in practicei. i. Birks J, Flicker L. The efficacy and safety of selegiline for the symptomatic treatment of Alzheimer's disease: a systematic review of the evidence. Cochrane Database of Systematic Reviews. Cochrane Library 1998 Issue 2
(Type I evidence - systematic review)
3.4g. A review provides no convincing evidence that high dose tacrine is a useful treatment for the symptoms of Alzheimers disease i. i. Qizilbash N, Birks J, Lopez Arrieta J, Lewington S, Szeto S. The efficacy of tacrine in Alzheimer’s disease. Cochrane Database of Systematic Reviews. Cochrane Library 1998 Issue 1
(Type I evidence - systematic review)
3.4h. Glycosaminoglycan was found to be superior to placebo in a multicentre double blind trial in the treatment of the earliest manifestations of a dementing process i. i. Ban TA, Morey LC, Fjetland OK et al. Early manifestations of dementing illness treatment with glycosaminoglycan polysulfate. Progress in Neuro-Psychopharmacology and Biological Psychiatry 1992; 16: 661-676
(Type II evidence - randomised controlled trial)
3.4i. Nicergoline is superior to placebo in treating multi-infarct dementia i. i. Herrmann WM, Stephan K, Gaede K, Apeceche M. A multicentre randomized double-blind study on the efficacy and safety of nicergoline in patients with multi-infarct dementia. Dementia and Geriatric Cognitive Disorders 1997; 8: 9-17
(Type II evidence - randomised controlled trial)
3.4 j. Further Cochrane reviews of drug therapies are in progress i,ii,iii. i. Rodriguez JL, Qizilbash N and Birks J. The efficacy of thiamine in Alzheimer's disease [Protocol]
ii. Harvey R, Kelly C. A systematic review of the evidence for the safety and efficacy of thioridazine in dementia [Protocol]
iii. Kaye JA et al. Vitamin E in the treatment of Alzheimer’s disease [Protocol]
Cochrane Database of Systematic Reviews. Cochrane Library 1998 Issue 2. Reviews in preparation.
3.4k. An initial randomised controlled trial suggested that donepezil probably produces an improvement corresponding to "turning the clock back" by 3-6 months (equivalent to a gain of about 0.05-0.08 QALYs) but that the benefits were small and the weight of evidence unconvincingi,ii
The results of further ongoing studies are awaited.
i. Rogers SL, Friedhoff LT . The Efficacy and Safety of Donepezil in patients with Alzheimers disease. Dementia 1996; 7: 293.
(Type II evidence - randomised controlled trial)
ii.
Bandolier 4 no. 40. 1997
(Type I evidence - Review of the above paper and two unpublished randomised controlled trials)
3.4l. Psychotherapeutic interventions are of little help to patients but may be of help to carers i. i. Roth AD, Fonagy P. What works for whom? A critical review of psychotherapy research. New York. Guilford Press 1996
(Type I evidence-systematic review)

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3.5 Rehabilitation and Continuing Care
3.5a. 24hr support services should be availablei. i. Melzer D, Hopkins S, Pencheon D, Brayne C, Williams R. Dementia. Chapter 16 in Health Care Needs Assessment. Volume 1. (Stevens A, Raftery J, eds.). Wessex Institute of Public Health Medicine. Oxford: Radcliffe Medical Press, 1994
(Type IV evidence - observational studies)
3.5b. Efforts to reduce carers stress are beneficial i. A programme of patient and caregiver training, with long-term follow-up, suggested statistically significant (but not huge) increases in survival and time spent at homeii.
A review is due sooniii.
i. Melzer D, Hopkins S, Pencheon D, Brayne C, Williams R. Dementia. Chapter 16 in Health Care Needs Assessment. Volume 1. (Stevens A, Raftery J, eds.). Wessex Institute of Public Health Medicine. Oxford: Radcliffe Medical Press, 1994
(Type IV evidence - observational studies)
ii. Brodaty H, Gresham M, Luscombe G. The Prince Henry Hospital dementia caregivers’ training programme. International Journal of Geriatric Psychiatry. 1997; 12: 183-192
(Type II evidence - randomised controlled trial of 96 patients)
iii. Thompson C, Thompson G. [Protocol]
Supporting Carers of people with Alzheimer’s type dementia-a review of the evidence of effectiveness. Cochrane Database of Systematic Reviews. Cochrane Library 1998 Issue 2. Review in preparation
3.5c. The following strategies are likely to be beneficial in the care of patients with dementiai:
  • Formal care planning with identified key workers
  • Maximising the use of remaining abilities
  • Regular reviews and continuing backup
  • Maintaining sufferer in the most appropriate place
  • Timely referral to new services to match changing services
  • Joint planning of care between health and social services and voluntary agencies
  • Advice to carers on financial and other services
  • Support to carers through pre and post-death grief
  • Provision of specialist services for younger sufferers
i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
3.6 Prognosis-Length of survival
3.6a. There is a clear relationship between severity of dementia and survival time.
The combination of wandering, falling and behavioural problems is associated with shorter survival i,ii.
i. Walsh JS, Welch G, Larson E.B. Survival of out patients with Alzheimers type dementia. Annals of Internal Medicine 1990; 113: 429-434
(Type III evidence - non-randomised interventional studies)
ii. Hirsch CH. ACP Journal Club 1991; 114(1): 21. Review of the above

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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk