Drug Treatment for Patients with Dementia: American College of Physicians and American Academy of Family Physicians Recommendations

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The summary below is from the full reports titled "Current Pharmacologic Treatment of Dementia: A Clinical Practice Guideline from the American College of Physicians and the American Academy of Family Physicians" and "Effectiveness of Cholinesterase Inhibitors and Memantine for Treating Dementia: Evidence Review for a Clinical Practice Guideline." They are in the 4 March 2008 issue of Annals of Internal Medicine (volume 148, pages 370-378 and pages 379-397). The first report was written by A. Qaseem, V. Snow, J.T. Cross Jr., M.A. Forciea, R. Hopkins Jr., P. Shekelle, A. Adelman, D. Mehr, K. Schellhase, D. Campos-Outcalt, P. Santaguida, D.K. Owens, and the Joint American College of Physicians/American Academy of Family Physicians Panel on Dementia; the second report was written by P. Raina, P. Santaguida, A. Ismaila, C. Patterson, D. Cowan, M. Levine, L. Booker, and M. Oremus.

Who developed these recommendations?

The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) developed these recommendations. Members of the ACP are internists—specialists in the care of adults.

What is the problem and what is known about it so far?

Dementia affects memory and thinking enough to interfere with normal daily activities. About 1 out of every 10 Americans older than 65 years has some degree of dementia. Poor memory alone is not dementia, and some declines in short-term memory are normal as people age. Several conditions can cause dementia, but the 2 most common diseases are Alzheimer disease and cerebrovascular disease. In Alzheimer disease, build-up of abnormal proteins damages brain cells. In cerebrovascular disease, low blood flow to the brain damages brain cells. There is no cure for dementia. However, the U.S. Food and Drug Administration has approved 5 drugs that can modestly slow the worsening of dementia in some patients. Four of them belong to a class of drugs called cholinesterase inhibitors (donepezil, galantamine, rivastigmine, and tacrine). The fifth drug, memantine, belongs to a class of drugs called neuropeptide-modifying agents. These drugs cannot cure dementia, can be costly, and can have side effects. It is uncertain how they can best be used to improve health outcomes for people with dementia.

How did the ACP and the AAFP develop these recommendations?

The authors reviewed published trials that compared 1 of the 5 drugs with no drug treatment or with another of the 5 drugs. They collected information from these trials on the benefits and side effects of each drug. The benefits included improvement in cognitive function (thinking and memory), global function (ability to do usual activities), behavior, quality of life, and caregiver burden. Harms included any unwanted symptom that was possibly related to the drug.

What did the authors find?

Fifty-nine studies met the authors' criteria for inclusion. Most trials of the 5 dementia drugs showed statistical improvements in measures of thinking and memory, but the improvements were generally too small to lead to clinically important improvements in the daily lives of patients and their caregivers. Outcomes related to behavior and quality of life were studied less frequently and did not show consistent improvements with the drugs. Studies of tacrine were weaker than studies of other drugs. Tacrine also had more side effects than the other drugs. Most studies were short (less than 12 months). Only 3 of the studies compared 1 of the dementia drugs with another, and these showed no differences. The most common side effects were gastrointestinal symptoms, such as nausea.

What do the ACP and the AAFP suggest that patients and doctors do?

Doctors, patients, and caregivers should consider the patient's situation and preferences when deciding whether to try 1 of the 5 available dementia drugs. Because there is not enough information that compares the effectiveness of 1 drug with that of another, doctors and patients should consider side effects, ease of use, and cost when choosing from the 5 drugs approved for treating dementia. Doctors and patients should advocate for more research on drugs to treat dementia.

What are the cautions related to these recommendations?

These recommendations may change when new studies become available.

Read all Rapid Responses

In Response

Ben Seltzer

Annals Online, 3 Apr 2008 [Full text]

Letter to the Editor

Theresa Rowe, et al.

Annals Online, 18 Apr 2008 [Full text]