Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; J. Thomas Cross, Jr., MD, MPH; Mary Ann Forciea, MD; Robert Hopkins, Jr., MD; Paul Shekelle, MD, PhD; Alan Adelman, MD; David Mehr, MD, MS; Kenneth Schellhase, MD, MPH; Doug Campos-Outcalt, MD, MPA; Pasqualina Santaguida, PhD; Douglas K. Owens, MD, MS; and the Joint American College of Physicians/American Academy of Family Physicians Panel on Dementia (*)
Clinical Efficacy and Assessment Subcommittee of the American College of Physicians: Douglas K. Owens, MD, MS (Chair); Donald E. Casey Jr., MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Paul Dallas, MD; Nancy C. Dolan, MD; Mary Ann Forciea, MD; Lakshmi Halasyamani, MD; Robert H. Hopkins Jr., MD; and Paul Shekelle, MD, PhD. Commission on Science of the American Academy of Family Physicians: Eric M. Wall, MD, MPH; Jonathan E. Rodnick, MD; Kenneth G. Schellhase, MD, MPH; Steven W. Strode, MD, MEd, MPH; Kurtis S. Elward, MD, MPH; James W. Mold, MD, MPH; Jonathan L. Temte, MD, PhD; Frederick M. Chen, MD, MPH; Thomas F. Koinis, MD; Donya A. Powers, MD; James M. Gill, MD, MPH; Kevin Peterson, MD, MPH; Robert C. Marshall, MD, MPH; Herbert F. Young, MD, MA; and Bellinda K. Schoof, MHA, CPHQ.
Note: Clinical practice guidelines are “guides” only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication, or once an update has been issued.
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Financial Support: Financial support for the development of this guideline comes exclusively from the American College of Physicians' and American Academy of Family Physicians' operating budgets.
Potential Financial Conflicts of Interest:Honoraria: P. Santaguida (American College of Physicians). Grants received: V. Snow (Centers for Disease Control and Prevention, Novo Nordisk, Bristol-Myers Squibb, Robert Wood Johnson Foundation, Boehringer-Ingelheim, Endo Pharmaceuticals).
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Qaseem and Snow: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Cross: 1761 South 8th Street, Suite H, Colorado Springs, CO 80906.
Dr. Forciea: 3615 Chestnut Street, Philadelphia, PA 19104.
Dr. Hopkins: 4301 West Markham Street, Suite 641, Little Rock, AR 72205.
Dr. Shekelle: 1776 Main Street, Santa Monica, CA 90401.
Dr. Adelman: 500 University Drive, Hershey, PA 17033.
Dr. Mehr: MA306 Medical Sciences Building DC032.00, Columbia, MO 65212.
Dr. Schellhase: 8701 Watertown Plank Road, Milwaukee, WI 53226.
Dr. Campos-Outcalt: 11400 Tomahawk Creek Parkway, Leawood, KS 66211.
Dr. Santaguida: McMaster University Evidence-based Practice Center, 50 Main Street East, DTC-FLR 3, Hamilton, Ontario L8N 1E9, Canada.
Dr. Owens: 117 Encina Commons, Stanford, CA 94305.
The American College of Physicians and American Academy of Family Physicians developed this guideline to present the available evidence on current pharmacologic treatment of dementia.
The targeted literature search included evidence related to the effectiveness of 5 U.S. Food and Drug Administration–approved pharmacologic therapies for dementia for outcomes in the domains of cognition, global function, behavior/mood, and quality of life/activities of daily living.
Clinicians should base the decision to initiate a trial of therapy with a cholinesterase inhibitor or memantine on individualized assessment. (Grade: weak recommendation, moderate-quality evidence.)
Clinicians should base the choice of pharmacologic agents on tolerability, adverse effect profile, ease of use, and cost of medication. The evidence is insufficient to compare the effectiveness of different pharmacologic agents for the treatment of dementia. (Grade: weak recommendation, low-quality evidence.)
There is an urgent need for further research on the clinical effectiveness of pharmacologic management of dementia.
Table 1. The American College of Physicians' Guideline Grading System
Does pharmacologic treatment of dementia with any of the 5 FDA-approved drugs improve cognitive symptoms and outcomes?
What is the evidence for efficacy of the cholinergic neurotransmitter–modifying agents, such as cholinesterase inhibitors (donepezil, galantamine, rivastigmine, tacrine) and the noncholinergic neurotransmitter– or neuropeptide-modifying agent (memantine) in the treatment of dementia?
Table 2. Studies That Reported the Proportion of Patients Who Achieved a Clinically Significant Change on 2 Domains of Dementia
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Harvard Medical School
March 26, 2008
As a neurologist/investigator who participated in clinical trials of all 5 FDA-approved drugs for Alzheimer's disease (AD), I read with consternation the recommendations of Qaseem et al for the treatment of dementia. I fear they will set back for many years efforts of AD specialists, the Alzheimer Association, and others to improve the lot of AD patients.
If we had strongly effective, disease-modifying therapies for AD, there would be no argument about treatment. But such therapies are not available and may not be for a long time. In the meantime we have an ever growing number of AD patients and family members who are in great distress.
Qaseem et al have decided to accept only certain psychometric changes, e.g. improvement of 4 or more points on the ADAS-cog scale, as evidence of clinically significant benefit from therapy. But such a decision is purely arbitrary. The FDA set up many other well-thought out criteria, which also have validity as indicators of improvement and were in fact met by all currently available drugs.
Qaseem et al. admit that many AD patients do meet their high standard for clinically important improvement with current therapies. Predicting who will respond in such a way is a topic of intense interest, but still unresolved. In the absence of such information, it seems reasonable to give most patients with AD the opportunity to benefit from anti-AD medications. The recommendation of Qaseem et al. to base treatment on an "individualized assessment" is ambiguous because they do not present any information on how to decide whom to treat. Rather than guide the physician, they cause further confusion.
Their guidelines are also at substantial variance with those of the American Academy of Neurology (Doody et al., Neurology 2001;56:1154-1166) and the American Psychiatric Association (available at www.psych.org).
Past Research support, honoraria for speaking: Eisai/Pfizer; Janssen; Novartis; Forest
Johns Hopkins Bayview Campus
April 18, 2008
Letter to the Editor
The clinical practice guideline on pharmacologic treatment of dementia (1) is ambiguous and misleading. Does Recommendation 1, "Clinicians should base the decision to initiate a trial of therapy "¦" mean that there is such a decision to initiate? In our opinion, this could be stated more clearly as, "the decision whether to initiate therapy". The studies of cholinesterase inhibitors (ChEIs) have shown consistent small improvements in cognition and global assessments, and none have shown consistent improvement in quality of life or behavior. Comparing placebo to donepezil on the Alzheimer Disease Assessment Scale- cognitive subscale, for example, the accompanying evidence review states that "no group achieved a change of 4 points (the change considered clinically significant)," and concludes "Treatment of dementia with cholinesterase inhibitors and memantine can result in statistically significant but clinically marginal improvement in measures of cognition and global assessment of dementia."(2) The 2001 American Academy of Neurology practice guideline on the same subject concludes that studies of cholinesterase inhibitors "suggest a small average degree of benefit."(3).
Recommendation 1 continues that the decision to initiate a trial of therapy should be based on an individualized assessment. What are we to assess? Might there be a particular subgroup that would benefit? If so, what are the characteristics of this group?
Recommendation 3 notes "an urgent need for further research on the clinical effectiveness of current pharmacological treatment for dementia". According to the article 59 unique trials of at least moderate quality have been published that study current treatment. The authors could say that research is needed to determine whether there is a subset of patients who might realize meaningful benefit from these drugs. These studies have not been done. They could also say that there is an urgent need for pharmacological treatment that can provide meaningful help to patients suffering from this terrible illness.
The multibillion dollar sales of drugs whose actual clinical effectiveness has not really been shown is based in part on guidelines like these.
Theresa A. Rowe, MD Thomas E. Finucane, MD Johns Hopkin Bayview Medical Center Baltimore, MD 21224
(1) Qaseem A, Snow V, Cross JT, et al. Current pharmacologic treatment of dementia: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2008 March 4; 148(5):370-8.
(2) Parminder R, Pasqualina S, et al. Effectiveness of cholinesterase inhibitors and memantine for treating dementia: evidence review for a clinical practice guideline. Ann Intern Med. 2008 March 4; 148(5):379-97.
(3) Doody RS, Stevens JC, et al. Practice parameter: management of dementia (an evidence-based review). Report of the quality standards subcommittee of the American Academy of Neurology. Neurology. 2001 May 8; 56(9):1154-66.
Qaseem A, Snow V, Cross JT, Forciea MA, Hopkins R, Shekelle P, et al. Current Pharmacologic Treatment of Dementia: A Clinical Practice Guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2008;148:370-378. doi: 10.7326/0003-4819-148-5-200803040-00008
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Published: Ann Intern Med. 2008;148(5):370-378.
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