This statement was prepared by a Task Force authorized by the AAGP Board of Directors and was then adopted by the AAGP Board at its September 14, 2005, meeting. The Task Force consisted of Constantine Lyketsos (Chair), Christopher Colenda, Cornelia Beck, Karen Blank, Murali Doriaswamy, Douglas Kalunian, and Kristine Yaffe.

POSITION

There exists currently an effective, systematic care/treatment model for patients with dementia resulting from Alzheimer disease (AD). This consists of a series of therapeutic interventions-pharmacologic and nonpharmacologic-targeted at patients with AD and their caregivers. Although these interventions do not produce a cure of the underlying disease and do not appear to stop its progression, they have been shown to produce benefits for patients and their caregivers. The aims of this care model, often referred to as "Dementia Care," are to delay disease progression, delay functional decline, improve quality of life, support dignity, control symptoms, and provide comfort at all stages of AD. This evolving model is based on scientific evidence of beneficial outcomes, with acceptable risks, and is increasingly targeted at an improving pathophysiological understanding of the biology of AD. Although the evidence is limited, the existing evidence, coupled with clinical experience and common sense, is adequate to produce a minimal set of care principles. In this context, the American Association for Geriatric Psychiatry (AAGP) affirms that there now exists a minimal set of care principles for patients with AD and their caregivers. Consequently, the detection and treatment of AD must now be considered part of the typical care practices for any physician and other licensed clinicians who interact with patients with this disease. This document articulates these principles of care.

DEFINITIONS

Cognitive Impairment No Dementia (CIND)
A clinical syndrome consisting of measurable or evident decline in memory or other cognitive abilities with little effect on day-to-day functioning that does not meet criteria for dementia as defined by DSM-IV-TR.¹

Mild Cognitive Impairment (MCI)
A clinical syndrome that is a subgroup of CIND with prominent amnestic symptoms that is in all likelihood a prodrome of AD.

Dementia
A clinical syndrome, that is not entirely the result of delirium, consisting of global cognitive decline with memory plus one other area of cognition affected with significant effects on day-to-day functioning and meets DSM-IV-TR criteria.

Dementia Resulting From Alzheimer Disease
The most common type of dementia characterized by decline primarily in cortical aspects of cognition and following a characteristic time course of gradual onset and progression.

Alzheimer Disease
A specific degenerative brain disease characterized by senile plaques, neuritic tangles, and progressive neuronal loss; also, the presumptive cause of AD.

CONTEXT OF THIS POSITION STATEMENT

The aim of this statement is to assert the position of the AAGP regarding the existence of specific principles of care for patients with AD for the purpose of improving care, and access to care, for patients with AD and their caregivers. This statement also aims to provide clinicians with guidance about the key elements of these care principles and about the reasons for which this care should be made available to patients with AD and caregivers. Because this is a position statement about treatment, it is assumed that appropriate diagnostic confirmation of AD has been carried out before the application of this model of care.

Being a position statement, not a practice guideline or parameter, this statement reflects the beliefs and opinions of the members of a professional association with special expertise in the care of patients with AD. As much as possible, this statement is based on the available evidence and is an effort to articulate best principles of care by synthesizing the available evidence with clinical judgments and practices. However, it is recognized that available evidence is not conclusive in most cases and that there are differing views and opinions about how to implement dementia care. Nevertheless, it is important from time to time to produce statements such as this as a guide to clinical practice.

The statement is targeted at AAGP members, other physicians, and other licensed clinicians who care for people with dementia. Although there are similarities in the care of patients with all types of dementia, this document is intentionally targeted at AD, not other forms of dementia, so as to retain focus, because most of the evidence supporting the effectiveness of dementia care is derived from studies of patients with AD and because AD is the most common form of dementia. The reader is referred to other documents regarding the care of patients with non-Alzheimer dementia. Furthermore, this document is not targeted at "mild cognitive impairment" (MCI), considered by many to be the earliest clinical manifestation of AD, because the evidence base regarding the treatment of the latter is limited and in evolution.

This position statement is intended to encompass clinical care for patients with AD in typical clinical settings (e.g., primary care, specialist care, and longterm care, including assisted living environments). Given its scope and purpose, this document intentionally does not address nonclinical aspects of dementia care as related to diagnostic tests, research, policy, or reimbursement for care. The reader is referred to other AAGP position statements involving the latter.

WHY THIS DOCUMENT NOW

Dementia is a major public health problem already that is expected to worsen given the aging of the population. Over 4.5 million Americans have the most common form of dementia, AD; this number will likely triple in the next 40-50 years.² Despite the commitment of significant effort and resources to the development of curative therapy for AD, a cure remains many years, possibly decades, away. In the meantime, it is important that medical professionals care for patients who currently have the disease, and their caregivers, using the most advanced methods available. The public has an increasing awareness of AD and is presenting to the healthcare system for care in ever-increasing numbers. Improvements in the diagnosis and the understanding of the biology of AD and significant evidence to support the effectiveness of therapies for AD all contribute to the timeliness of this position statement. The evidence base supports the effectiveness of the dementia care "package," which has been shown now in a variety of clinical settings to have wide-ranging benefits for patients and caregivers with regard to delay of functional decline, control of many symptoms, maximization of quality of life, and delay of disability and institutionalization. The evidence supporting dementia care has been extensively articulated in a series of Practice Guidelines, Care Parameters, Consensus Statements, Conference Proceedings, scientific papers, and books proposed previously by AAGP, and also by the American Psychiatric Association, the American Academy of Neurology, the Alzheimer Association, the federal Agency for Health Care Policy and Research (now AHRQ), and others. Despite this, detection rates for dementia remain low overall, no better than a decade ago,³ and the Guidelines are probably not being followed in most settings where dementia patients are seen, in part as a result of failure to detect.^4,5 In the current climate where there is evidence of treatment efficacy, for treatment albeit not cure, it is incumbent on professional organizations such as AAGP to assert minimal care principles for the medical profession in their areas of expertise.

ORGANIZATION OF THIS DOCUMENT

The remainder of this document articulates general principles of dementia care, encompassing the full spectrum of available treatments, both pharmacologic and nonpharmacologic, organized around the following key areas of therapy:

• Disease therapies for AD, targeted specifically at aspects of the current pathophysiological understanding of the disease;
• Symptomatic therapies for cognitive symptoms;
• Symptomatic therapies for other neuropsychiatric symptoms;
• Interventions targeted at, and the provision of, supportive care to patients; and
• Interventions targeted at, and the provision of, supportive care to caregivers.