This is the December 31, 2007, issue of Elder Law FAX, a free newsletter published by the Elder Law Practice of Timothy L. Takacs   Psychiatrists Release Updated Guidelines for Treating Patients With Dementia New guidelines for the treatment of persons suffering from Alzheimer's disease and other dementias have been released by the American Psychiatric Association (APA). The guidelines update a previous edition issued by the association in 1997.   The chair of the guidelines working group, Peter V. Rabins, MD, from Johns Hopkins University School of Medicine, in Baltimore, Maryland, is co-author of the popular book The 36-Hour Day: A Family Guide to Caring for Persons with Alzheimer Disease, Related Dementing Illnesses, and Memory Loss in Later Life.   Since the publication of the first edition of the guidelines, in 1997, advances in the diagnosis and treatment of dementia have been made.   There has been some preliminary evidence that the use of positron emission tomography (PET) scanning may be advantageous in the diagnosis of Alzheimer's disease. In fact, Medicare has recently approved for reimbursement PET scans for the indication of differentiating between Alzheimer's disease and fronto-temporal dementia.   Similarly, studies using magnetic resonance imaging (MRI) to measure the size of key brain structures (among them the hippocampus and amygdala) have suggested that a smaller size of these structures in persons with only minor cognitive complaints can identify individuals who will have diagnosable Alzheimer's dementia within three years.   Despite much research, no significant advances have been made in the use of biological markers for the diagnosis of dementia, the APA guidelines note.   Although advances have been made in the area, genetic testing for apolipoprotein E4 (APOE4) is not generally recommended for use in diagnosis. Apolipoprotein E4 is one form of a gene on chromosome 19 that is more common in individuals with Alzheimer's disease than in elderly individuals without dementia and is associated with late-onset Alzheimer's disease occurring with or without a family history. However, it is also found in many elderly patients who do not have dementia and is not found in many patients who do have Alzheimer's disease.   Since the 1997 guidelines were published, three cholinesterase inhibitor drugs -- galantamine, rivastigmine, and donepezil -- are now approved by the U.S. Food and Drug Administration (FDA) and are used for the treatment of Alzheimer's disease. There is no convincing evidence that any one cholinesterase inhibitor has greater efficacy than another. It remains unclear whether use of these drugs slows progression of the disease, delays nursing home placement, or alters mortality.   As the new guidelines state, "Whenever cholinesterase inhibitors are prescribed, patients and their families should be apprised of the limited potential benefits as well as the potential costs."   In an interview with Medscape Psychiatry, Dr. Rabins said, "I think that we have been able to strengthen many of the recommendations that were made, because there have been a number of confirming studies." Nonetheless, "There's really nothing new. It's just that the evidence is stronger."   An important change in the new guidelines from the earlier edition is that Vitamin E is no longer recommended as a treatment for Alzheimer' disease, and new studies have demonstrated health risks to patients who take it at higher doses.   The new guidelines also caution physicians about the use or overuse of certain anti-psychotic drugs, with particular emphasis placed on side effects these medications may cause.   Moreover, analyses of clinicaltrials of the second-generation antipsychotics aripiprazole, olanzapine, quetiapine, and risperidone, as well as of first-generation antipsychotics, have found an increased mortality when used in elderly patients with dementia. These concerns have led to warnings on the second-generation antipsychotics.   The 55-page guidelines include an executive summary in which recommendations are coded according to three levels of degree of clinical evidence.   The section that follows this is an extensive guide for developing and implementing a stage-specific treatment plan for the individual patient. The last section details specific clinical features influencing the treatment plan.   Link to Guidelines: http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm