Background

It is estimated that there will be over 8 million people with dementia in the United States by the year 2030.

The American Academy of Neurology recently released a series of practice guidelines reviewing current evidence related to the diagnosis and treatment of different

Diagnosis

The diagnosis of dementia of the Alzheimer's type should rely on the criteria published in the DSM-III-R or the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) scales.

There are no good laboratory tests to make the diagnosis of Alzheimer's disease, and there are no genetic markers recommended for routine use in the diagnosis.

Creutzfeldt-Jakob disease should be considered in the presence of rapidly progressive dementia. The cerebrospinal fluid 14-3-3 protein assay is useful for confirming the diagnosis of Creutzfeldt-Jakob. The 14-3-3 protein immunoassay has a sensitivity of 96% in patients who have not had a stroke within 1 month of specimen collection.

Noncontrast CT or MRI is useful in routine initial evaluations of patients with dementia to exclude a structural etiology for patients' mental status change.

PET imaging and/or linear or volumetric MRI or CT are not recommended for routine use.

Patients with dementia should be screened for [B.sub.12] deficiency and for hypothyroidism. Unless the patient is at significant risk, screening for syphilis is not justified in all patients. Patients with dementia should be assessed for depression and treated appropriately Depression is a comorbidity in at least 10% of patients with dementia.

Management

* Cholinesterase inhibitors (tacrine, donepezil, rivastigmine, and galantamine) should be considered in patients with mild to moderate Alzheimer's disease, although studies suggest a small average degree of benefit. Side effects are common with these agents and require discontinuation of therapy in 25% or more of patients. Tacrine elevates liver enzymes in as many as 30% of patients.

Evidence-based trials are lacking for the pharmacologic treatment of patients with multi-infarct dementia.

* Hydergine had no effects in Alzheimer's patients at 3 mg/day and did not meet benefit standards at 6 mg/day. Its use for Alzheimer's disease is not supported by current evidence.

* Vitamin E 1,000 IU b.i.d. by mouth should be considered in an attempt to slow progression of Alzheimer's disease and selegiline 5 mg b.i.d. by mouth is an alternative agent. These drugs should not be combined in therapeutic regimens.

* Estrogen should not be prescribed to treat Alzheimer's disease.

There is insufficient evidence to support the prescription of anti-inflammatories or other disease modifying agents for Alzheimer's disease.

Although strong evidence is lacking, some patients with unspecified dementia have benefited from Gingko biloba.

Antipsychotics are useful in the treatment of patients with dementia who suffer from agitation or psychosis when environmental manipulation fails.

Depression in patients with dementia can be treated with selected tricyclics, MAO-B inhibitors, and selective serotonin reuptake inhibitor medications.

A variety of environmental nonpharmacologic interventions such as behavior modification for toileting, positive reinforcement, and environmental information (lighting, music, nature sounds) can be useful to improve the functional performance of patients with dementia.

Educating family caregivers can improve household satisfaction and delay time to nursing home placement. Targeted education of long-term-care staff can reduce the use of antipsychotic medication. Patients with dementia may have fewer behavioral problems when exposed to music or mild exercise.

Dr. William E. Golden is director of general internal medicine and Dr. Robert H. Hopkins is associate director of the medicine/pediatrics residency program at the University of Arkansas. Write to Dr. Hopkins and Dr. Golden at our editorial offices.

References

D.S. Knopman et al. Practice parameter: diagnosis of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 56(9):1143-53, 2001.

R.S. Doody et al. Practice parameter: management of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 56(9):1154-66, 2001.