Addressing Alzheimer’s: A pragmatic approach

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Applied Evidence

Addressing Alzheimer’s: A pragmatic approach

J Fam Pract. 2015 January;64(1):10-18

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References

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2, 2014.

11. Jack CR, Knopman DS, Jagust WJ, et al. Tracking pathophysiological processes in Alzheimer’s disease: an updated hypothetical model of dynamic biomarkers. Lancet Neurol. 2013;12:207-216.

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13. Centers for Medicare and Medicaid Services. National coverage determination (NCD) for FDG PET for dementia and neurodegenerative diseases (220.6.13). Centers for Medicare and Medicaid Services Web site. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=288&ncdver=3&bc=BAABAAAAAAAA&. Accessed December 2, 2014.

14. Albert MS, DeKosky ST, Ruckson D, et al. The diagnosis of mild cognitive impairment due to Alzheimer’s disease: recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimers Dement. 2011;7:270-179.

15. Mitchell AJ, Shiri-Feshki M. Rate of progression of mild cognitive impairment to dementia—meta-analysis of 41 robust inception studies. Acta Psychiatr Scand. 2009;119:252-265.

16. Farias ST, Mungas D, Reed BR, et al. Progression of mild cognitive impairment to dementia in clinic- vs community-based cohorts. Arch Neurol. 2009;66:1151-1157.

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18. Ngo-Metzger Q, August KJ, Srinivasan M, et al. End-of-life care: guidelines for patient-centered communication. Am Fam Physician. 2008;77:167-174.

19. Sayegh P, Knight BG. Cross-cultural differences in dementia: the Sociocultural Health Belief Model. Int Psychogeriatr. 2013;25:517-530.

20. McDaniel SH, Campbell TL, Hepworth J, et al. Family-Oriented Primary Care. 2nd ed. New York, NY: Springer; 2005.

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22. Russ TC, Morling JR. Cholinesterase inhibitors for mild cognitive impairment. Cochrane Database Syst Rev. 2012;9:CD009132.

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25. Fillit HM, Doody RS, Binaso K, et al. Recommendations for best practices in the treatment of Alzheimer’s disease in managed care. Am J Geriatr Pharmacother. 2006;4(suppl A):S9-S24;quiz S25-S28.

26. Schneider LS, Tariot PN, Dagerman KS, et al; CATIE-AD Study Group. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med. 2006;355:1525-1538.

27. US Food and Drug Administration. Public health advisory: Deaths with antipsychotics in elderly patients with behavioral disturbances. US Food and Drug Administration Web site. Available at: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm053171.htm. Published April 11, 2005. Updated August 16, 2013. Accessed December 2, 2014.

28. The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60:616-631.

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Step 3: Neuropsychological evaluation. The NIA/AA recommends neuropsychological testing when the brief cognitive tests, history, and clinical work-up are not sufficient for a definitive diagnosis of dementia.⁹When brief cognitive tests, history, and clinical work-up are inconclusive, refer patients for neuropsychological testing.This generally involves a referral to a neuropsychologist, who conducts a battery of standardized tests to evaluate attention, memory, language, visual-spatial abilities, and executive functions, among others. Neuropsychological testing can confirm the presence of cognitive impairment and aid in the differential diagnosis by comparing the patient’s performance in these domains with characteristic features of different dementia syndromes.

Step 4: Brain imaging with either computed tomography or magnetic resonance imaging can be included in the work-up for patients with suspected AD to rule out abnormalities—eg, metastatic cancer, hydrocephalus, or occult chronic subdural hematoma—that could be causing cognitive impairment.^9,10 Clinical features that generally warrant brain imaging include onset of cognitive impairment before age 60; unexplained focal neurologic signs or symptoms; abrupt onset or rapid decline; and/or predisposing conditions, such as cancer or anticoagulant treatment.¹⁰

The role of biomarkers and advanced brain imaging

Biomarkers that might provide confirmation of AD in patients who exhibit early symptoms of dementia have been studied extensively.¹¹ The NIA/AA identified 2 categories of AD biomarkers:

tests for β-amyloid deposition in the brain, including spinal fluid assays for β-amyloid (Aβ₄₂) and positron emission tomography (PET) scans after intravenous injection of florbetapir or flutemetamol, which bind to amyloid in the brain; and
tests for neuronal degeneration, which would include spinal fluid assays for tau protein and PET scans after injection of fluorodeoxyglucose (FDG), which shows decreased uptake in patients with AD.⁹

Research reveals the promise of these biomarkers as diagnostic tools, particularly in patients with an atypical presentation of dementia or mild cognitive impairment (MCI) that may be associated with early AD.¹² (More on MCI in a moment.) However, the NIA/AA concluded that additional research is needed to validate these tests for routine diagnostic purposes. Medicare covers PET scans with FDG only for the differential diagnosis of AD vs frontotemporal dementia.¹³

Mild cognitive impairment: How likely that it will progress?

Along with diagnostic criteria for AD, the NIA/AA developed criteria for a symptomatic predementia phase of AD—often referred to as MCI.¹⁴ According to the workgroup, MCI is diagnosed when:

1. the patient, an informant, or a clinician is concerned about the individual’s cognitive decline from previous levels of functioning;
2. there is evidence of cognitive impairment, ideally through psychometric testing, revealing performance below expectation based on the patient’s age and education;
3. the patient is able to maintain independent functioning in daily life, despite mild problems or the need for minimal assistance; and
4. there is no significant impairment in social or occupational functioning.¹⁴

Progression: Less likely than you might think

Patients with MCI are at risk for progression to overt dementia, with an overall annual conversion rate from MCI to dementia estimated at 10% to 15%.^15,16 This estimate must be interpreted with caution, however, because most studies were conducted prior to the 2011 guidelines, when different diagnostic criteria were used. Observers have noted, too, that the numbers largely reflect data collected in specialty clinics and that community-based studies reveal substantially lower conversion rates (3%-6% per year).¹⁶ In addition, evidence suggests that many patients with MCI demonstrate long-term stability or even reversal of deficits.¹⁷

While there is some consideration of the use of biomarkers and amyloid imaging tests to help determine which patients with MCI will progress to AD, practice guidelines do not currently recommend such testing and it is not covered by Medicare.

When evidence indicates an AD diagnosis

When faced with the need to communicate an AD diagnosis, follow the general recommendations for delivering any bad news or discouraging prognosis:

Prioritize and limit the information you provide, determining not only what the patient and family want to hear, but also how much they are able to comprehend.

Confirm that the patient and family understand the information you’ve provided.

Offer emotional support and recommend additional resources¹⁸ (TABLE 2).

Given the progressive cognitive decline that characterizes AD, it is important to address the primary caregiver’s understanding of, and ability to cope with, the disease. It is also important to explore beliefs and attitudes regarding AD. Keep in mind that different cultural groups tend to differ in their beliefs about the nature, cause, and appropriate management of AD, as well as the role of spirituality, help-seeking, and stigma.^19,20

When communicating an Alzheimer's disease diagnosis, prioritize information and offer emotional support. The progressive and ultimately fatal nature of AD also makes planning for the future a priority. Ideally, patients should be engaged in discussions regarding end-of-life care as early as possible, while they are still able to make informed decisions and express their preferences. Discussing end-of-life care can be overwhelming for newly diagnosed patients and their families, however, so it is important that you address issues—medical, financial, and legal planning, for example—that families should be considering.