New Consensus Guidelines on

Management of Dementia
7 May 2008
Symposium on the Changes & Challenges in Geriatric Care
Waterloo, Ontario
Michael Borrie, MB ChB, FRCPC
Aging Brain and Memory Clinic
Division of Geriatric Medicine, UWO
Parkwood Site, St. Josephs Health Care

Disclosure Statement
Research Support
CIHR
Alzheimer Society Canada
Physician Services Incorporated
Lawson Health Research Institute
Consultant and CME Programs
Pfizer
Janssen-Ortho
Novartis
Lundbeck

Clinical Trials Funding

Purdue-Pharma
Neotherapeutics
HMR
Pharmacia
Boehringer-Ingelheim
Sanofi-Synthelabo
Myriad Pharmaceuticals
ONO Pharma USA
Neurochem
Elan
Elan/Wyeth

Objectives
Using case scenarios, review and discuss relevant
guidelines from the 3rd Canadian Consensus Conference
on Diagnosis and Treatment of Dementia, March 2006.

3rd Canadian Consensus Conference on

Diagnosis and Treatment of Dementia
CCCDTD3
March 9-11, 2006. Montreal
Specialists & Family Physicians.
140 guidelines.
Translation of Research to practice.
Clinical scenarios to illustrate how guidelines can
inform practice.

Criteria for assigning levels of evidence

Level Criteria

1. Evidence obtained from at least 1 properly randomized controlled

trial.
2a.Evidence obtained from well-designed controlled trials without
randomization.
2b.Evidence obtained from well-designed cohort or case-control
analytic studies, preferably from more than 1 centre or
research group.
2c. Evidence obtained from comparisons between times or places
with or without the intervention. Dramatic results in
uncontrolled experiments are included in this category.
3. Opinions of respected authorities, based on clinical experience,
descriptive studies or reports of expert committees.

Grades of recommendations
Grade

Criteria

A.

There is good evidence to support this manuvre.

B.

There is fair evidence to support this manuvre.

C.

There is insufficient evidence to recommend for or

against this manuvre, but recommendations may
be made on other grounds.

D.

There is fair evidence to recommend against this

procedure.

E.

There is good evidence to recommend against this

procedure.

Spectrum of Cognitive Decline

Super Normal
no deterioration
from young
Age-consistent loss
average for age
Mild Cognitive Impairment
1.5 SD > Normal of age
and education matched
controls
Dementia

Adapted from Chertkow & Murtha, 1998

MCI

SergeGauthier,2001

Recommendations for the General Criteria for Mild

Cognitive Impairment Consensus Report 2004
Not normal, not demented (Does not meet criteria (DSM IV,
ICD 10) for a dementia syndrome)
Cognitive decline
Self and/or informant report and impairment on objective
cognitive tasks
and/or
Evidence of decline over time on objective cognitive tasks
Preserved basic activities of daily living / minimal impairment
in complex instrumental functions
Winblad B, Palmer K, Kivipelto M et al. Mild cognitive impairment beyond controversies,
towards a consensus report of the International Working Group on Mild Cognitive Impairment.
Journal of Internal Medicine 2004;256:240-246

Diagnostic Criteria for Dementia of the

Alzheimers Type (DSM IV)
1) The development of multiple cognitive deficits manifested by both
1) memory impairment, and 2) one or more of the following
cognitive disturbances:

Language disturbance (Aphasia)

Impaired ability to carry out motor behaviours despite intact

motor function (Apraxia)

Failure to recognize or identify objects (Agnosia)

Disturbance in planning, organizing, sequencing, abstracting

(Executive Functioning)
2) Cognitive deficits cause significant impairment in social or
occupational functioning
3) Gradual onset and continual decline
4) Cognitive deficits are not due to a) other CNS conditions, b) other
Systemic conditions known to cause dementia, c) substance
induced dementia, d) delirium, and e) another primary
psychiatric disorder

Types of Dementia
Alzheimers (AD)
Gradual on-set of memory and functional loss

Vascular Dementia (VaD)

Step wise decline of memory and functional loss
Often occurring 3 months or so after a stroke

Mixed Dementia (AD + VaD)

Now the most common form of dementia
When AD and VaD (cerebrovascular disease) co-exist
Reference: Patterson C, et al. The recognition, assessment and management of dementing disorders:
Conclusions from the Canadian Consensus Conference in Dementia. Can J Neurol Sci. 2001;28(Suppl. 1): S3-S16.

Types (continued)
Fronto-temporal Dementia (FTD)
The mirror image of AD with pronounced behaviour
problems initially and memory problems later

Lewy Body Dementia (LBD)

Hallucinations (visual)
Parkinson-like symptoms
Fluctuations in level of consciousness

MEMORY
trials.

Read list of words, subject

must repeat them. Do 2

FACE

VELVET

CHURCH

DAISY

RED

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Dementia Risk Factors

Age
Family history
Vascular risk factors
High blood pressure
Diabetes
Smoking
Obesity
High Cholesterol
Atrial Fibrillation
Low education
Head injury/concussion

The Doubling Rule (Think 2) For Dementia Risk

< 65
65
70
75
80
85

=
=
=
=
=
=

1%
2%
4%
8%
16%
32%

* Risk Doubles every 5

years

The Doubling Rule (Think 2) For Dementia Risk

< 65
65
70
75
80
85

=
=
=
=
=
=

1%
2%
4%
8%
16%
32%

* Risk Doubles every 5

years
* But each additional risk
factor approximately doubles
the risk
* Positive family history
doubles the risk

CS #2
75 year old woman, retired secretary, grade 12 education
- Sudden confusion with slurred speech for 1 hour,
5 years ago
- Forgetting names, 3 years
- gradually worse.
- Falls x 3 (2 trips) in last 12 months
- gait slower and less certain (cane), 6 months

CS #2
Collateral History spouse and daughter
- gradual progression since onset.
- stopped driving 1 month ago. Getting disoriented & ran a red
light
- purchasing several unneeded grocery items, 1 year
- cooking quality changed
- forgetting medications
Past History
- High blood pressure,
- Diabetes,
- Elevated cholesterol,
- Atrial Fibrillation,

15 years, on meds
10 years, on meds
5 years, on meds
3 years, on meds

P/S no alcohol, no smoking

- less energy. No initiative. Depressed?

1 year

Is this history suggestion of:

Mild cognitive impairment?

White

Dementia?

Black

Unsure

Red

CS #2
Examination
- Weight 160 lbs, Height 52, BP 160/90 sitting and standing
- MMSE 25/30 0/3 delayed recall, date, place
- MOCA 17/30, 0/5 delayed recall, modified Trails B, cube,
clock, abstraction 0/2, fluency, serial 7s, date, day
- Geriatric Depression Scale 4/15
- Cornell for depression 10/38
- Diabetes HB A1C .078
- Gait slightly wide-based, unpredictable steps to right,
improved with cane. Knee pain sit to stand
- Knee reflexes brisk, more on the right Babinski flexor right
& left
- hip flexion strength 4/5 right & left

Clinically, is the dementia likely due to:

Alzheimer disease (AD)?

White

Vascular dementia (VaD)?

Black

Mixed AD/VaD?

Blue

Unsure

Red

CS #2
Clinical Impression
1.
2.
3.
4.
5.

Dementia Mild. Mixed (AD VaD).

Early OA knees
Quadriceps weakness
Vascular risk factors
Depressive symptoms

CCCDTD3 Recommendations

Should this person and their family be referred to

the Alzheimer Society?
Yes

White

No

Black

Unsure

Red

CS#2 Recommendations
T5 #1a - All patients with dementia and their families who consent
should be referred to the local chapter of the Alzheimer Society
(eg: First Link program where available); and
T5 #1b - Primary care physicians should be aware of the
resources available for the care of those with dementia in their
community (eg: support groups, adult day program) and to
make appropriate referrals to them. (GB, L3)

Should the diagnosis of dementia be disclosed to

the person and their family?
Yes

White

No

Black

Unsure

Red

CS #2 Ethico-legal recommendations
T5 #6a Although each case should be considered individually, in
general, the diagnosis of dementia should be disclosed to the
patient and family. This process should include a discussion of
prognosis, diagnostic uncertainty, advance planning, driving
issues, treatment options, support groups, and future plans. (GB,
L3)
T5 #6b Primary care physicians should be aware of the
pertinent laws in their jurisdiction about informed consent, the
assessment of capacity, the identification of a surrogate decisionmaker, and the responsibilities of physicians in these matters.
(GB, L3)
T5 #6c While patients with AD (dementia) retain capacity, they
should be encouraged to update their will and to enact both an
advance directive and an enduring power of attorney. (GB, L3)

CS#2 Recommendations
Other therapeutic interventions
T7 #2 Investigations for vascular risk factors. It is recommended
that vascular risk factors are identified in all patients with vascular
cognitive impairment. (GC, L3)
T7 #3 Treating hypertension. There is some evidence that
treating hypertension may prevent further cognitive decline
associated with cerebrovascular disease. There is no compelling
evidence that one class of agent is superior to another; calcium
channel blockers or ACE-inhibitors may be considered (Grade B,
Level I). Treatment for hypertension should be implemented for
other reasons, including the prevention of recurrent stroke. (GA,
LI)

In a person with mild dementia, will cognitive

training/rehab improve and/or maintain cognitive
and or function performance?
Yes

White

No

Black

Unsure

Red

CS #2 Recommendations non-pharmacological
therapy in Mild AD
T5 #7a There is insufficient evidence to come to any firm
conclusions about the effectiveness of cognitive training/cognitive
rehabilitation in improvement and/or maintaining cognitive and/or
functional performance in persons with mild to moderate
dementia. (GC, L1)

Could an individualized exercise program have an

impact on functional performance?
Yes

White

No

Black

Unsure

Red

CS #2 Recommendations non-pharmacological
therapy in Mild AD
T5 #7d - There is good evidence to indicate that
individualized exercise programs have an impact
on functional performance in persons with mild to
moderate dementia. (GA, L1)

Should a cholinesterase inhibitor be prescribed?

Yes

White

No

Black

Unsure

Red

CS#2 Recommendations Use of

cholinesterase inhibitors
T7 #7 - Use of cholinesterase inhibitors in dementia due
to combined Alzheimers and Cerebrovascular
Disease: There is fair evidence of benefits of small
magnitude for Galantamine in cognitive, functional,
behavioural and global measures in AD with CVD.
Galantamine can be considered a treatment option
for mixed Alzheimers with Cerebrovascular Disease.
(GB, LI)

Should neuroimaging be requested?

Yes

White

No

Black

Unsure

Red

T3 Structural neuroimaging #2 - There is fair

evidence to support use of structural
neuroimaging to rule in concomitant
cerebrovascular disease that can affect patient
management. (GB, L2)

CS #2
Plan

Alzheimer Society referral

Caregiver education
Control/monitor vascular risk factors. BP,
cholesterol
Weight loss
Exercise program
Head CT/MRI scan
Symptomatic treatment of dementia
Depressive symptoms non drug approaches
- medications?

CS #4
78-year-old retired truck driver/grade 10 education
a bit forgetful, just old age 1 year
- Collateral hx. Wife.
- Repeating stories and questions 3 yrs
- Gave up woodworking 2 yrs not interested
- Not as handy about house 1 yr
- Difficulty reassembling lawn mower 2 mths ago
- More irritable, easily angered at other drivers 1 yr
- Rolling stops 1 yr
- Late to pick up grandson from school x 3 - 2 mths

CS#4
Past History
- 2 yrs ago, confused after prostate surgery
- Diabetes diet only 5 yrs
P/S
- Alcohol 2-4 beers at the Legion 1 x /week-drives
- Smoker 40 pk yrs, stopped at age 60
Medication
Acetaminophen 1 gram 3x/day (sometimes forgets it)
Examination
- Weight 220 lbs, Height 59
- BP 130/80
- Osteoarthritis in hips and knees
- Normal neurological exam

Could this man have:

Mild cognitive impairment?

White

Dementia, probable Alzheimer Disease? Black

Vascular Dementia?

Blue

Unsure

Red

CS#4
MMSE 23/30 (1/3 recall, 3/5 world, day, date, place)
MoCA 16/30 (0/5 recall, trails, hands on clock,
fluency, abstraction, date, 7s)
Geriatric Depression Scale 0/15
Cornell 2/38 irritability
Fasting glucose 12, N<7
Hb A1C 0.074, N<0.06

What do you think the diagnosis is now?

Mild cognitive impairment?

White

Dementia, probable Alzheimer Disease? Black

Vascular Dementia?

Blue

Unsure

Red

CS#4
Clinical Impression
Alzheimer Disease mild
Over weight
Diabetes
Still driving
Drinking while driving

CCCDTD3 Recommendations

CS#4 Recommendations
T5 #1b Primary care physicians should be aware of the
resources available for the care of those with dementia in their
community (eg, support groups, adult day programs) and to make
appropriate referrals to them. (GB, L3)
T3 #3 - Mild Alzheimers disease can be diagnosed with a high
degree of specificity, when the presenting clinical picture is one of
memory impairment (GB, L1)
T5 #7d - There is good evidence to indicate that individualized
exercise programs have an impact on functional performance in
persons with mild to moderate dementia (GA, L1).

Should a cholinesterase inhibitor be prescribed?

Yes

White

No

Black

Unsure

Red

CS#4 Recommendations on cholinesterase inhibitors

T5 #14a - All three cholinesterase inhibitors available in Canada
are modestly efficacious for mild to moderate AD. They are all
viable treatment option for most patients with mild to moderate
AD. (GA, LI)
T5 #14b While all three cholinesterase inhibitors available in
Canada have efficacy for mild to moderate AD, equivalency has
not been established in direct comparisons. Selection of which
agent to be used will be based on adverse effect profile, ease of
use, familiarity, and benefits about the importance of the
differences between the agents in their pharmacokinetics and
other mechanisms of action. (GB, L1)

CS#4 Recommendations
Neuropsychology testing
T3 Neuropsych #6 - The diagnosis and differential
diagnosis of dementia is currently a clinically integrative
one. Neuropsychological testing alone cannot be used for
this purpose and should be used selectively in clinical
settings (GB, L3)

Should people and their families be counselled about

eventually giving up driving?
Yes

White

No

Black

Unsure

Red

Does an abnormal score on the MMSE mean a person

should not drive?
Yes

White

No

Black

Unsure

Red

CS#4 Driving Recommendations

T5 #25a Clinicians should counsel persons with a
progressive dementia (and their families) that giving up
driving will be an inevitable consequence of their
disease. Strategies to ease this transition should occur
early in the clinical course of the disease. (GB, L2)
T5 #25b - No single brief cognitive test (e.g. MMSE) or
combination of brief cognitive tests has sufficient
sensitivity or specificity to be used as a sole determinant
of driving ability. Abnormalities on cognitive tests such as
the MMSE, clock drawing and Trails B should result in
further in-depth testing of driving ability. (GB, L2)

People with cognitive impairment and impaired

instrumental activities of daily living should stop
driving.
Yes

White

No

Black

Unsure

Red

T5 #25c - Driving is contraindicated in persons

who, for cognitive reasons, have an inability to
independently perform multiple instrumental
activities of daily living (e.g. medication
management, banking, shopping, telephone use
cooking) or any of the basic activities of daily living
(e.g. toileting, dressing). (GB, L3)
T5 #25d - The driving ability of persons with earlier
stages of dementia should be tested on an
individual basis (GB, L3)

An on-road driving assessment is the best method

of driving assessment.
Yes

White

No

Black

Unsure

Red

CS#4 Driving Recommendations

T5 #25e - A health professional-based comprehensive off and onroad driving evaluation is the fairest method of individual testing
(GB, L3)
T5 #25f - In places where comprehensive off and on-road driving
evaluations are not available, clinicians must rely on their own
judgment. (GB, L3)
T5 #25g - For persons deemed safe to drive, reassessment of
their ability to drive should take place every 6-12 months. (GB, L3)
T5 #25h - Compensatory strategies are not appropriate for those
deemed unsafe to drive. (GB, L3)

CS#4 Plan
1.
2.
3.
4.
5.
6.
7.
8.

First link Alzheimer Society/CCAC

Nutritional counselling
Weight loss
Exercise
Oral meds for diabetes?
Driving testing DriveABLE
Lipid profile
EC ASA 81mg

Summary
1.

Identify Mild Cognitive Impairment early by

listening to concerns about memory loss (patient and
caregiver).

2.

Follow memory impairment with a sensitive measure

MoCA.

3.

Address vascular risk factors and depressive symptoms.

4.

Treat symptoms of dementia (except FTD) with

cholinesterase inhibitors.

5.

Begin discussion about driving early and assessment with

on-road assessment.