• The Review Course in Family Medicine

Recommendations of the 5th Canadian Consensus Conference on the diagnosis and treatment of dementia

Updated: Jul 14





The Canadian Consensus Conferences on the Diagnosis and Treatment of Dementia

(CCCDTD) brings us new evidence-based RECOMMENDATIONS FOR CLINICAL PRACTICE.


1) Utility of framework… NIA-AA (National Institute on Aging) research framework proposes BIOLOGICAL DEFINITION of Alzheimer’s disease based on amyloid beta deposition, tau accumulation, and neurodegeneration (ATN) and NOT based on signs/symptoms.

2) Updating diagnostic criteria and treatment…

  • MRI preferrable to CT

  • STANDARDIZED CRITERIA recommended for diagnosis of VCI and vascular dementia

  • Identify and TREAT HYPERTENSION. Antihypertensives STRONGLY recommended with target SBP <120mmHg

  • STROKE PREVENTION is CRUCIAL, but aspirin not recommended if no confirmed history of stroke

  • Cholinesterase inhibitors and memantine may be considered for treatment


3) Dementia case finding and detection… New emphasis on obtaining information from a

RELIABLE INFORMANT and across multiple domains including cognition, behaviour,

and function, to recognize a more extensive spectrum of disease


RECOMMENDATIONS:

  • Cognitive screening NOT RECOMMENDED in asymptomatic persons

  • Distinction between mild cognitive impairment (MCI) and dementia is important; MMSE = most widely used; MoCA = most sensitive to MCI

  • FUNCTIONAL AUTONOMY should be assessed

  • Assess CAREGIVER BURDEN regularly = major determinant of hospitalization

4) Use of neuroimaging and fluid biomarkers… New research since 2012 highlights

indications and suggestions for structural and neuroimaging and for quantitative software

and analysis.


RECOMMENDATIONS:

  • Indications for CT sections and MRI sequences: altered or unexpected cognitive function or decline, trauma, new neurological deficits, history of cancer, significant vascular risk factors, risk of intracranial bleed

  • Use of semi-quantitative scales and quantification software for interpretation of imaging

  • Fluorodeoxyglucose (FDG) PET and single-photon emission computed tomography (SPECT) for differential diagnosis


5) Non-cognitive markers of dementia… Now we understand that there may be early

indicators of disease; motor function, sensory function, neurobehavioural symptoms,

frailty, and sleep markers have been associated with the development of dementia.


STRONG EVIDENCE suggests that SLOWER GAIT SPEED, PARKINSONISM,

FRAILTY and HEARING IMPAIRMENT are majorly associated. A careful SLEEP

HISTORY should also be obtained.


6) Risk reduction… The CCCDTD have outlined several key risk factors associated with

the disease based on its occurrence in the later years of life.


RECOMMENDATIONS based on plausibility in the primary, secondary, and tertiary

settings:

  • Mediterranean diet

  • High consumption of unsaturated fats and low consumption of saturated fats

  • High intake of fruits and vegetables

  • Physical exercise (especially at moderate intensity, especially aerobic)

  • Everyone with MCI should be questioned about their hearing

  • Sleep apnoea should be corrected with CPAP

  • Avoid sleep deprivation (<5 hours/night)

  • Maintain social engagement - crucial for cognitive stimulation

  • Avoid medication known to exhibit anticholinergic properties


7) Psychosocial interventions…

GOAL: improve cognition, limit symptoms, and enhancing well-being, including that of

caregivers. We need to tailor organizations to the needs of these populations.


The CCCDTD recommends this can be achieved for our patients through exercise,

group cognitive stimulation therapy, psychoeducational interventions for caregivers

(counselling, strategy development), dementia friendly organizations (promoting

community inclusion), and effective case management.


8) Description of anti-dementia drugs…

The benefit of the drugs we use to optimize cognition (cholinesterase inhibitors and

memantine) must be considered for each patient on an individual basis, based on their

goals and the indication for medical intervention.


RECOMMENDATIONS FOR USE:

  • Discontinuation of cholinesterase inhibitors (ChEIs) or memantine should be considered after 12 months if condition has worsened, if no benefit was observed, if the patient is at end stage disease, if intolerable side effects develop, or if adherence is poor

  • ChEIs indicated for AD, PDD, DLB, or VD ONLY

  • Deprescribing should be a GRADUAL PROCESS and treatment should be reinstated if patient clinically worsens

  • ChEIs not to be discontinued in individuals with current psychotic symptoms until they have stabilized

  • ChEIs and memantine should be DEPRESCRIBED for MCI



Recommendations of the 5th Canadian Consensus Conference on the diagnosis and treatment of dementia

Alzheimer’s Dement. 2020;16:1182–1195. https://doi.org/10.1002/alz.12105


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