Guideline Development
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www.psychiatry-malaysia.org www.neuro.org.my GUIDELINE DEVELOPMENT The development group for these guidelines comprised of family medicine specialists, geriatricians, psychiatrists, geriatric psychiatrists, a neurologist, a psychologist, a public health specialist, an occupational therapist, a scientific officer and pharmacists from the Ministry of Health and the Ministry of Higher Education, Malaysia. During the process of development of these guidelines, there was active involvement of a review committee from both the public and private sector, consisting of geriatricians, psychiatrists, occupational therapist, neurologists and a representative from the caregivers group. This document is the 2nd Edition of Clinical Practice Guideline (CPG) on the Management of Dementia updating the previous CPG on Management of Dementia (2003). Since the publication of the first guidelines, there have been many advances in the field of dementia and mild cognitive impairment. There is a movement towards very early detection of dementia with the development of genetic, neuroimaging and biomarkers. Acetylcholinesterase inhibitors (AChEI) have been around for the past twenty years for the treatment of Alzheimer disease and related dementias. Currently there has been another drug developed to treat severe dementia. There are also many more drugs undergoing Phase II and III trials that are targetting beyond the neurotransmitters. Drugs and other preventive measures, such as exercise and mental stimulation, have been investigated to determine the extent of risk that these factors have in the development of dementia. This CPG was adapted from DEMENTIA, A NICE –SCIE Guideline on Supporting People with Dementia and their Cares in Health and Social Care, the British Psychological Society & Royal College of Psychiatrists, 2006 and the Scottish Intercollegiate Guidelines Network, Management of Patients with Dementia, February 2006. These CPGs were evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE) tool prior to adaptation. Further evidence was then retrieved from 2006 onwards. For the purposes of updating these guidelines, June 2009 should be considered the starting point for searching for new evidence. i Literature search was carried out at the following electronic databases, PUBMED/ MEDLINE, PsycINFO, Cochrane Database of Systemic Reviews (CDSR), International Health Technology Assessment Websites, Journal full text via the OVID search engine, Database of Abstracts of Reviews of Effectiveness; Cochrane Controlled Trials Registered, Clinical Trial and Registry, EBSCO search engine. A snowball method was used to manually check the references of the included studies to identify any relevant studies that had not yet been included. Refer to Appendix 1 for the search terms used to retrieve articles. Reference was also made to other guidelines such as the Ministry of Health Singapore - Clinical Practice Guideline, Dementia, 2006 and the Royal Australian College of General Practitioners, Care of Patients with Dementia in General Practice, September 2003. The clinical questions were divided into four subgroups and members of the development group were assigned individual clinical question within these subgroups. The group members met a total of 25 times throughout the development of the guidelines. All literature retrieved were appraised by at least two members, presented in the form of evidence tables and discussed during group meetings. All the statements and recommendations formulated were agreed upon by both the development group and review committee. Where the evidence was insufficient, the recommendations were derived by consensus of the development group and review committee. This CPG is based largely on the findings of systematic reviews and meta-analyses in the literature, taking into consideration local practices. These articles were graded using U.S. Preventive Services Task Force while the grading of recommendation in this guideline was modified from grades of recommendation of the Scottish Intercollegiate Guidelines Network (SIGN). Refer to inside back cover for Levels of Evidence and Grade of Recommendations. The draft guideline was posted on the Ministry of Health Malaysia and Family Medicine Specialist websites for comment and feedback. These guidelines had also been presented to the Technical Advisory Committee for Clinical Practice Guidelines, and the Health Technology Assessment and Clinical Practice Guidelines Council, Ministry of Health Malaysia for review and approval. ii OBJECTIVE GENERAL OBJECTIVES The aim of these guidelines is to assist clinicians in making evidence based decisions on the management of people with dementia and their caregivers. SPECIFIC OBJECTIVES R To describe the syndrome of dementia and its common subtypes as well as mild cognitive impairment R To discuss risk factors and preventive strategies in the development of dementia R To review the assessment and diagnostic tools in dementia R To provide evidence based guidance on the management for people with dementia and mild cognitive impairment R To address the ethical issues and end-of-life issues in dementia R To understand the impact of dementia on the individual and caregiver CLINICAL QUESTIONS Refer to Appendix 2 for details TARGET POPULATION a. Inclusion Criteria (Target Group) Adults with dementia and mild cognitive impairment b. Exclusion criteria People with learning disabilities who develop dementia and dementia secondary to medical conditions e.g. normal pressure hydrocephalus, AIDS, dementia complex, etc. iii TARGET USERS These guidelines are applicable to healthcare professionals who are involved in the management of dementia:- R Primary Care Physicians R Psychiatrist/Geriatric Psychiatrist/Neuropsychiatrist R Physicians/Geriatricians/Neurologists R Nurses R Social Workers R Physiotherapists/Occupational Therapists R Pharmacists R Psychologists R And all others involved in the management of patients with dementia HEALTH CARE SETTINGS Outpatient, inpatient and community setting PROPOSED CLINICAL AUDIT INDICATORS FOR QUALITY MANAGEMENT Indicator Percentage of people with a possible diagnosis of dementia from primary clinic referred to memory clinics/specialist clinic = Total number of those suspected dementia who are referred from primary care to memory clinic x 100% Total number of referrals for suspected dementia in the memory clinic Percentage of patients with BPSD prescribed atypical antipsychotics = Number of patients with BPSD prescribed atypical antipsychotics appropriately x 100% Total number of BPSD cases iv GUIDELINE DEVELOPMENT GROUP Chairperson Dr. Suraya Yusoff Head of Department and Senior Consultant Geriatric Psychiatrist Hospital Sultan Ismail Johor Members (alphabetical order) Dr. Bharathi Vengadasalam A/Prof Normah Che Din Geriatric Psychiatrist and Senior Lecturer Clinical Psychologist and Lecturer Faculty of Medicine and Health Sciences Faculty of Allied Health Sciences Universiti Putra Malaysia, Serdang, Selangor Universiti Kebangsaan Malaysia Kuala Lumpur Ms Hor Yee Yee Dr. Norzarina Md Zabidi Pharmacist Clinical Psychiatrist Hospital Sultan Ismail Hospital Melaka Johor Melaka Dr. Ismail Drahman Dr. Shanti Viswanathan Head of Department and Senior Consultant Neurologist Geriatric Psychiatrist Neurology Department Hospital Umum Sarawak. Sarawak Hospital Kuala Lumpur, Kuala Lumpur Dr. Khairuddin A. Wahab Dr Sheamini Sivasampu Consultant Psychiatrist Public Health Physician Hospital Permai, Johor Bharu Health Technology Assessment Section Johor Medical Development Division, MOH Dr. Joseph Ngeh Dr. Sukumar Rajaretnam Consultant Geriatrician Family Medicine Specialist Hospital Umum Sarawak, Sarawak Poliklinik Komuniti Tanglin, Kuala Lumpur Dr. Lee Fatt Soon Mr.Tan Chee Chin Senior Consultant Geriatrician Pharmacist Hospital Kuala Lumpur Hospital Sultanah Aminah, Johor Bharu Kuala Lumpur Johor Ms. Mariammah Krishnasamy Mr.Thillainathan Krishnan Scientific Officer ( Microbiology) Occupational Therapist Health Technology Assessment Section Hospital Selayang Medical Development Division, MOH Selangor Dr. Mohd Daud Che Yusof Dr. Yau Weng Keong Family Medicine Specialist Senior Consultant Geriatrician Klinik Kesihatan Sungai Mati,Muar, Johor Hospital Kuala Lumpur, Kuala Lumpur Dr. Norhashim Ahmad Consultant Neuropsychiatrist Hospital Sultanah Aminah, Johor Bharu v REVIEW COMMITTEE The draft guideline was reviewed by a panel of independent expert referees, who were asked to comment primarily on the comprehensiveness and accuracy of interpretation of the evidence supporting the recommendations in the guidelines. Chairperson Professor Dr. Phillip Poi Jun Hua Senior Consultant Geriatrician Universiti Malaya Medical Centre Kuala Lumpur Members (alphabetical order) Dr. Chin Ai-Vyrn Datin Dr. Rugayah Bakri Consultant Geriatrician and Senior Lecturer Deputy Director Universiti Malaya Medical Centre Health Technology Assessment Section Kuala Lumpur Medical Development Division, MOH Dr. Esther Ebenezer Dato’ Dr. Suarn Singh Consultant Geriatric Psychiatrist and Lecturer Head of Services for Psychiatry and Universiti KL Royal Medical College Ipoh Senior Consultant Psychiatrist Perak Hospital Bahagia Ulu Kinta, Perak Prof Dr. Goh Khean Jin Puan Tan Foo Lan Senior Consultant Neurologist Head of Department Universiti Malaya Medical Centre Department of Occupational Therapy Kuala Lumpur Hospital Kuala Lumpur Prof Dr. Raymond Azman Ali Dr. Yen Teck Hoe Deputy Dean and Senior Consultant Neurologist President Universiti Kebangsaan