Many cases of dementia have more than one condition contributing to causation. Most commonly this will be a combination of Alzheimer’s disease with other brain pathology. We recommend that management be based on those diagnoses that are believed to be the predominant contributing cause(s) (Grade 1B).
We recommend cholinesterase inhibitors as a treatment option for Alzheimer’s disease with cerebrovascular disease (Grade 1B).
We recommend cholinesterase inhibitors as a treatment option for dementia associated with Parkinson’s disease (Grade 1A).
There is insufficient and inconsistent evidence on which to make a recommendation either for or against the use of the currently available cholinesterase inhibitors for the treatment of vascular dementia (Grade 2B).
All three cholinesterase inhibitors have demonstrated efficacy for mild to severe AD. We recommend a trial of a cholinesterase inhibitor for most patients with AD (Grade 1A).
Direct comparisons do not suggest differences between cholinesterase inhibitors (Grade 2B). Selection of which agent to be used will be based on adverse effect profile, ease of use, familiarity, and differences between the agents in their pharmacokinetics and other mechanisms of action.
Combination therapy of a cholinesterase inhibitor and memantine is rational (as the medications have different mechanisms of action) and appears to be safe, but there is insufficient evidence to recommend for or against this combination (Grade 2B).
If the patient had an inadequate response to the non-pharmacological interventions or has a Major Depressive Disorder, severe dysthymia, or severe emotional liability, we recommend that a trial of an antidepressant could be considered (Grade 2A).
Based on good evidence we recommend that valproate should not be used for agitation and aggression in AD (Grade 1A).
There is no good evidence to recommend for or against the use of cholinesterase inhibitors and/or memantine for the treatment of neuropsychiatric symptoms as a primary indication (Grade 2B).
We recommend that risperidone, olanzapine and aripiprazole be used for severe agitation, aggression and psychosis associated with dementia where there is risk of harm to the patient and/or others. The potential benefit of all antipsychotics must be weighed against the significant risks such as cerebrovascular adverse events and mortality (Grade 2A).
There is insufficient evidence to recommend for or against the use of quetiapine in the management of severe agitation, aggression and psychosis associated with dementia (Grade 2B).
There is insufficient evidence to recommend for or against the use of SSRIs or trazodone in the management of agitated patients (Grade 2B).
