Position StatementPosition Statement of the American Association for Geriatric Psychiatry Regarding Principles of Care for Patients With Dementia Resulting From Alzheimer Disease
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POSITION
There exists currently an effective, systematic care/treatment model for patients with dementia resulting from Alzheimer disease (AD). This consists of a series of therapeutic interventions—pharmacologic and nonpharmacologic—targeted at patients with AD and their caregivers. Although these interventions do not produce a cure of the underlying disease and do not appear to stop its progression, they have been shown to produce benefits for patients and their caregivers. The aims of this care
Cognitive Impairment No Dementia (CIND)
A clinical syndrome consisting of measurable or evident decline in memory or other cognitive abilities with little effect on day-to-day functioning that does not meet criteria for dementia as defined by DSM–IV–TR.1
Mild Cognitive Impairment (MCI)
A clinical syndrome that is a subgroup of CIND with prominent amnestic symptoms that is in all likelihood a prodrome of AD.
Dementia
A clinical syndrome, that is not entirely the result of delirium, consisting of global cognitive decline with memory plus one other area of cognition affected
CONTEXT OF THIS POSITION STATEMENT
The aim of this statement is to assert the position of the AAGP regarding the existence of specific principles of care for patients with AD for the purpose of improving care, and access to care, for patients with AD and their caregivers. This statement also aims to provide clinicians with guidance about the key elements of these care principles and about the reasons for which this care should be made available to patients with AD and caregivers. Because this is a position statement about
WHY THIS DOCUMENT NOW
Dementia is a major public health problem already that is expected to worsen given the aging of the population. Over 4.5 million Americans have the most common form of dementia, AD; this number will likely triple in the next 40–50 years.2 Despite the commitment of significant effort and resources to the development of curative therapy for AD, a cure remains many years, possibly decades, away. In the meantime, it is important that medical professionals care for patients who currently have the
ORGANIZATION OF THIS DOCUMENT
The remainder of this document articulates general principles of dementia care, encompassing the full spectrum of available treatments, both pharmacologic and nonpharmacologic, organized around the following key areas of therapy:
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Disease therapies for AD, targeted specifically at aspects of the current pathophysiological understanding of the disease;
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Symptomatic therapies for cognitive symptoms;
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Symptomatic therapies for other neuropsychiatric symptoms;
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Interventions targeted at, and the
DISEASE THERAPIES FOR ALZHEIMER DISEASE TARGETED SPECIFICALLY AT ASPECTS OF THE CURRENT PATHOPHYSIOLOGICAL UNDERSTANDING OF THE DISEASE
A detailed discussion of the current understanding of the complex pathophysiology of AD is beyond the scope of this document. Briefly, this understanding implicates the misprocessing of the amyloid precursor protein (APP) as the key initial event. Processing of this protein in brain neurons through the beta secretase pathway leads eventually to the deposition of insoluble deposits referred to as beta amyloid plaques, eventually leading to synaptic failure, neuronal injury, formation of tangles
SYMPTOMATIC THERAPIES FOR COGNITIVE SYMPTOMS
One of the earliest pathologic findings associated with AD was the loss of neurons in the nucleus basalis, the main origin of cholinergic neurotransmission to the cortex. Although the cholinergic hypothesis of AD has lost favor in light of the amyloid hypothesis, overcoming this cholinergic deficit of AD continues to be a mainstay of treatment for the cognitive symptoms of the disease. Several lines of evidence suggest that acetylcholine (ACh) neurotransmission is important to the normal
General Approach
Although cognitive deficits are the clinical hallmark of dementing diseases, including AD, noncognitive neuropsychiatric symptoms (NPS) are nearly universal, affecting over 90% of patients with AD, and can influence the presentation and course of the dementia.31 These NPS of dementia include agitation, aggression, delusions, hallucinations, repetitive vocalizations, and wandering, among others. In addition, an affective disturbance, referred to as “depression of Alzheimer disease” or
General Approach
A key component of the principles of care involves the provision of proper supportive care to patients with AD. The specific interventions that individual patients require should be tailor-made to their condition and their circumstances and typically change with the progression of cognitive and functional decline associated with AD. Clinicians caring for patients with AD should become familiar with and or develop checklists (e.g., the checklists offered by Rabins et al.42) that will help them
General Approach
A key component of the principles of care involves the provision of proper support to the family and other informal caregivers of patients with AD. Such interventions have been shown in controlled trials to enhance life quality for patients and caregivers, and to delay institutionalization for home residing caregivers. The specific interventions that individual caregivers require should be tailor-made to their condition and their circumstances, and typically change with the progression of
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This statement was prepared by a Task Force authorized by the AAGP Board of Directors and was then adopted by the AAGP Board at its September 14, 2005, meeting. The Task Force consisted of Constantine Lyketsos (Chair), Christopher Colenda, Cornelia Beck, Karen Blank, Murali Doriaswamy, Douglas Kalunian, and Kristine Yaffe. Christine deVries, AAGP Executive Director, was instrumental in its development.
Disclosures for the AAGP Board are on file with the AAGP office and available upon request. Please visit their website at www.AAGPonline.org.