Managing severe Alzheimer disease: what are the evidence-based guidelines?

This summary is based on the guidelines published by the Canadian Medical Association (CMA): Diagnosis and treatment of dementia: 6. Management of severe Alzheimer disease. The article was retrieved from the CMA Infobase: Clinical Practice Guidelines Database (CPGs)

Access the article here (PDF)

Context

The management of severe Alzheimer disease often presents difficult choices for clinicians and families. The disease is characterized by a need for full-time care and assistance with basic activities of daily living. The authors outline an evidence-based approach for these choices based on recommendations from the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia.

The authors developed evidence-based guidelines using systematic literature searches, with specific criteria for the selection and quality assessment of articles, and a clear and transparent decision-making process. The authors selected articles published between January 1996 to December 2005 that dealt with the management of severe Alzheimer disease. Subsequent to the conference, the authors searched for additional articles published from January 2006 to March 2008 using the same search terms. The authors graded the strength of the evidence using the criteria of the Canadian Task Force on Preventive Health Care.

Key Messages

• The authors identified 940 articles, of which 838 were selected for further study. Thirty-four articles were judged to be of at least good or fair quality and were used to generate 17 recommendations.
• Assessment of severe Alzheimer disease should include the measurement of cognitive function and the assessment of behaviour, function, medical status, nutrition, safety and caregiver status.
• Management could include treatment with a cholinesterase inhibitor or memantine, or both. Treatment of neuropsychiatric symptoms begins with nonpharmacologic approaches to addressing behavioural problems.
• Severe agitation, aggression and psychosis, which are potentially dangerous to the patient, the caregiver and others in the environment, can be treated with atypical antipsychotics, with consideration of their increased risk of cerebrovascular events and death. 
• All pharmacologic approaches require careful monitoring and periodic reassessment to determine whether continued treatment is necessary. Caregiver support and use of community resources are essential.

Clinical Interpretation

• Severe Alzheimer disease requires frequent monitoring by health professionals. Simple nonpharmacologic approaches may address problems with mood and agitation.
• Antipsychotic drug therapy is occasionally necessary despite the inherent risks. Therapy with a cholinesterase inhibitor and memantine may be useful for selected patients.