The grades of recommendations (A-E) and the levels of evidence (I-VI) are defined at the end of the "Major Recommendations" field.
General Indications for Diagnosis
I/A - The general practitioner knows the cognitive-behavioral profile of his/her patients and can identify the clinical signs of cognitive decay at their onset, taking also into account the observations of relatives.
III/A - The general practitioner should assess the presence of symptoms of depression in case of cognitive-behavioral alterations, adopting, if it is the case, psychometric tools and other professional competences. The use of the Geriatric Depression Scale with 15 items is suggested (see the original guideline document).
III/A - Delirium can be suspected in subjects presenting a clinical/behavioral profile similar to the one described by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) diagnostic criteria.
|Diagnostic Criteria of Delirium Due to a General Medical Condition
(From Diagnostic and Statistical Manual of Mental Disorders, IV Edition, Text Revision, 2000)
- Disturbance of consciousness (reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention.
- A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.
- The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
- There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition
I/A - Dementia can be suspected in subjects presenting a clinical profile similar to the one described by the DSM-IV criteria for the definition of dementia.
|Diagnostic Criteria for Dementia from the DSM-IV, 1994 (multiple etiologies)
|A The development of multiple cognitive deficits manifested by both
- Memory impairment (impaired ability to learn new information or to recall previously learned information)
- One (or more) of the following cognitive disturbances:
- Aphasia (language disturbance)
- Apraxia (impaired ability to carry out motor activities despite intact motor function)
- Agnosia (failure to recognize or identify objects despite intact sensory function)
- Disturbance in executive functioning (planning, organizing, sequencing, abstracting)
|B The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
|C The deficits do not occur exclusively during the course of a delirium.
I/A - The general practitioner raises the diagnostic hypothesis of dementia through the anamnesis, a general examination, an assessment of possible iatrogenic causes, and a structured interview, carried out within a multi-professional team.
VI/A - General practitioners should assess all pathological conditions that could cause cognitive disorders.
VI/A - In raising the diagnostic hypothesis of dementia, general practitioners should assess the presence of co-morbidities and identify risk factors due to social isolation.
VI/B - General practitioners should prescribe blood tests to patients with suspect dementia.
VI/A - General practitioners should prescribe to patients with suspect dementia a brain imaging exam (computed tomography [CT] or magnetic resonance [MR]) for a diagnostic definition of dementia.
VI/A - General practitioners can refer to specialist services for diagnostic confirmation, differential diagnosis, and for the organization of interventions and stabilization of complex situations.
I/A - Starting a therapy with acetylcholinesterase inhibitors, whose effectiveness on core symptoms is proven, should be considered at moment of diagnosis of mild and moderate Alzheimer's disease. Expected benefits and potential adverse effects of the treatment should be discussed with patients and caregivers. Evidence of effectiveness of acetylcholinesterase inhibitors is available also in dementia with Lewy bodies and in dementia associated with Parkinson's disease. The option of starting a therapy with memantine should be considered in patients with moderate-severe Alzheimer's disease to treat core symptoms. No evidence is available on natural remedies.
VI/B - The use of antidepressant drugs, preferably selective serotonin reuptake inhibitors (SSRI), can be useful in the treatment of patients with dementia and depression. Trazodone can be useful in case of agitation.
II/A - Antipsychotic drugs have partial efficacy in the treatment of psychosis and aggressiveness associated with dementia. Their use should be limited to at-risk, or extremely suffering patients or caregivers, and should be limited if possible in time, due to the potentially severe adverse effects of these drugs. Associations of antipsychotic drugs should be avoided.
V/A - There is currently no evidence supporting the use of mood stabilizers for the treatment of behavioral disorders in patients with dementia.
V/A - There is no evidence supporting the use of benzodiazepines in patients with dementia.
Non-pharmacological Treatments (Behavioral)
V/A - The first line treatment for psychological and behavioral disorders is non-pharmacological, due to the potentially severe adverse effects caused by pharmacological treatments. The possibility of a non-pharmacological treatment for cognitive disorders should be considered at the diagnosis of dementia, even if evidence from the literature is not conclusive. Expected benefits should be discussed with patients and caregivers, and times and ways for the training and support of caregivers should be planned. General practitioners should refer to specialist services for these activities.
Level of Evidence
I Evidences from randomized controlled clinical trials and/or systematic reviews of randomized trials.
II Evidences from one single adequately designed randomized trial.
III Evidences from non-randomized cohort studies with concurrent or historical control or their metaanalysis.
IV Evidences from non-controlled retrospective case-control studies.
V Evidences from non-controlled case-series studies.
VI Evidences from experts' opinions or opinions from panels as indicated in guidelines or consensus conferences, or based on opinions from members of the work group responsible for this guideline.
Strength of Recommendations
A Carrying out the specified procedure or diagnostic test is strongly recommended. The recommendation is supported by good-quality evidences, even if not necessarily type I or II.
B It would be inappropriate to always recommend the specified procedure or intervention, considered the still existing doubts, but it should anyway be carefully considered.
C Significant uncertainties exist against recommending to carry out the specified procedure or intervention.
D The specified procedure is not recommended.
E The specified procedure is strongly not recommended.