Age and Ageing Advance Access published October 22, 2014

Age and Ageing 2014; 0: 19

doi: 10.1093/ageing/afu143

The Author 2014. Published by Oxford University Press on behalf of the British Geriatrics Society.
All rights reserved. For Permissions, please email: journals.permissions@oup.com

SYSTEMATIC REVIEW

Systematic review of recent dementia practice

guidelines
JENNIFER NGO, JAYNA M. HOLROYD-LEDUC
Department of Medicine, University of Calgary, Calgary, Alberta, Canada
Address correspondence to: J. Ngo, South Health Campus, 4448 Front Street SE, Calgary, Alberta T3M1M4, Canada.
Tel: (+1)403 956 2401; Fax: (+1)403 956 2995. Email: jtvngo@gmail.com

Background: dementia is a highly prevalent acquired cognitive disorder that interferes with activities of daily living, relationships and quality of life. Recognition and effective management strategies are necessary to provide comprehensive care for
these patients and their families. High-quality clinical practice guidelines can improve the quality and consistency of care in all
aspects of dementia diagnosis and management by clarifying interventions supported by sound evidence and by alerting
clinicians to interventions without proven benet.
Objective: we aimed to offer a synthesis of existing practice recommendations for the diagnosis and management of
dementia, based upon moderate-to-high quality dementia guidelines.
Methods: we performed a systematic search in EMBASE and MEDLINE as well as the grey literature for guidelines
produced between 2008 and 2013.
Results: thirty-nine retrieved practice guidelines were included for quality appraisal by the Appraisal of Guidelines Research
and Evaluation II (AGREE-II) tool, performed by two independent reviewers. From the 12 moderate-to-high quality guidelines included, specic practice recommendations for the diagnosis and/or management of any aspect of dementia were
extracted for comparison based upon the level of evidence and strength of recommendation.
Conclusion: there was a general agreement between guidelines for many practice recommendations. However, direct comparisons between guidelines were challenging due to variations in grading schemes.
Keywords: dementia, diagnosis, management, clinical practice guideline, older people

Introduction
Dementia is becoming a highly prevalent chronic neurodegenerative disease in the context of a rapidly ageing world
population. The prevalence of dementia was 35.6 million
peoples worldwide in 2010, and it is expected to affect an
estimated 65.7 million people by 2030 [1]. This condition has
signicant health-care cost and resource utilisation impact,
with an estimated global health-care cost equivalent to
1%
of the global gross domestic product [1].
Recognition and assessment of dementia, and the development of effective and comprehensive care plans are
important for reducing the disease burden. Clinical practice
guidelines are an important tool to assist in the evidencebased diagnosis and management of dementia. A clinical

practice guideline is dened by the Institute of Medicine as

statements that include recommendations intended to optimise patient care that are informed by a systematic review of
evidence and an assessment of the benets and harms of
alternative care options [2]. Many clinical practice guidelines
on the diagnosis and management of dementia exist, but
they are of variable quality. These guidelines vary not only in
their development, but also in the grading systems utilised to
assess both the quality of evidence and the strength of
recommendations. It can be challenging for practitioners to
determine which guidelines are of high quality, which recommendations are consistent among guidelines and, ultimately,
how to best integrate guidelines into clinical practice.
To our knowledge, no systematic attempts have been
made to compare recommendations from existing dementia

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Abstract

J. Ngo and J. M. Holroyd-Leduc

practice guidelines with respect to all aspects related to the
diagnosis and management of this condition. Therefore,
we sought to synthesise existing practice recommendations
by identifying and appraising clinical practice guidelines on
the diagnosis and management of dementia; by extracting
practice recommendations from guidelines appraised to be
of at least moderate quality; and by summarising key
recommendations for which there is agreement among
guidelines.

Methods
Literature search strategy

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A systematic search for existing clinical practice guidelines on

dementia diagnosis and/or management was performed in
EMBASE and Medline (Ovid) on 5 April 2013. The following search string was used in Ovid, with Medical Subject
Headings (MeSH): Dementia [Mesh] with limits: English
language, published between 2008 and 2013; guideline OR
practice guideline OR clinical pathway OR clinical protocol
OR consensus development as publication type. In addition,
we searched the grey literature on 1 May 2013 including websites of organisations that produce guidelines and websites of
relevant organisations and societies including the Alzheimer
Society and the Alzheimer Association. Specically, a search
strategy using terms including dementia and clinical practice
guidelines was undertaken via Google and Google Scholar
Internet search engines. Guidelines were also retrieved from
searches in databases including, but not limited to, National
Guidelines Clearinghouse; CMA InfoBase; US Centres for
Disease Control and Prevention task force on Community
Preventive Services and NHS Evidence in Health and Social
Care. Overall, we included guidelines either produced or
updated within the past 5 years, 200813. A owchart of
the search is presented in Figure 1.

The titles and abstracts of retrieved citations were reviewed

for relevance related to diagnosis, evaluation and/or management of dementia, and if deemed relevant, the full
guideline was retrieved. References were excluded if they
were review papers on guidelines, did not contain specic
clinical practice recommendations or focused on predementia or mild cognitive impairment.
The quality of retrieved practice guidelines was independently appraised by two reviewers ( J.H. and J.N.), using the
standardised AGREE-II instrument [3]. Differences were
resolved through consensus. Each domain within the
AGREE-II instrument was graded, but the overall rating was
used to determine the guideline inclusion. Guidelines achieving an overall rating of 5 or greater were deemed to be of at
least moderate overall quality and included. Guidelines
achieving a score of 4 were re-reviewed to determine inclusion status. Guidelines with a score of 3 or less were deemed
to be of overall low quality and excluded.

Figure 1. Search and appraisal strategy.

Guideline selection

Systematic review of dementia practice guidelines

Recommendation extraction process

Screening

Included guidelines were scrutinised in depth by one reviewer ( J.N.) to extract specic practice recommendations.
These specic practice recommendations were listed per
guideline into summary tables and classied into various
categories that included screening, evaluation, diagnosis and
management.

General screening in patients at average risk of developing

cognitive impairment is not recommended [15, 21]. However,
those with underlying co-morbidities associated with developing dementia, such as prior stroke, learning disability or
Down syndrome, are candidates for screening [15, 21].
Genetic screening is recommended only in individuals at risk
of autosomal-dominant dementia [5, 15, 17, 18] after consent
has been obtained [5, 17, 18] and genetic counselling provided [5, 17]. Apolipoprotein E (ApoE) genotyping is not
recommended [5, 8, 17] (refer to Supplementary data,
Table A2 available in Age and Ageing online).

Results

Cognitive testing

Eight guidelines address cognitive testing. There is agreement

that a cognitive assessment should be performed for those in
whom carers describe cognitive decline [4, 5, 14, 15, 18, 19,
23], using a valid, standardised tool. Specic tools recommended vary (refer to Supplementary data, Table A3 available in Age and Ageing online). Six guidelines recommend
performing neuropsychological testing, as an adjunct to the
standard tools, in mild or questionable cases of dementia
[4, 5, 8, 14, 15, 18, 21].
Co-morbid conditions

Assessment for and/or management of co-morbid medical

conditions and potentially reversible causes of cognitive
impairment is recommended [4, 5, 8, 14]. Seven guidelines
support ordering complete blood count (CBC), thyroidstimulating hormone (TSH), electrolytes, calcium, fasting
blood glucose and vitamin B12 levels as routine investigations, and six support ordering folate levels [4, 5, 8, 14, 18,
21, 23]. Several guidelines advise syphilis and human

Table 1. GDGs included

GDG

Abbreviation Country

Year Dementia Dementia

diagnosis management

No. of
references

Systematic
search
strategy

Grading of
evidence

Funding

....................................................................................
1. Ministry of Health Singapore [14]
2. European Federation of Neurological Sciences
[46]

MOH(S)
EFNS

Singapore 2013 Y
Europe
2012 Y

Y
Y

N
Y

Y
Y

Y
Y

280
100 [4];
307 [6];
189 [5]
19 [12]
768

Y
N

Y
N

NS
N
Y (P)
N
NS
Y (NP)

3. Canadian Consensus Conference [713]

4. National Institute for Health and Clinical
Excellence [15]
5. British Association for Psychopharmacology [16]
6. American College of Medical Genetics [17]
7. Clinical Research Centre for Dementia of South
Korea [18]
8. California Workgroup on Guidelines [19]
9. American Academy of Neurology Driving [20]
10. Ministry of Health Malaysia [21]
11. American College of Physicians [22]
12. Queensland University of Technology [23]

CCC
NICE

Canada
UK

2012 Y
2011 Y

BAP
ACMG
CRCSK

UK
USA
Korea

2011 N
2011 Y
2011 Y

Y
N
Y

NN
118
NN

Y
Y
N

Y
N
Y

Y (P)
NS
Y (G)

CWG
AAN(D)
MOH (M)
ACP
QUT

USA
USA
Malaysia
USA
Australia

2011
2010
2009
2008
2008

Y
Y
Y
Y
Y

NN
41
333
63
78

Y
Y
N
Y
N

N
Y
Y
Y
Y

NS
N
Y (P)
Y (NP)
Y (NP)

Y
N
Y
N
Y

Y, Yes; N, No; NN, Not numbered; P, Pharmaceutical; NP, Non-pharmaceutical; G, Governmental; NS, Not stated.

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The broad Medline and EMBASE searches yielded 104,003

and 110,630 citations, respectively, which were reduced by
the lters to 61 and 83 references published in English
between 2008 and 2013. Once abstracts were reviewed for
relevance and duplicate publications removed, 24 guidelines
were identied. Among these unique guidelines, some
belonged to the same guideline development group (e.g.
European Federation of Neurological Sciences (EFNS)
[46]; Canadian Consensus Conference (CCC) [713]) and
were therefore consolidated into one overall guideline, yielding a total of 13 unique guideline development groups
(GDGs). The grey literature search resulted in retrieval of an
additional 19 guidelines, and of those, 16 met inclusion criteria. Some of these latter guidelines had corresponding manuscripts found in the database search, and again these guidelines
were consolidated as the composite work of one single GDG.
We retrieved guidelines from 27 GDGs (Appendix): 11 from
the database search; 2 represented in both the database and
grey literature searches; and 14 from the grey literature search.
Twelve guidelines scored at least 4 or higher on the AGREE-II
instrument and were therefore included (Table 1). From the
12 guidelines, we extracted specic practice recommendations. Tables 2 and 3 outline the different grading systems
used by these 12 guidelines.

J. Ngo and J. M. Holroyd-Leduc

Table 2. Selected recommendations for evaluation of
dementia, with consensus from three or more guideline groups

immunodeciency virus (HIV) testing only if there is a suggestive history [4, 5, 14, 15, 21] (refer to Supplementary
data, Table A4 available in Age and Ageing online).
Diagnosis of dementia

There is agreement among the guidelines that international

consensus diagnostic criteria should be used in the diagnostic
process [8, 14, 16, 21]. Usage of the DSM-IV is recommended
by three guideline groups [8, 14, 21], while other diagnostic
criteria recommended include the ICD-10 [21] and NINCDSADRDA [8, 21]. The diagnosis should be made by clinicians
with experience in dementia assessment [14, 15, 21, 23]. Some
guideline groups suggest referral to a specialised dementia assessment centre [15] or to specialist clinicians such as geriatricians, geriatric psychiatrists or neurologists [23]. Diagnosing
subtype dementia is more complex, with agreement that these
diagnoses should be made by clinicians with expertise in the
differential diagnoses using international standardised criteria
[14, 15, 21, 23] (refer to Supplementary data, Table A5 available in Age and Ageing online).
Imaging and/or ancillary tests for diagnosing dementia
are addressed by nine guideline groups. There is agreement
that structural imaging, including computed tomography
(CT) or magnetic resonance imaging (MRI), should be performed at least once in the workup [4, 6, 8, 1416, 18, 21, 23].

Disclosing and providing information

It is generally agreed upon that the patient be asked their

wishes about knowing the diagnosis, and with whom information can be shared [14, 15, 21]. There is agreement on
early and timely disclosure [4, 10, 14], as well as the need to
support, discuss, educate and provide information to patients
and their families [4, 10, 19, 21, 23] (refer to Supplementary
data, Table A7 available in Age and Ageing online).
Non-pharmacologic management

In general, professionals should acquire adequate knowledge

and skills, based on the CCC [10] and the British National
Institute for Health and Clinical Evidence (NICE) [15]
guidelines. Care plans should be formulated, incorporating
patients values, cultures and specic needs [15, 19, 21]. The
CCC [11] and Queensland University of Technology (QUT)
[23] groups advise to promote and maintain function and independence. There is agreement that home assessments and
related environmental modications should be conducted
[15, 21]. Three guidelines address activities of daily living
(ADLs) assessment and management [15, 19, 23]; one consistent recommendation shared by two groups is to conduct
assessments and document changes in ADLs [15, 19].
Exercise and recreational activities are encouraged, although
there is inconsistency among the guidelines in terms of evidence grading [10, 14, 19]. Cognitive stimulation programs
are addressed by four guidelines, but not all guidelines agree
that there is sufcient evidence to make recommendations
[4, 10, 15, 21]. Three guidelines favour evaluating for and
reporting abuse of patients with dementia [15, 19, 23].
Driving is addressed by six guidelines. There is agreement
that driving ability should be evaluated at diagnosis, but the
grading of the evidence is inconsistent [4, 5, 10, 19, 23].
Three guidelines advise to refer patients to local support services, as part of management [10, 15, 19]. Four guidelines

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Cognitive testing
Perform cognitive assessment when carers describe cognitive decline in a
person
Use a standardised tool for cognitive testing, such as MMSE, GPCOG,
MOCA
Formal neuropsychological testing can form part of the assessment in mild
or questionable cases of dementia
Co-morbid conditions
Assess for and manage potentially reversible conditions contributing to
cognitive dysfunction
Tests including CBC, TSH, electrolytes, calcium, fasting blood glucose,
vitamin B12 and folate should be performed
HIV and syphilis testing should be done only with a suggestive history
Clinical diagnosis
Make a clinical diagnosis only after completing comprehensive evaluation
including history and physical exam
Use internationally agreed consensus criteria for diagnosis such as DSM-IV,
NINCDS-ADRDA
Subtype dementia diagnoses are more challenging and should be made by
clinicians with experience in the differential diagnoses and familiarity with
the international consensus criteria
Imaging and specialised tests
Structural imaging should be performed at least once and can be used to
exclude reversible causes
Either CT or MRI can be used, but there are no recommendations to use
both modalities in the same patient
Cerebrospinal fluid analysis is not recommended routinely, but it can be
considered in atypical presentations
Electroencephalogram is not recommended routinely, but it can be
considered in atypical presentations
Genetic studies, including the ApoE marker, are not routinely recommended

Functional imaging is not recommended routinely by the

Ministry of Health Malaysia [21] (MOH(M)), while other
guideline groups suggest using modalities such as perfusion
hexamethylpropyleneamine oxime single-photon emission
computed tomography and 2-[18F]uoro-2-deoxy-D-glucose
positron emission tomography when the diagnosis of dementia is uncertain after performing structural imaging, or if
differentiating among dementia subtypes is required [5, 6, 15,
16, 18]. Only the EFNS group addresses amyloid imaging,
which they do not recommend for routine clinical use [6].
Cerebrospinal uid analysis [15, 18, 21] and electroencephalogram [5, 15, 21] should not be performed routinely.
However, in atypical presentations and select situations, some
guideline groups support the use of these tests [4, 5, 15, 16,
18]. Brain biopsy should be utilised only in highly selected circumstances [5, 15, 18]. Genetic tests, including ApoE, are not
recommended routinely [14, 17, 18, 21]. Detailed recommendations are given in Supplementary data, Table A6 available in
Age and Ageing online.

Systematic review of dementia practice guidelines

Table 3. Selected recommendations for management of dementia with consensus from three or more guideline groups

conclude that information should be provided on community and medical resources, but there is inconsistency in evidence grading [4, 5, 14, 15, 23]. The topic of facility-based
care is addressed by three guidelines, with differing recommendations [10, 15, 23] (refer to Supplementary data,
Table A8 are available in Age and Ageing online).
Pharmacologic management

Cognitive enhancers can be used as an adjunct to nonpharmacologic intervention [14, 21]. Three guidelines suggest
discussing the pharmacotherapy decision along with risks,

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General non-pharmacologic management

Incorporate values, cultures and specific needs in care plans and interventions
Exercise and recreational activities are encouraged
Encourage participation in programs aimed at cognitive stimulation
Be aware of the risk of abuse and report as required by law
Evaluate driving ability at diagnosis and advise, and report, if necessary
Provide information at all stages of disease on available community and medical resources
Regularly re-evaluate disease progression in a comprehensive manner, including the option of using scales such as the MMSE
Pharmacologic management of cognitive aspects of dementia
Involve patient and family in pharmacotherapy decision, including discussion of medication risks, benefits and side-effects
Assess and monitor changes in medications, the effects and adherence at every visit
In Alzheimers dementia, consider cholinesterase inhibitors to treat mildmoderate dementia
Cholinesterase inhibitors may be beneficial in moderatesevere dementia
Memantine may provide benefit in moderatesevere dementia
In VD, identify and treat vascular risk factors
Acetylcholinesterase inhibitors should not be prescribed in VD
Both acetylcholinesterase inhibitors and memantine can be used to manage cognitive symptoms in DLB
Acetylcholinesterase inhibitors can be considered for cognitive symptoms in Parkinsons disease-associated dementia
Neither acetylcholinesterase inhibitors nor memantine is recommended in FTD
Supplements, herbal products and other pharmacotherapy including, but not limited to, gingko biloba, folic acid, vitamin B12, vitamin E, steroidal and
non-steroidal anti-inflammatory drugs, hormonal therapy and statin therapy are not recommended routinely for dementia management
Evaluation of typical BPSD symptoms
Assess for BPSD at the time of diagnosis and at regular intervals (i.e. 3 months) thereafter
Identify and treat delirium that may be contributing to neuropsychiatric symptoms
Non-pharmacologic management of typical BPSD symptoms
Recommended therapies include music therapy and massage therapy
Controversial therapies that cannot be recommended include aromatherapy and multisensory stimulation (also known as Snoezelen therapy)
Pharmacologic management of typical BPSD symptoms
Use medications sparingly only after non-pharmacologic approaches have failed, with awareness of side-effects
Advise patients and families on the risks and benefits prior to commencement of pharmacotherapy
Atypical antipsychotics are preferred (over typical antipsychotics)
Low doses should be used and carefully uptitrated; taper as early as possible
Those with DLB are very sensitive to antipsychotics; therefore, this therapy is not first line
There is lack of consensus for using benzodiazepines, anticonvulsants, mood stabilizers and SSRIs in typical BPSD symptoms
Evaluation and management of mood and other symptoms
Evaluate for co-morbid depression
Non-pharmacologic therapy, such as cognitive behavioural therapy or psychotherapy and reminiscence therapy, is recommended first
In severe disease or after failed non-pharmacologic therapies, use an antidepressant; SSRIs are recommended, while tricyclic antidepressants are advised against
Patients should be assessed for pain
Caregiver support
Caregivers needs should be routinely evaluated
Cognitive behavioural therapy or psychotherapy is beneficial for caregivers facing psychological morbidity
Anticipate the financial impact of caring for a person with dementia in the home and discuss potential benefits available
Decision-making and advanced care planning
Discuss the use of advanced directives and identify surrogates for medical and legal decision-making
Discuss advanced planning regarding cardiopulmonary resuscitation, including informing patients and families of poor outcomes in advanced dementia
Palliative care
End-of-life issues should be discussed with patients and families as appropriate
Tube feeding is discouraged

benets and medication side-effects, based upon the weakevidence or group consensus [10, 14, 22]. In Alzheimers dementia,
there is agreement for cholinesterase inhibitor use to manage
mildmoderate and moderatesevere cases (moderate-to-strong
quality evidence) [4, 10, 11, 1416, 19, 21, 22]. There is disagreement on use of memantine (an N-methyl-D-aspartic acid
(NMDA) inhibitor) in mild dementia [10, 14]. However, there is
agreement that memantine may be benecial in moderate
severe dementia (strong recommendation based on high-quality
evidence) [4, 11, 14, 16]. There are conicting recommendations
to support combining cholinesterase inhibitor therapy with
memantine in moderatesevere dementia [10, 11, 16, 21].

J. Ngo and J. M. Holroyd-Leduc

Evaluation and management of typical behavioural

and psychological symptoms of dementia

There was agreement among guideline groups that behavioural

and psychological symptoms of dementia (BPSD) should be
assessed at diagnosis and at regular intervals thereafter [4, 5,
10, 14, 15, 18, 19, 23]. The guidelines advise to evaluate for precipitants of behaviours that can be intervened upon [10] and
to identify and treat delirium [4, 18] (refer to Supplementary
data, Table A10 available in Age and Ageing online).
In general, non-pharmacologic interventions should be rst
line, followed by pharmacologic therapies [4, 10, 11, 14, 19].
There is sufcient agreement among the guidelines regarding
environmental modication [14, 15, 19]. Music therapy is
addressed by four guidelines and recommended by all [10, 14,
15, 21]. Aromatherapy is addressed by four guidelines [10, 14,
15, 21], but only supported by CCC [10] and NICE [15].
Animal-assisted therapy is advocated by NICE [15]. Of the
four guidelines that examined massage therapy, three recommend its use [10, 14, 24]. Bright light therapy is evaluated by

two guidelines [10, 21], and only the CCC recommends its use
based on the low-quality evidence [10]. The use of multisensory stimulation, also referred to as Snoezelen therapy, lacks
agreement among the guidelines [10, 11, 14, 15, 21].
Introduction of pharmacotherapy should be done with
caution and awareness of side-effects [10, 14, 15]. There is
agreement that patients and families should be advised of
risks and benets prior to commencing pharmacotherapy [4,
14, 21]. Antipsychotics can be prescribed to treat severe psychosis and agitation, with strong agreement by the guidelines that
atypical agents are preferred [4, 11, 21]. Initial doses should be
low with careful titration [4, 10, 15]. Antipsychotics should be
reassessed and tapered as early as possible [10, 11, 14, 21].
Antipsychotics are generally not preferred in DLB [10, 15].
The CCC suggests using benzodiazepines, based upon
weak evidence, while there was insufcient evidence to recommend for or against trazodone [11]. Mood stabilizers are
strongly discouraged by MOH(S) [14]. There is disagreement
about SSRI use in FTD-related BPSD [14, 16, 21].
Trialling acetylcholinesterase inhibitors or NMDAreceptor antagonists for BPSD in Alzheimers disease is recommended if antipsychotic medications are ineffective. However,
there is clear inconsistency among guidelines in the grading of
the recommendation [10, 14, 15, 21]. There is a general agreement based on moderate-quality evidence that these agents
should be used rst line in BPSD associated with DLB [14,
24]. The MOH(S) weakly recommends the use of these cognitive enhancers in BPSD associated with FTD [14], and the one
guideline that addressed its use in VD rejects this practice [24].
Evaluation and management of mood and related
symptoms

Guidelines recommend evaluating for co-morbid depression

[10, 14, 15, 21]. There is no consensus on evaluating for
anxiety. The guidelines consistently agree, based on moderate-quality evidence, that cognitive behavioural therapy/
psychotherapy should be rst-line modalities to manage depression [14, 15, 21]. Reminiscence therapy is weakly recommended by two guidelines [21, 24]. There is agreement that
antidepressant medications should be utilised when nonpharmacologic therapy fails or in severe cases [10, 11, 14, 15].
SSRIs are preferred (moderatestrong recommendation)
[4, 11, 21]. Tricyclic antidepressant therapy is strongly rejected
[4, 10, 15].
Four guidelines address the need to assess patients for
pain (weakmoderate recommendation) [14, 15, 21, 23]. A
stepped protocol for treating pain is weakly recommended
(low-quality evidence) [14, 21]. The CCC recommends sleep
hygiene and prescribing benzodiazepines in selected cases
[10] (weak evidence).
Caregiver support

There is a strong recommendation by three guideline groups

to evaluate caregivers needs routinely [10, 15, 21], and similar
agreement that multi-component and individualised

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In vascular dementia (VD), several guidelines make a weak

recommendation that vascular risk factors should be identied
and managed pharmacologically [10, 14, 21]. Only the Ministry
of Health Singapore [14] (MOH(S)) guidelines strongly recommend prescribing an acetylcholinesterase inhibitor for VD,
whereas CCC [10] recommends specically donepezil as a
treatment option. This practice is discouraged by NICE [15]
and the British Association for Psychopharmacology [16]
(BAP), and judged by the MOH(S) [14] as having too weak
evidence to support for or against its use. MOH(S) [14] also
advises to consider an NMDA antagonist in VD, whereas
CCC [10] does not support this intervention.
There is agreement that an acetylcholinesterase inhibitor
should be prescribed to manage Dementia with Lewy Bodies
(DLB) (moderate-to-strong quality evidence) [14, 16], and
rivastigmine is the agent of choice [5, 21]. Only EFNS
addresses whether NMDA antagonists should be used, and
the evidence is such that a strong recommendation for or
against this agent cannot be made [5].
In frontotemporal dementia (FTD), the guidelines unanimously agree that acetylcholinesterase inhibitor therapy
would be harmful [5, 16, 21]. EFNS [5] and MOH(M) [21]
address memantine use, which is also not recommended.
The EFNS guideline also advises against selective serotonin
reuptake inhibitor (SSRI) and dopamine agonist therapy [5]
(weak recommendation).
Other pharmacotherapies, including vitamins and supplements, are addressed by multiple guidelines (Supplementary
data, Table A9 available in Age and Ageing online). Gingko
Biloba is not recommended [10, 14, 16, 21]. All guidelines
reject treatment with omega-3 [14, 21], folic acid [10, 14, 16,
21], vitamin B12 [10, 14, 16] and vitamin E [4, 10, 14, 21].
They also unanimously recommend against steroids and
non-steroidal anti-inammatory agents [4, 10, 14], acetylsalicylic acid [4, 10], statins [4, 10, 14, 16] and hormone replacement therapy [4, 10, 14, 16].

Systematic review of dementia practice guidelines

interventions are required [14, 15, 23]. Cognitive behavioural
therapy is recommended, despite signicant inconsistencies
in grading the level of recommendation [5, 10, 15, 19, 21, 23].
The nancial impact of caring for a patient with dementia
should be anticipated, and available benets discussed (weak
recommendation) [14, 15, 23]. Two guidelines agree that
respite care should be offered [14, 15].
Decision-making and advanced care planning

Valid consent should always be sought [10, 15]. Evaluating for

capacity and changes in legal competency over time is recommended by CCC [10] and QUT [23] (weak-quality evidence).
Discussing the use of advanced directives and identifying surrogates for medical and legal decision-making should be
pursued [4, 19, 21, 23]. Patients should be encouraged to make
a lasting power of attorney when decision-making capacity still
exists [4, 10, 14, 15, 19].

Five guidelines address issues related to palliative care [14, 15,

19, 21, 23]. There is agreement that practitioners should discuss
end-of-life issues with patients and their families [15, 19, 23].
Eating and drinking by mouth is encouraged [15, 21]. Tube
feeding should be discouraged [15, 21, 23]. Individualised decisions about cardiopulmonary resuscitation should be made
based upon previously expressed patient wishes [15, 21].

Discussion
There is generally adequate guidance on the evaluation and
diagnosis of dementia, while the recommendations on the
management of this condition often lack depth, consistency
and/or consensus. Only half of the guidelines address dementia screening, and in general, it should be limited to
select cases where individuals are at risk. ApoE testing is not
recommended, which is appropriate as its diagnostic and predictive role remains undened in the literature [25]. Cognitive
testing using a standardised tool has been established and is
supported by a number of guidelines. There are a myriad of
diagnostic tools, yet limited advice on which of those tools is
preferred and in which situations. Furthermore,
1 dozen
tools are unique to the specic regions from where the guideline development group originates, and the reliability and validity of these tools are unclear.
Performing imaging at least once is well supported by the
guidelines. CT or MRI are options, and there is no specic
guidance on the preferred modality. One study found insufcient evidence to suggest that MRI is superior to CT in identifying cerebrovascular changes in autopsy-conrmed and
clinical cohorts of VD, Alzheimers dementia and mixed dementia [26]. Only a few guidelines address the role of functional imaging, with variable strength of recommendations to
pursue this investigation in cases of questionable diagnoses.
This technology requires further research into its value in
diagnosing dementia.

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Palliative care

Several guideline groups address disclosure and information provision, with agreement on the value of open communication, early disclosure, education and support. However,
due to lack of evidence for these practices, the recommendations are generally weak.
Over two-thirds of the guideline groups discussed nonpharmacologic management strategies for various aspects of
dementia care. There are a myriad of recommendations that
lack consistency among the guideline groups, and overall, the
recommendations are generally weak and/or based upon
low-quality evidence. This makes it challenging for caregivers
to determine what approach to take.
In terms of pharmacological management for cognitive
symptoms of dementia, the strongest recommendations for
cholinesterase inhibitors are for Alzheimers dementia and
DLB. Memantine is also strongly recommended for moderatesevere Alzheimers dementia. However, the impact of
these medications on cognition and global functioning is
modest and there are varying opinions regarding their costeffectiveness [24].
Guidance on the pharmacologic management of BPSD
supports judicious use of atypical antipsychotics, but guidelines do not elaborate on specic indications, doses and titration, nor on discontinuation regimens. Although tapering is
generally recommended, there is no mention of potential
harms of abrupt discontinuation of antipsychotics. A recent
study suggests that abrupt discontinuation of these agents in
the population affected by BPSD may actually be feasible
[27]. There is lack of advice on physical restraints, which are
still used to manage disruptive behaviours caused by dementia despite no evidence of benet and the potential for harm
[28]. Cognitive behavioural therapy or psychotherapy is
recommended by several guidelines to manage mood disorder, although the sustained benets of this therapy in
those with dementia are unclear.
Approximately half of the guideline groups address
advanced care planning, and all of these guidelines support
this intervention; however, the strength of the recommendations is variable. Although dementia is a progressive and terminal disease, palliation is addressed by only one-third of the
guideline groups and there is a lack of clarity and consistency
among the recommendations. The end-of-life care guideline
by Alzheimer Europe was examined, but ultimately excluded
from our review as it did not achieve an AGREE-II score of
4 or higher based on the information available about its
development [29]. There is a need for more research on
end-of-life planning and care so that more evidence-based
recommendations can be made.
Our study has some limitations. While a comprehensive
literature search was performed, it is possible that not all
existing clinical practice guidelines were identied. Restricting
our search to English language documents likely also limited
the number of guidelines available for inclusion in our study.
The AGREE-II instrument that we applied assesses overall
guideline quality, based largely on the development process,
but does not address the quality of the specic recommendations in the guidelines. Additionally, some guidelines are

J. Ngo and J. M. Holroyd-Leduc

extremely focused such that the recommendations cannot
be compared with the general recommendations from other
broader guidelines. Finally, we included guidelines dated
from 2008 to 2013 to limit this review to the most recent
evidence-based recommendations. However, during this time
span, divergent recommendations may have occurred based
on differences in available evidence and its interpretations.
However, overall, there was general agreement for many of
the recommendations.

Conclusion
In conclusion, there are several evidence-based practice
guidelines for the diagnosis and management of dementia.
Although direct comparisons are challenging due to variations in grading schemes, most guidelines agree on many key
recommendations that can help guide clinical practice.

There is generally adequate guidance on the evaluation

and diagnosis of dementia.
Recommendations on the management of dementia often
lack depth, consistency and/or consensus.
Most guidelines agree on many key recommendations that
can help guide clinical practice.

Acknowledgements
We thank Elizabeth Aitken for her assistance with the systematic literature search.

Conflicts of interest
None declared.

Funding
J.H.-L. is funded as the Scientic Director of the Seniors
Health Strategic Clinical Network within Alberta Health
Services.

Authors contributions
Study conception and design: all authors. Acquisition of data:
J.N. Interpretation of results: all authors. Drafted manuscript:
all authors. Critically revised the manuscript: all authors. Final
approval of manuscript: all authors.

Supplementary data
Supplementary data mentioned in the text are available to
subscribers in Age and Ageing online.

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