AAFP-ACP Guideline Looks At Drug Treatment Of Dementia

April 2017

Ageing

Country of origin: USA

A new clinical practice guideline on pharmacological treatment of dementia has been issued from the American Academy of Family Physicians and the American College of Physicians, or ACP. The guideline appears in Annals of Internal Medicine. The types of dementia covered in the guideline include dementia related to Alzheimer's disease and vascular dementia.

The guideline was developed under the auspices of the AAFP Commission on Science.

"With the aging population in the United States, dementia has become an important public health problem," the guideline notes. "The prevalence of Alzheimer's disease is projected to quadruple in the next 50 years to 1 in 45 Americans. In addition, the long duration, caregiver burden and costs associated with providing care contribute to making dementia a major health care problem."

The AAFP-ACP guideline panel reviewed the medical literature and found limited evidence regarding the effectiveness of the five approved drugs in regard to these outcomes: cognition, global function, behavior/mood, and quality of life/activities of daily living. The five drugs are the cholinesterase inhibitors donepezil (Aricept), galantamine (Nivalin, Razadyne, Reminyl), rivastigmine (Exelon) and tacrine, and the neuropeptide-modifying agent memantine (Namenda).

The guideline panel found that some clinical trials showed statistically significant improvements in dementia patients treated with one or another of these medications. The problem is that "those improvements often weren't clinically significant," says panelist Kenneth Schellhase, M.D., M.P.H., director of research and assistant professor in the family and community medicine department at the Medical College of Wisconsin, Milwaukee. Schellhase was a member of the AAFP Commission on Science when he was appointed to the panel.

"The magnitude of improvement in those trials often was so small that patients or their caregivers may not be interested in exposing the patient to the potential side effects of the drug for such a modest benefit," Schellhase says. "And for patients and doctors who do choose a trial of therapy, there is little evidence to guide the duration of treatment."

Recommendations include:

? Clinicians should base the decision to initiate a trial of therapy with a cholinesterase inhibitor or memantine on individualised assessment.
? Clinicians should base the choice of pharmacological agents on tolerability, adverse effect profile, ease of use and cost of medication. The evidence is insufficient to compare the effectiveness of different pharmacological agents for the treatment of dementia.
? There is an urgent need for further research on the clinical effectiveness of pharmacological management of dementias.

The guideline also issues an urgent call for more research. That research should further evaluate the effectiveness of drug therapy and assess whether treatment affects outcomes such as institutionalisation. In particular, it should look at the appropriate duration of therapy, provide head-to-head drug comparisons and test combination therapy.

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