CMAJ • November 4, 2008; 179 (10). doi:10.1503/cmaj.081103.
© 2008 Canadian Medical Association or its licensors
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Right arrow Dementia
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Review

Diagnosis and treatment of dementia: 5. Nonpharmacologic and pharmacologic therapy for mild to moderate dementia

David B. Hogan, MD, Peter Bailey, MD, Sandra Black, MD, Anne Carswell, MSc PhD, Howard Chertkow, MD, Barry Clarke, MD, Carole Cohen, BA MD, John D. Fisk, PhD, Dorothy Forbes, RN PhD, Malcolm Man-Son-Hing, MSc MD, Krista Lanctôt, PhD, Debra Morgan, RN PhD and Lilian Thorpe, MD PhD

From the Departments of Medicine and Clinical Neurosciences (Hogan), University of Calgary, Calgary, Alta.; the Division of Neurology, Department of Medicine (Bailey), the School of Occupational Therapy (Carswell), the Department of Family Medicine (Clarke) and the Department of Psychiatry (Fisk), Dalhousie University, Halifax, NS; the Department of Medicine (Black), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ont.; the School of Nursing (Forbes), Faculty of Health Sciences, University of Western Ontario, London, Ont.; the Department of Neurology and Neurosurgery (Chertkow), McGill University, Montréal, Que.; the Departments of Psychiatry (Cohen, Lanctôt) and Pharmacology (Lanctôt), University of Toronto, Toronto, Ont.; the Department of Medicine (Man-Son-Hing), University of Ottawa, Ottawa, Ont.; and the Canadian Centre for Health and Safety in Agriculture (Morgan) and the Department of Psychiatry (Thorpe), University of Saskatchewan, Saskatoon, Sask.

Correspondence to: Dr. David B. Hogan, Department of Clinical Neurosciences, Health Sciences Centre, University of Calgary, 3330 Hospital Dr. NW, Calgary AB T2N 4N1; fax 403 283-6151; dhogan{at}ucalgary.ca

Abstract

Background: Practising physicians frequently seek advice on the most effective interventions for dementia. In this article, we provide practical guidance on nonpharmacologic and pharmacologic interventions for the management of mild to moderate dementia based on recommendations from the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia.

Methods: We 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. We selected articles published from January 1996 to December 2005 that dealt with the management of mild to moderate stages of Alzheimer disease and other forms of dementia. Recommendations based on the literature review were drafted and voted on. Consensus required 80% or more agreement by participants. Subsequent to the conference, we searched for additional articles published from January 2006 to April 2008 using the same major keywords and secondary search terms. We graded the strength of the evidence using the criteria of the Canadian Task Force on Preventive Health Care.

Results: We identified 1615 articles, of which 954 were selected for further study. From a synthesis of the evidence in these studies, we made 48 recommendations for the management of mild to moderate dementia (28) and dementia with a cerebrovascular component (8) as well as recommendations for addressing ethical issues (e.g., disclosure of the diagnosis) (12). The updated literature review did not change these recommendations. An exercise program is recommended for patients with mild to moderate dementia. Physicians should decide whether to prescribe a cholinesterase inhibitor on an individual basis, balancing anticipated benefits with the potential for harm. For mild mood and behavioural concerns, nonpharmacologic approaches should be considered first.

Interpretation: Although the available therapies for dementia can help with the management of symptoms, there is a need to develop more effective interventions.