Clinical practice guidelines for severe Alzheimer's disease

BACKGROUND: Although severe Alzheimer's disease (AD) represents a prevalent, serious, and costly public health problem, few practice guidelines exist to help physicians manage this disorder. METHODS: A search of English language medical databases was performed from 1996 to the present for articles pertaining to the management of AD. The focus of this review was on studies that included patients with severe disease. Studies were assessed by considering the subjects, trial design, analysis, and results. Recommendations were based on the best available evidence. RESULTS: Severe AD can be defined and diagnosed reliably by using measures of cognition, function, behavior, and global staging. Specific assessments would also include medical status, safety issues, and the health status of the caregiver. Disease-specific management would include treatment with cholinesterase inhibitors and/or memantine. Treatment of neuropsychiatric symptoms begins with nonpharmacologic behavioral and environmental approaches. Severe agitation, aggression, and psychosis that are potentially dangerous to the patient, caregiver, and others in the environment can be treated with atypical antipsychotics, with consideration of their increased risk of cerebrovascular adverse events and mortality. All pharmacologic approaches require careful monitoring and regular periodic reassessments to determine whether ongoing treatment is necessary. CONCLUSIONS: Evidence-based guidelines for the management of severe AD have the potential to improve the quality of life for the patient and their caregiver. More randomized controlled trials aimed specifically at this phase of illness are still urgently required.