Alzheimer’s Association reveals first Alzheimer’s disease, dementia evaluation guidelines
The first clinical practice guidelines (CPGs) for evaluating Alzheimer’s disease and Related Dementias (ADRD) in both the primary and specialty care settings were revealed at the recent Alzheimer’s Association International Conference (AAIC 2018) in Chicago, Illinois, US.
The CPG recommendations, which will be published in detail in late 2018, are the result of the Alzheimer’s Association Diagnostic Evaluation Clinical Practice Guideline (AADx-CPG) workgroup, a multispecialty team incorporating medical, neuropsychology, and nursing experts, who combed systematic reviews and literature to establish the 20 recommendations.
According to members of the workgroup, the recommendations for physicians and nurse practitioners in primary and specialty care will be used to clinically evaluate patients presenting with Cognitive Behavioural Syndrome (CBS) and clinical spectrums of Alzheimer’s disease dementia.
“Our goal is to provide evidence-based and practical recommendations for the clinical evaluation process of cognitive behavioural syndromes, Alzheimer’s disease, and related dementias that are relevant to a broad spectrum of US health care providers,” said Dr Alireza Atri, co-chair of the AADx-CPG workgroup.
“Until now, we have not had highly specific and multispecialty US national guidelines that can inform the diagnostic process across all care settings, and that provide standards meant to improve patient autonomy, care, and outcomes,” he said.
The recommendations stress the importance of an individualized approach, taking a comprehensive history from the patient as well as someone close to the patient to identify major changes in the patient’s behaviour, assess causes of the behavioural changes to accurately diagnose the condition, and promote optimum care and support.
The recommendations were divided into six sections – patient types and process (recommendations 1–4), history of present illness (recommendations 5 and 6), office-based patient examination (recommendations 7–10), neuropsychological patient evaluation (recommendation 11), laboratory imaging tests (recommendations 12–18), and communication of diagnostic findings and recommended follow-up (recommendations 19 and 20). Of these, 16 recommendations were given an A rating, indicating the need for said recommendation as adherence would improve outcomes in almost all cases.
The recommendations encourage physicians to initiate a multitiered evaluation – taking into account individual risk factors and presentation, and identify causes – when patients (or their caregivers) report cognitive, behavioural, or functional changes, with the evaluation expedited and specialist referral encouraged in patients whose symptoms are atypical or rapidly progressing or in the case of uncertain diagnosis.
The recommendations also highlighted the importance of communicating with patients and their caregivers throughout the evaluation process, particularly with regard to understanding of the presence and severity of their condition, and ensuring proper management, care, and support. Patients and their caregivers should be provided with the name, characteristics, severity, stage, and cause of CBS and be given reasonable expectations of their treatment options, safety concerns, and support services available.
The recommendations also pointed to the importance of cognition, mood, behaviour, and dementia-focused neurological examinations using validated tools in patients being tested for cognitive-behavioural symptoms, whereas among patients with cognitive-behavioural symptoms, a comprehensive history and cognitive, neuropsychiatric, and neurological office-based examinations are warranted. Neuropsychological assessments – including testing of memory, language, learning, and executive and visuospatial function – are encouraged if office-based examinations are insufficient.
Tier 1 laboratory tests are crucial for all patients and should be tailored to each patient, with the option of Tier 2–4 tests when there is uncertainty regarding diagnosis. Genetic testing may be necessary in patients with CBS who may have an autosomal dominant family history.
Optimizing use of the guidelines
“Too often cognitive and behavioural symptoms due to Alzheimer’s disease and other dementias are unrecognized, or they are attributed to something else,” said Dr James Hendrix, Director of Global Science Initiatives of the Alzheimer’s Association and staff representative to the workgroup. “This causes harmful and costly delays in getting the correct diagnosis and providing appropriate care for persons with the disease. These new guidelines will provide an important new tool for medical professionals to more accurately diagnose Alzheimer’s and other dementias. As a result, people will get the right care and appropriate treatments; families will get the right support and be able to plan for the future.”
“Whether in primary or specialty care, the recommendations guide best practices for partnering with the patient and their loved ones to set goals, and to appropriately educate and evaluate memory, thinking, and personality changes,” said Atri.
“Next steps include reaching out to physician groups and medical societies to encourage primary care doctors, dementia experts, and nurse practitioners to adopt these new best CPGs,” Hendrix said.