Patient Care Neurology & Psychiatry - November 2007 - (Page 13)

Dementia I high index of suspicion or who reside in the few areas of the United States with high numbers of syphilis cases.8 Depression is an additional comorbidity for which the AAN recommends screening. Validated screening instruments for depression include the Geriatric Depression Scale, short form, the Centers for Epidemiologic Studies Depression scale, and the Hamilton Depression Scale.17-19 One study revealed nearly 12% of patients with dementia were also depressed.20 The AAN acknowledges treatment of depression may not completely reverse cognitive dysfunction but should be addressed.8 Who needs imaging? Structural and functional neuroimaging is controversial. Current AAN guidelines recommend the use of either a noncontrast CT or MR scan in the routine initial evaluation. Pathologies such as brain neoplasm, subdural hematomas, and normal pressure hydrocephalus may be detected with the CT or MR scans. Because of insufficient data to support the validity of other diagnostic procedures, no other imaging study is recommended in current guidelines. SPECT and PET scans hold some promise, but these functional neuroimaging studies are better utilized for research.8 Therapies that work Do the drugs really work? Yes, but so do many behavioral interventions. These include functional assistance, such as laying out clothing, assisting with dressing, preparing food, providing additional water, protecting from harm, cleaning and moisturizing, and attention; minimizing choices, such as not asking an AD patient what he or she wants for lunch—instead, preparing a nutritious lunch of favorite foods; and reorientation, orienting the AD patient as to date, time, season, and weather as part of routine conversation, and redirecting problem behavior to calmer environments and activities. In addition to caregiver education, primary care physicians commonly attend to functional and cognitive status of the AD patient, multimorbidity and polypharmacy common to the elderly, preventive measures, and, particularly in the AD population, treatment of depression and chronic pain. Decisions to treat with currently available medications are guided by multiple influences. Some families cannot afford the acquisition cost, despite savings due to nursing home care. Some physicians cannot see the value of prolonging a demented life, despite the improvements seen in quality of life for both the AD patient and the caregiver. Cholinesterase inhibitors Many studies confirm the superiority of cholinesterase inhibitors (ChEIs) to placebo, typically in the realm of cognition.21 A large meta-analysis revealed that ChEIs have a modest beneficial impact on neuropsychiatric and functional outcomes, improving 1.72 points on the Neuropsychiatric Inventory (0-120 points), and 0.03 points on the Alzheimer Disease Assessment Scale, noncognitive (0-50 points).22 Thus, these modest improvements leave reason for clinicians to doubt the practical significance of response to ChEIs. With regard to clinically significant agitation, donepezil has been shown to be no more effective than placebo23; and the drugs most commonly used (atypical antipsychotics) are associated with a slightly increased risk of mortality and stroke for which they have garnered black-box warnings. No drugs have received an FDA-approved indication for agitation associated with dementia, but the atypical antipsychotics have the strongest evidence of efficacy. Other reports, however, show that ChEIs have significant efficacy in the treatment of neuropsychiatric symptoms in AD patients.24 A meta-analysis of 16 randomized, double-blind, placebo-controlled, parallel-group trials of ChEIs involving 7954 patients demonstrated that the numbers needed to treat (NNT) for 1 additional patient to experience benefit in the area of cognition were 7 for stabilization or better, 12 for minimal improvement or better, and 42 for marked improvement.25 Statistically, a NNT of 7 or 12 compares with the cardiovascular benefit of statins, while a NNT of 42 reflects the risk-benefit of wearing seat belts. Other tangible clinical outcomes include demonstrated delays in nursing home placement (for dementia-related illness) of 21.4 months on average for patients taking NOVEMBER 2007 PATIENT CARE NEUROLOGY & PSYCHIATRY 13

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Patient Care Neurology & Psychiatry - November 2007 Contents Research Digest Medicine in the News The 15-Minute Visit Dementia workup and treatment: Do the drugs really work? Help for Your Patients Who Suffer from Specific Phobias Clinical Clips Case & Comment The Science of Healing Classified Advertising

Patient Care Neurology & Psychiatry - November 2007

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