Treatment

For many conditions the goals of treatment or intervention are self-evident—cure, prevention of relapse, and resolution of symptoms. For AD, however, the goals of treatment can be less obvious and differ between patients and for individual patients over time. Ultimately, the quality of life of the patient should be improved, but assessing quality of life is difficult in those with dementia, and given the early loss of insight who is to judge such issues? (68) Quality of life may appear poor—patients may have diminished emotional repertoires, few pleasurable activities, and considerable handicap—but they may share none of the negative cognitions experienced by others with a similarly questionable quality of life induced by different illnesses. Other patients may appear content or happy, despite the loss of the autonomy and self-awareness normally considered an essential component of a good quality life. Equally, the treatment unit in AD includes carers, and there are times when the patient's quality of life is in conflict with the quality of life for other members of the family. Resolving such conflicts of interest and other moral and ethical issues is part of the treatment process in AD. With the arrival of specific treatments for AD and the prospect of disease-modifying therapies, an even harder question arises regarding prolonging life for those with dementia: if quality of life appears poor to observers, is it right to prolong the process, can quality of life in those with dementia truly be assessed, or should carers and families be allowed to assess for themselves the benefits and costs of treatment? (69)

There is no single model of management of patients with AD. In many countries management is the role of the gerontologist or neurologist. In others, as in the United Kingdom, the old-age psychiatry team provide the core specialist services. Many, perhaps even the majority, of those with AD are managed within primary care with the support of social services. Referral from primary care to specialist services will be according to local agreements, but most would concur that behavioural disturbance or the use of specific drugs to treat AD warrant referral to secondary care. Interventions for aD, whether provided in primary or secondary care, can be thought of as directed towards the patient, the patient's family, and the patient's environment. Guidelines on the identification and management of patients with dementia have been produced and may be a constructive approach to ensuring best clinical practice. (70,71 and72)

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