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## Complete Summary

#### GUIDELINE TITLE

Practice parameter: management of dementia (an evidence-based review).
Report of the Quality Standards Subcommittee of the American Academy of
Neurology.

#### BIBLIOGRAPHIC SOURCE(S)

Doody RS, Stevens JC, Beck C, Dubinsky RM, Kaye JA, Gwyther L, Mohs RC,
Thal LJ, Whitehouse PJ, DeKosky ST, Cummings JL. Practice parameter:
management of dementia (an evidence-based review). Report of the Quality
Standards Subcommittee of the American Academy of Neurology.
Neurology 2001 May 8;56(9):1154-66. \[175 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

According to the guideline developer, this guideline has been reviewed
and is still considered to be current as of October 2003. This review
involved new literature searches of electronic databases followed by
expert committee review of new evidence that has emerged since the
original publication date.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [June 17, 2008, Antipsychotics (conventional and
    atypical\])](http://www.fda.gov/medwatch/safety/2008/safety08.htm#Antipsychotics):
    The U.S. Food and Drug Administration (FDA) notified healthcare
    professionals that both conventional and atypical antipsychotics are
    associated with an increased risk of mortality in elderly patients
    treated for dementia-related psychosis. The prescribing information
    for all antipsychotic drugs will now include information about the
    increased risk of death in the BOXED WARNING and WARNING sections.

-   [September 17, 2007, Haloperidol
    (Haldol)](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Haloperidol):
    Johnson and Johnson and the U.S. Food and Drug Administration (FDA)
    informed healthcare professionals that the WARNINGS section of the
    prescribing information for haloperidol has been revised to include
    a new Cardiovascular subsection.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Dementia

-   Alzheimer´s disease

#### GUIDELINE CATEGORY

Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Geriatrics\
Internal Medicine\
Neurology\
Pharmacology\
Psychiatry

#### INTENDED USERS

Advanced Practice Nurses\
Health Care Providers\
Nurses\
Pharmacists\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To define and investigate key issues in the management of dementia

-   To make literature-based treatment recommendations for the
    management of dementia

#### TARGET POPULATION

Elderly patients with dementia or Alzheimer´s disease

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Pharmacologic Treatment of Alzheimer´s Disease**

1.  Cholinesterase inhibitors, such as tacrine, donepezil, rivastigmine,
    and galantamine

2.  Precursors and agonists to improve cholinergic transmission and a
    number of other cognitive-enhancing drugs (considered but not
    recommended)

3.  Vitamin E (alpha-tocopherol)

4.  Selegiline

5.  Estrogen (e.g., Premarin®), other antioxidants, and
    anti-inflammatories (e.g., diclofenac, indomethacin, prednisone) are
    considered but not recommended.

**Pharmacotherapy in Mixed Populations or Patients with Mixed
Dementias**

1.  Gingko biloba

**Pharmacotherapy in Ischemic Vascular Dementia**

1.  Oxiracetam, cyclandelate, flunarizine, and pentoxifylline are
    considered but not recommended.

**Pharmacotherapy for Noncognitive Symptoms (behavioral symptoms,
depression)**

1.  Antipsychotics, such as risperidone, haloperidol, thioridazine,
    olanzepine, quetiapine

2.  Antihistamines, (e.g., diphenhydramine), benzodiazepines, (e.g.,
    oxazepam), chelating agents (e.g., desferroxamine) and
    anticonvulsants (e.g, carbemazepine) are considered but not
    recommended

3.  Antidepressants, such as selected tricyclic antidepressants
    (clomipramine, maprotiline); monoamine oxidase (MAO) inhibitors; and
    selective serotonin reuptake inhibitors (fluoxetine, fluvoxamine,
    citalopram, paroxetine)

**Educational Interventions**

1.  Short-term educational programs for caregivers of dementia patients

2.  Intensive long-term education and support services for caregivers

3.  Education of staff at long-term facilities

**Non-pharmacologic Interventions**

1.  Interventions to improve functional performance, such as behavior
    modification, scheduled toileting, prompted voiding to reduce
    urinary incontinence; measures to increase functional independence;
    low lighting levels, music, simulated nature sounds to improve
    eating behaviors; intensive multimodality group training to improve
    activities of daily living are considered but not recommended.

2.  Non-pharmacologic interventions for problem behaviors, such as
    music, walking and other forms of light exercise, simulated presence
    therapy, massage, pet therapy, cognitive remediation, bright light,
    white noise, and other psychosocial programs are considered but not
    recommended.

3.  Care environment alterations, such as special care units in
    long-term facilities are considered but not recommended.

4.  Interventions for caregivers, such as support groups and training
    programs

#### MAJOR OUTCOMES CONSIDERED

-   Effectiveness of pharmacotherapy for cognitive symptoms on outcomes
    of patients with dementia as compared to no therapy

-   Effectiveness of pharmacotherapy for noncognitive symptoms on
    outcomes of patients with dementia as compared to no therapy

-   Effectiveness of educational interventions on outcomes in patients
    and/or caregivers of patients with dementia as compared to no
    interventions

-   Effectiveness of nonpharmacologic interventions other than
    educational interventions on outcomes in patients and/or caregivers
    of patients with dementia as compared to no interventions

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

*Literature review process* [Search terms]{.underline}. Alzheimer´s
disease, vascular or multi-infarct dementia, dementia with associated
parkinsonian disorder (diffuse Lewy body disease, dementia with Lewy
bodies, Parkinson´s disease with dementia), progressive supranuclear
palsy, frontotemporal dementia (including Pick´s disease), and senile
dementia. Additional search terms were question-specific:

-   Question 1: Cholinesterase inhibitors, antioxidants, hormones,
    anti-inflammatory agents/drugs, cholinergic agents/drugs, nootropics
    (class of compounds structurally related to piracetam), metabolic
    enhancers, neurotrophic agents/drugs, (complementary) alternative
    medicines, treatment, and pharmacotherapy.

-   Question 2: Hypnotics, antidepressants, anxiolytics, tranquilizers,
    sleep medications, selective serotonin reuptake inhibitors (SSRI),
    treatment and sleep, treatment and depression, treatment and
    anxiety, treatment and agitation, treatment and disinhibition,
    treatment and affective disorders, management, treatment and
    maintain (trunc), and treatment and discontinue (trunc).

-   Questions 3 and 4: Counseling, education and caregiver, education
    and patient, environment, behavior (trunc) manag (trunc), behavior
    (trunc) and modif (trunc), advance directive, rehabilitation, and
    terminal care.

The key and index words for the special issue of cooperation between
specialists were the following: treatment and multidisciplinary,
treatment and team, treatment and community, neurologist (trunc),
primary care, respite care, services, providers, transfer of care,
long-term care, and family advocacy. Special issues related to economic
models used the following key and index words: health care systems,
health maintenance organization, preferred provider organization,
medicaid, medicare, insurance, managed care, economic (trunc), and
quality of care. Special issues related to determining capacity to
consent used were the following: competency, decision-making, patient
refusal of therapy/treatment, physician patient relations, patient
rights, patient involvement, and informed consent.

[Databases]{.underline}. For questions 1 and 2 the following databases
were searched: MEDLINE, Embase, Current Contents, Psych Abstracts, and
Cochrane databases. For questions 3 and 4: MEDLINE, Embase, Current
Contents, Psychology Info, Cochrane, and CINAHL.

[Inclusion/exclusion criteria and process]{.underline}. Studies selected
included the following: randomized, controlled studies in all languages
and other types of studies limited to English; human subjects with N
greater than 20, regardless of outcome measured; and review articles
published between January 1998 and November 1999. The nonpharmacologic
intervention questions allowed smaller N for supporting studies to
reflect the activity in the field. Members of the work group reviewed
all search results and the bibliographies of the review articles to
identify any articles that they thought were missing; these articles
were submitted to the same inclusion/exclusion criteria. The initial
search was conducted in October 1998; additional articles were added
until July 2000.

[Number and disposition of articles, data extraction, and classification
of evidence]{.underline}. The search strategy identified 2,548 articles.
A total of 380 met the predefined inclusion/exclusion criteria and were
reviewed by at least two individuals. Selected items from each article
were entered into a standardized data extraction form, and each article
was assigned a class of evidence based upon a priori definitions, which
determined whether or not study results were ultimately translated into
Standards, Guidelines, or Practice Options.

#### NUMBER OF SOURCE DOCUMENTS

380

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Classification of Evidence**

I.  Evidence provided by one or more well-designed, randomized,
    controlled clinical trials, including overviews (meta-analyses) of
    such trials.

II. Evidence provided by well-designed, observational studies with
    concurrent controls (e.g., case control or cohort studies).

III. Evidence provided by expert opinion, case series, case reports, and
     studies with historical controls.

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

For all extracted articles, evidence tables were developed according to
search question. These tables indicate the author and year of the study,
level of evidence, main purpose of the study, population, intervention,
out-come measures, and results.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Levels of Recommendations**

*Standard*. Principle for patient management that reflects a high degree
of clinical certainty (usually this requires Class I evidence that
directly addresses the clinical questions, or overwhelming Class II
evidence when circumstances preclude randomized clinical trials).

*Guideline*. Recommendation for patient management that reflects
moderate clinical certainty (usually this requires Class II evidence or
a strong consensus of Class III evidence).

*Practice Option*. Strategy for patient management for which the
clinical utility is uncertain (inconclusive or conflicting evidence or
opinion).

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

After the Quality Standards Subcommittee´s review and approval, the
document was circulated to the members of the full Dementia Practice
Parameter Work Group (committee members drafting the early detection and
diagnosis of dementia sections), members of the American Academy of
Neurology, Member Review Network, appropriate sections of the American
Academy of Neurology, United States and international dementia experts,
and selected patient advocacy and physician organizations.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

*Classification of evidence ratings, I-III, and the levels of
recommendations (Standard, Guideline, Practice Option) are defined at
the end of the \"Major Recommendations\" field.*

**Pharmacologic Treatment of Alzheimer\'s Disease**

-   Cholinesterase inhibitors should be considered in patients with mild
    to moderate Alzheimer\'s disease **(Standard)**, although studies
    suggest a small average degree of benefit.

-   Vitamin E (1000 I.U. PO BID) should be considered in an attempt to
    slow progression of Alzheimer\'s disease **(Guideline)**.

-   Selegiline (5 mg PO BID) is supported by one study, but has a less
    favorable risk-benefit ratio **(Practice Option)**.

-   There is insufficient evidence to support the use of other
    antioxidants, anti-inflammatories, or other putative
    disease-modifying agents specifically to treat Alzheimer\'s disease
    because of the risk of significant side effects in the absence of
    demonstrated benefits **(Practice Option)**.

-   Estrogen should not be prescribed to treat Alzheimer\'s disease
    **(Standard)**.

*Mixed Populations or Patients with Mixed Dementias*

-   Some patients with unspecified dementia may benefit from ginkgo
    biloba, but evidence-based efficacy data are lacking **(Practice
    Option)**.

*Ischemic Vascular Dementia*

-   There are no adequately controlled trials demonstrating
    pharmacologic efficacy for any agent in ischemic vascular
    (multi-infarct) dementia.

**Treatment of Behavioral Disturbances**

-   Antipsychotics should be used to treat agitation or psychosis in
    patients with dementia where environmental manipulation fails
    **(Standard)**. Atypical agents may be better tolerated compared
    with traditional agents **(Guideline)**.

-   Selected tricyclics, monamine oxidase-B (MAO-B inhibitors), and
    selective serotonin reuptake inhibitors (SSRI) should be considered
    in the treatment of depression in individuals with dementia with
    side effect profiles guiding the choice of agent **(Guideline)**.

**Educational Interventions**

-   Short-term programs directed toward educating family caregivers
    about Alzheimer\'s disease should be offered to improve caregiver
    satisfaction **(Guideline)**.

-   Intensive long-term education and support services (when available)
    should be offered to caregivers of patients with Alzheimer\'s
    disease to delay time to nursing home placement **(Guideline)**.

-   Staff of long-term care facilities should receive education about
    Alzheimer\'s disease to reduce the use of unnecessary antipsychotics
    **(Guideline)**.

**Interventions to Improve Functional Performance**

-   Behavior modification, scheduled toileting, and prompted voiding
    should be used to reduce urinary incontinence **(Standard)**.

-   Graded assistance, practice, and positive reinforcement should be
    used to increase functional independence **(Guideline)**.

-   Low lighting levels, music, and simulated nature sounds may improve
    eating behaviors for persons with dementia, and intensive
    multimodality group training may improve activities of daily living,
    but these approaches lack conclusive supporting data **(Practice
    Options)**.

**Nonpharmacologic Interventions for Problem Behaviors**

-   Persons with dementia may experience decreased problem behaviors
    with the following interventions: music, particularly during meals
    and bathing **(Guideline)**; walking or other forms of light
    exercise **(Guideline)**.

-   Although evidence is suggestive only, some patients may benefit from
    the following **(Practice Options)**:

    -   Simulated presence therapy, such as the use of videotaped or
        audiotaped family

    -   Massage

    -   Comprehensive psychosocial care programs

    -   Pet therapy

    -   Commands issued at the patient´s comprehension level

    -   Bright light, white noise

    -   Cognitive remediation

**Care Environment Alterations**

-   Although definitive data are lacking, the following environments may
    be considered for patients with dementia **(Practice Options)**:

    -   Special care units (SCU) within long-term care facilities

    -   Homelike physical setting with small groups of patients as
        opposed to traditional nursing homes

    -   Short-term, planned hospitalization of 1 to 3 weeks with or
        without blended inpatient and outpatient care

    -   Provision of exterior space, remodeling corridors to simulate
        natural or home settings, and changes in the bathing environment

**Interventions for Caregivers**

-   The following interventions may benefit caregivers of persons with
    dementia and may delay long-term placement **(Guidelines)**:

    -   Comprehensive, psychoeducational caregiver training

    -   Support groups

-   Additional patient and caregiver benefits may be obtained by use of
    computer networks to provide education and support to caregivers
    **(Practice Option)**, telephone support programs **(Practice
    Option)**, and adult day care for patients and other respite
    services **(Practice Option)**.

**Definitions**:

**Classification of Evidence**

I.  Evidence provided by one or more well-designed, randomized,
    controlled clinical trials including overviews (meta-analyses) of
    such trials.

II. Evidence provided by well-designed, observational studies with
    concurrent controls (e.g., case control or cohort studies).

III. Evidence provided by expert opinion, case series, case reports, and
     studies with historical controls.

**Levels of Recommendations**

*Standard*. Principle for patient management that reflects a high degree
of clinical certainty (usually this requires Class I evidence that
directly addresses the clinical questions, or overwhelming Class II
evidence when circumstances preclude randomized clinical trials).

*Guideline*. Recommendation for patient management that reflects
moderate clinical certainty (usually this requires Class II evidence or
a strong consensus of Class III evidence).

*Practice Option*. Strategy for patient management for which the
clinical utility is uncertain (inconclusive or conflicting evidence or
opinion).

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on a review of the literature. The type of
supporting evidence is identified and graded for each recommendation on
the management of dementia.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate pharmacologic and non-pharmacologic management of dementia

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This statement is provided as an educational service of the American
Academy of Neurology. It is based on an assessment of current scientific
and clinical information. It is not intended to include all possible
proper methods of care for a particular neurologic problem or all
legitimate criteria for choosing to use specific procedures. Neither is
it intended to exclude any reasonable alternative methodologies. The
American Academy of Neurology recognizes that specific patient care
decisions are the prerogative of the patient and the physician caring
for the patient, based on all the circumstances involved.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Patient Resources\
Personal Digital Assistant (PDA) Downloads\
Quick Reference Guides/Physician Guides\
Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Doody RS, Stevens JC, Beck C, Dubinsky RM, Kaye JA, Gwyther L, Mohs RC,
Thal LJ, Whitehouse PJ, DeKosky ST, Cummings JL. Practice parameter:
management of dementia (an evidence-based review). Report of the Quality
Standards Subcommittee of the American Academy of Neurology.
Neurology 2001 May 8;56(9):1154-66. \[175 references\]

#### ADAPTATION

Not applicable: Guideline was not adapted from another source.

#### DATE RELEASED

2001 May (reviewed 2003)

#### GUIDELINE DEVELOPER(S)

American Academy of Neurology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American Academy of Neurology (AAN)

#### GUIDELINE COMMITTEE

Quality Standards Subcommittee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: R.S. Doody, MD, PhD; J.C. Stevens, MD; C. Beck, RN, PhD; R.M.
Dubinsky, MD; J.A. Kaye, MD; L. Gwyther, MSW; R.C. Mohs, PhD; L.J. Thal,
MD; P.J. Whitehouse, MD, PhD; S.T. DeKosky, MD; and J.L. Cummings, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Committee members disclosed any real or potential conflicts of interest.

#### ENDORSER(S)

American Association of Neuroscience Nurses - Professional Association\
American Geriatrics Society - Medical Specialty Society

#### GUIDELINE STATUS

This is the current release of the guideline.

According to the guideline developer, this guideline has been reviewed
and is still considered to be current as of October 2003. This review
involved new literature searches of electronic databases followed by
expert committee review of new evidence that has emerged since the
original publication date.

#### GUIDELINE AVAILABILITY

Electronic copies: A list of American Academy of Neurology (AAN)
guidelines, along with a link to a Portable Document Format (PDF) file
for this guideline, is available at the [AAN Web
site](http://aan.com/go/practice/guidelines).

Print copies: Available from the AAN Member Services Center, (800)
879-1960, or from AAN, 1080 Montreal Avenue, St. Paul, MN 55116.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   AAN encounter kit for dementia: a multi-media, web-based algorithm.
    Available from the [American Academy of Neurology (AAN) Web
    site](http://www.aan.com/go/practice/quality/dementia)

-   AAN guideline summary for clinicians. Detection, diagnosis and
    management of dementia. St. Paul (MN): American Academy of
    Neurology, 2001. Electronic copies: Available from the [AAN Web
    site](http://www.aan.com/professionals/practice/pdfs/dementia_guideline.pdf).
    See the related QualityTool summary on the [Health Care Innovations
    Exchange Web site](http://innovations.ahrq.gov/content.aspx?id=821).

-   Practice parameter: management of dementia. American Academy of
    Neurology. 2001. 16 p. Available for personal digital assistant
    (PDA) download from the [AAN Web
    site](http://www.aan.com/professionals/practice/guidelines/pda/Dementia_management.pdf).

-   AAN guideline development process. St. Paul (MN): American Academy
    of Neurology. Electronic copies: Available from the [AAN Web
    site](http://aan.com/go/practice/guidelines/development).

#### PATIENT RESOURCES

The following is available:

-   AAN guideline summary for patients and their families: Alzheimer\'s
    disease guidelines. St. Paul (MN): American Academy of Neurology. 4
    p.

Electronic copies: Available in Portable Document Format (PDF) from the
[American Academy of Neurology (AAN) Web
site](http://www.aan.com/professionals/practice/pdfs/dem_pat.pdf). See
the related QualityTool summary on the [Health Care Innovations Exchange
Web site](http://innovations.ahrq.gov/content.aspx?id=817).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on February 12, 2002. The
information was verified by the guideline developer on September 5,
2003. This summary was updated by ECRI on April 1, 2005, following the
U.S. Food and Drug Administration advisory on Reminyl (galantamine).
This summary was most recently updated by ECRI on April 15, 2005
following the public health advisory concerning an unapproved
\"off-label\" use of atypical antipsychotic drugs in elderly patients
with dementia. This summary was updated by ECRI on August 15, 2005,
following the U.S. Food and Drug Administration advisory on
antidepressant medications. This summary was updated by ECRI on May 31,
2006 following the U.S. Food and Drug Administration advisory on Paxil
(paroxetine hydrochloride). This summary was updated by ECRI Institute
on October 2, 2007, following the U.S. Food and Drug Administration
(FDA) advisory on Haloperidol. This summary was updated by ECRI
Institute on November 2, 2007, following the U.S. Food and Drug
Administration advisory on Antidepressant drugs. This summary was
updated by ECRI Institute on July 25, 2008, following the U.S. Food and
Drug Administration advisory on Antipsychotics.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is
copyrighted by the American Academy of Neurology.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
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Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/10/2008