A review of currently available treatments suggests a number of areas for further study. Several of these are in the realm of evaluation and assessment. The first is better detection and evaluation of dementia, especially in the prodromal and early stages, when treatment that slows progression would be more likely to be beneficial. Another is earlier and more accurate detection of noncognitive problems, so as to facilitate optimal intervention. The next is better assessment of dangerous symptoms, especially impaired driving ability. The last is the development of a consensus on clinically meaningful outcome measures, including neuropsychological testing, functional assessment, and “hard” end points, such as institutionalization and mortality.
In the realm of pharmacologic treatments, there is a critical need for medications with greater ability to improve cognition or at least halt the progression of dementia. Promising leads being actively studied for patients with Alzheimer’s disease include additional cholinergic agents, further work on vitamin E (especially for mildly impaired patients) and other antioxidants, NSAIDs, and estrogen supplementation. In addition, medication development needs to go beyond these areas to identify and test new cognition-enhancing medications based on the pathophysiological picture of dementia emerging from neuroscience and molecular genetics. For example, pharmacologic agents that prevent or slow down amyloid deposition or remove precipitated amyloid might function as preventive or reversing therapies for Alzheimer’s disease. As the understanding of other dementing disorders advances, targeted therapies must be developed and tested for these illnesses as well. Efforts to prevent stroke and to decrease its destructive effect on brain tissue are particularly important avenues for dementia prevention.
Another arena is the optimal pharmacologic treatment of noncognitive symptoms, including psychosis, agitation, depression, and sleep disturbance. Many current recommendations are extrapolated from small uncontrolled studies of agents no longer in common use and/or at doses well above those used in current practice. There is a critical need for randomized controlled studies of up-to-date treatments for psychosis, agitation, depression, and sleep disturbance in dementia.
Further research into nonpharmacologic interventions, such as behavioral and environmental modification, is also needed. One aspect of dementia care that deserves further study is the rehabilitation model, which focuses on identifying and maximizing remaining abilities as a way to maximize function. Further research into this and other strategies may help to identify specific aspects of these therapies that benefit persons with dementia or specific types of dementia. Similarly, research is needed to better characterize the aspects of nursing homes and other environments most likely to improve patient outcomes.
In the health services arena, managed care organizations are beginning to enroll large numbers of elderly individuals. It will be critical to study the impact of this major shift in payment for health services on the care of individuals with dementia so that any needed changes in policy can be made in a timely fashion.
Research is also needed to identify which patients will benefit from alternative forms of living environments and supplemental caregiving. The identification of sites that are more comfortable, less costly, and equally safe and effective for the care of individuals with moderate to severe dementia would have enormous benefits for patients, their families, and society.
Excerpted from “The American Psychiatric Association’s Practice Guideline for the Treatment of Patients With Alzheimer’s Disease and Other Dementias of Late Life” This practice guideline was approved in December 1996 and was published in May 1997.
© Copyright 2000 American Psychiatric Association
