Guideline for primary care management of dementia

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From: British Medical Journal(Vol. 318, Issue 7185)
Publisher: BMJ Publishing Group Ltd.
Document Type: Article
Length: 2,316 words

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Such guidelines should consider all relevant effective treatments

Editor--Evidence based guidelines have a responsibility to consider all the relevant effective treatments and not to concentrate only on those with which clinicians are familiar. I was surprised by a serious omission from the North of England evidence based guidelines for the primary care management of dementia[1]--of category I evidence for the effectiveness of Ginkgo biloba extract in dementia, from a large randomised controlled trial.[2] The number needed to treat for a 4 point improvement in the cognitive subscale of the Alzheimer's disease assessment scale at one year of follow up has been calculated as 7.9 (95% confidence interval 4.2 to 67); for a significant improvement in the geriatric assessment by relative's rating instrument (a daily living and social behaviour score assessed by family members) it was 7.0 (3.3 to 97). The dose of G biloba extract was 120 mg a day.[3]

G biloba extract is available over the counter, and the cost of a year's treatment (from one major supermarket) is 85 [pounds sterling]. A year's treatment with donepezil, by contrast, costs 891 [pounds sterling] for 5 mg and 1248 [pounds sterling] for 10 mg.

Tom Marshall Honorary lecturer in public health medicine

Department of Public Health and Epidemiology, University of Birmingham, Birmingham B 15 2TT MarshaTP@HSRC1.bham.ac.uk

Competing interests: None declared.

[1] Eccles M, Clarke J, Livingstone M, Freemantle N, Mason J for the North of England Evidence Based Dementia Guideline Development Group. North of England evidence based guidelines development project: guideline for the primary care management of dementia. BMJ 1998;317:802-8. (19 September.)

[2] Le Bars PL, Katz MM, Berman N, Itil TM, Freedman AM, Schatzberg AF for the North American RGb Study Group. A placebo-controlled, double-blind, randomized trial of an extract of Ginkgo biloba for dementia. JAMA 1997; 278:1327-32.

[3] Dementia: diagnosis and treatment. Bandolier 1998;5(2): 2-3.

Guideline should cover differential diagnosis

Editor--The summary version of the guideline for primary care management of dementia is inadequate and in some respects inaccurate.[1] Not to cover differential diagnosis is a major omission; treatments for Alzheimer's disease now exist, and general practitioners and the primary healthcare team need to identify patients with vascular dementia and cognitive impairment (many such patients have treatable risk factors) as well as those with Lewy body dementia (for which diagnostic advice is in fact provided). The guideline should at least have recommended referral to specialist services, since distinguishing between the dementias is one of our most important clinical problems and an area where guidelines are most urgently required. Advice about when to refer to social services is essential.

The section on physical screening failed to recommend a physical examination, which is an essential part of the assessment--to identify treatable vascular risk factors, for example. Recommended routine screening tests should have included vitamin B-12 assay and liver function tests. The search strategy and synthesis included only the findings of studies published before 1996, apart from two 1998 references. Thus many of the statements about drug treatment are inaccurate, and the recommendations are...

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Gale Document Number: GALE|A54342435