Overview of clinical and pharmaceutical issues in dementia care

The session will deal with priority clinical and management issues regarding the symptomatic and future treatment of dementia, including the treatment of Behavioural and Psychological Symptoms.

Key issues covered include:

• • The evidence for and clinical use of current symptomatic treatments for Alzheimer's disease

• • What are the emerging treatments

• • What is the role for anti psychotics in the treatment of BPSD

• • What is the evidence for non-antipsychotic pharmacological treatments in the treatment of BPSD

Current and future treatment of Alzheimer's disease

Serge Gauthier MD, FRCPC McGill Center for Studies in Aging Douglas Mental Health Research Institute, Montreal, Canada

Up to now the treatment of Alzheimer's disease (AD) has been focused on improving symptoms as they emerge through the different stages of dementia. The combination of available drugs (cholinesterase inhibitors and NMDA receptor antagonist) is becoming the norm. Caregiver support and education is an essential component oftreatment.

There is a progressive shift to earlier diagnosis of AD in its prodromal or predementia or MCI stage, using the Dubois and the NIA-AA criteria. No specific treatment is currently available at this stage of AD, but there is cautious optimism that cognitive training and drugs acting on certain aspects of the pathophysiology of AD will be effective.

For persons without cognitive symptoms the level of risk of developing AD in later life could be estimated using known genetic and acquired risk factors. Cohorts of persons with different levels of risk could be treated preventively with interventions appropriate to their level of risk, ranging from PS1/PS2/APP mutation carriers to ApoE4 homozygots to subjective cognitive impairment.

The value of biomarkers as inclusion criteria and as outcomes is being actively studied worldwide.

Pharmacological management of behavioral and psychological symptoms in dementia

Clive Ballard, Professor of Age Related Diseases, King's College London, England, United Kingdom

Behavioral and Psychological Symptoms of Dementia (BPSD) are frequent amongst people with Alzheimer's disease (AD) and other dementias, commonly confer risk to the person and others, and present a significant management challenge for clinicians. The most widely prescribed pharmacological treatments -atypical anti psychotics - have a modest but significant beneficial effect in the short-term treatment of aggression and psychosis (over 6-12 weeks). The clearest evidence base is for risperidone, which is the only atypical antipsychotic licensed for the treatment of aggression in people with Alzheimer's disease. Conversely, there is clear evidence that quetiapine is ineffective. There have been increasing concerns regarding the potential for serious adverse outcomes for all anti psychotics in people with dementia, including stroke, pulmonary embolism, accelerated cognitive decline and death. Over longer term periods of treatment there is less evidence that antipsychotics confer any benefit in the treatment of aggression or psychosis, but there is a cumulative effect on the increased mortality risk. The potential pharmacological alternatives to atypical anti psychotics with the most encouraging preliminary evidence include memantine, carbamazepine and citalopram and large prospective, randomized, placebo-controlled trials are needed to establish the role of these agents as clinical therapies for the treatment ofBPSD. Recent large RCTs have indicated that the combination of donepezil and memantine may significantly delay the emergence ofBPSD and highlighted the important role of analgesics in managing agitation. There are very few studies examining the treatment ofBPSD in non-Alzheimer dementias, a gap which needs to be urgently addressed.