□ REVIEW ARTICLE □ A Guideline for the Treatment of Dementia in Japan Shigenobu NAKAMURA Abstract However, patients with dementia are treated with various drugs and many kinds of care. American Psychiatric Worldwide energetic efforts have provided several Association published a practice guideline for the treatment clues for the management of Alzheimer’s disease and re- of Alzheimer’s disease and other dementias of late life (3). lated dementias in elderly people, although the history of We recently prepared a guideline for the treatment of pa- dementia treatment is not long. Various pharmacological tients with dementia and published it for members of the or non-pharmacological treatments are carried out in Japanese Society of Neurology (4) and for the public (5). daily medical practice, but evidence for the validity of This article summarizes the guideline in Japan and recom- these treatments is limited. In United States and Europe, mends treatments for future research. several pharmacological and a few non-pharmacological treatments have been proven effective and a few drugs General Principle are approved by various governments and used in prac- tice. In contrast, only one acetylcholinesterase inhibitor, Medical management in treatment of the dementia donepezil has been proven effective and used for patients Demented patients in Japan are mainly treated or cared for with mild or moderate Alzheimer’s disease in Japan. at home (73.9%) and the rest in hospitals or institutes. Most Anti-hypertensive or anti-platelet therapy has been caregivers are females and complain of physical and psycho- shown to reduce the incidence or recurrence of stroke, logical burdens from patients especially with dyssomnia, agi- probably preventing vascular dementia. Effectiveness of tation or psychosis. A psychological support system for drugs and types of care awaits to be validated in the light caregivers is desirable in order to continue the care at home. of scientific procedures. Since demented patients might not be cared enough in case (Internal Medicine 43: 18–29, 2004) of a heavy strain on caregivers, doctors should be well in- formed of the caregiver’s condition. Key words: dementia, Alzheimer’s disease, actylcholin- The medical assessment is important for the diagnosis of esterase inhibitor, donepezil, day service, neuro- dementias. We use Diagnostic and Statistical Manual of leptics Mental Disorders-III revised (DSM-III-R), Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) or International Classification of Disease 10 (ICD10) and National Institute of Neurological and Communicative Introduction Disorders and Strokes-Alzheimer’s Disease and Related Disorders Association (NINCDS-ARDA). A precise diagno- Dementia, such as Alzheimer’s disease (AD) had been re- sis should be obtained by taking correctly stated anamnesis, garded as untreatable and patients with dementia were not tests on cognitive or psychiatric state, laboratory tests on pe- given treatment. Since Davies and Maloney reported a selec- ripheral blood or biochemical parameters, including serum tive loss of central cholinergic neurons in AD in 1976 (1), vitamin B1,B12, folic acid, nicotinic acid and thyroid hor- many studies, including ours (2), have confirmed the de- mone, test on syphilis and blood sedimentation rate. These creased level of cholinergic activity in AD brains. While the examinations provide not only a clue to determine so-called abnormality is not the primary cause of AD, these findings ‘treatable dementias’, but also a therapeutic guide to treat have accelerated the biochemical studies on AD, which pathological conditions associated with dementias. might lead to a path of treatment for dementia. The history The psychiatric assessment is essential. Grading of cogni- of AD treatment is short and the only acetylcholinesterase tive impairment is important to determine the treatment or (AChE) inhibitor, donepezil, is admitted for the use in daily care. Cognitive function is generally examined by Mini- medical practice for Japanese AD patients. mental State Examinations (MMSE), revised version of From Department of Neurology, Otowa Hospital, Kyoto Reprint requests should be addressed to Dr. Shigenobu Nakamura, Department of Neurology, Otowa Hospital, 2 Chinnji-cho, Otowa, Yamashina-ku, Kyoto 607-8062 18 Internal Medicine Vol. 43, No. 1 (January 2004) Treatment of Dementias in Elderly Hasegawa’s Dementia Rating Scale (HDS-R) and Wechsler Care for demented patients adult intelligence scale-revised (WAIS-R). Recently various types of care have been introduced to the Alzheimer’s disease assessment scale (ADAS) and its management of demented patients. The purpose of the care cognitive subscale (ADAS-cog) are usually employed to es- covers not only the support in daily living of patients, but timate an effect in drug trials. ADAS reveals various aspects also psychological intervention. Many means of psycho- of disorders in AD patients, expressing the grade of social care are attempted through behavioral, emotional, cog- dysfunctions in AD patients, which increases according to nitive or stimulation approaches. the development of AD. Experience over a long period should suggest the effec- Behavioral disturbances are examined mainly by Clinical tiveness of various types of care carried out in Japan. Dementia Rating (CDR) which includes disorder in memory, However, no systematic procedure has been established and orientation, judgment, social adaptation, personal belongings the scientific evidence to date is poor. Although psychosocial such as family member, hobby, interest and caregivers. AD types of care have been evaluated abroad, the number of sub- patients are classified into 7 stages by Functional Assess- jects is small, therapeutic methods or patients’ conditions are ment Staging (FAST). Non-cognitive emotional problems inconsistent and the analysis of psychiatric states is unreli- such as decreased motivation, hallucination or delusion are able. Since the effect of drug therapies is insufficient, further called Behavioral and Psychological Symptoms of Dementia studies to establish evidence-based evaluation of psycho- (BPSD). Many scales or checklists are devised to assess social cares are expected. BPSD and some are translated into Japanese. Depression is often associated with dementia, resulting in Psychosocial types of care through behavioral approaches increased frequency of suicide attempts, anxiety, indiffer- Caregivers should analyze behaviors and environmental ence or dyssomnia. Since suicide occurs in the early stages factors which precede harmful abnormal patient conduct and of dementia, family members should be aware of the risk and try to avoid them. When caregivers in institutions learn careful management is needed. Violent behavior is observed methods of behavioral care, the aggressiveness is decreased in demented elderly, making it difficult for family members in demented elderly. Aggressive behaviors sometimes occur or caregivers to manage patients. as a consequence of agitation at the time of bathing and can Falls often deteriorate motor and cognitive functions due be reduced by changing the place or shape of bath or by tak- to bone fracture or head trauma. Attention should be paid to ing bath while a helper stays at their house. Simplified cloth- obstacles in the room, the height of the bed, room lamp at ing or foods may alleviate the agitated mood while dressing night, portable toilet or sedatives which may cause or eating. The behavioral care should aim to adjust environ- orthostatic hypotension and falls. Getting lost due to the ment for the patient to fulfil their daily life as comfortable as visuo-spacial disorder makes AD patients wander with a risk possible with their residual ability. of accidents. Caregivers should sew the patients’ address Teri et al (5) tried a video tape training program for agi- onto their clothing in order that a lost patient is more quickly tated AD patients for 16 weeks and found that the video pro- found. gram significantly improved MMSE scores and was more Many demented patients are restrained or secluded in effective, with less frequent side effects, than trazodone Japan (70%). Restraint or seclusion includes the confinement medication. Thus, behavioral care programs should be car- in institutes, binding to bed or wheelchair and sedation with ried out before drug administration. drugs. Although it may protect the patient from dangerous If the patients’ urination is regularly scheduled by care- accidents, mental activities are decreased and this should be givers, a urinary incontinence is reduced. Training for diet or avoided in consideration of patients’ rights and dignity, when dressing may improve the patients’ behavior. Dressing by possible. themselves decreases the time of nursing. Unfortunately the Because the risk of traffic accidents increases when the previous studies on behavioral care have generally been car- demented elderly drives a car, doctors may advise patients to ried out with a small number of subjects, detailed methods stop driving. The driver’s license in Japan is annulled when are not discussed and its reproducibility is not confirmed. demented patients are diagnosed not to recover within 6 Since behavioral care seems important for the management months. A patient with possible dementia (CDR=0.5) should of dementia, qualitative research is necessary. be reexamined every 6 months, since the patient is often ag- gravated to CDR=1 and may have a traffic accident. Psychosocial care