Alzheimer’s Association Releases First Clinical Evaluation Guideline
New evidence-based consensus guidelines for the evaluation of cognitive-behavioral symptoms of Alzheimer's disease (AD) and other dementias have been released and strongly encourage early diagnosis of all types of dementia. The guideline provides 20 recommendations for use by both primary and specialty care clinicians and was created by a multidisciplinary team of physicians and nurse practitioners, the Alzheimer’s Association Diagnostic Evaluation Clinical Practice Guideline workgroup (AADx-CPG).
Key among the recommendations is that concerns of a middle-aged or older individual, or their family member or clinician, about functional, cognitive, or behavioral changes should not be dismissed as normal aging, but rather should prompt assessment that includes a care partner (ie, family member or confidant) in a collaborative discussion taking into account the patient’s cognitive-behavioral profile, risk factors, and rate of symptom progression.
The guideline also recognizes a broader category of cognitive behavioral syndromes because neurodegenerative conditions can produce changes in mood, anxiety, sleep, personality, and relationships that are often noticeable before the more widely recognized signs of memory loss or difficulty thinking appear. It is recommended that structured and validated instruments be used to evaluate 4 domains: cognition, activities of daily living, mood and other neuropsychiatric symptoms, and sensory and motor function. Tier 1 laboratory studies, brain MRI, and head CT are recommended to search for etiology of symptoms.
It is strongly recommended that patients and families be referred to specialists when symptoms are progressing rapidly. In the case of clinical doubt, referral to a specialist for further evaluation is also warranted, and neuropsychologic testing is suggested if doubt remains after specialty evaluation. Neuropsychologic testing should include measurement against norms for the domains of learning and memory (in particular delayed free and cued recall/recognition); executive function; visuospatial function, and language. Tier 2-4 laboratory tests guided by the patient’s individual medical, neuropsychiatric, and risk profile should be obtained, and if doubt still remains a dementia specialist can obtain molecular imaging with fluorodeoxyglucose-positron emission tomography (FDG-PET) to improve diagnostic accuracy.
“Evaluation of cognitive or behavioral decline is often especially challenging in primary care settings,” said Bradford Dickerson, MD, MMSc, Cochair of AADx-CPG. “Also, with recent advances in available diagnostic technology, there is a need for guidance on use of such tests in specialty and subspecialty care settings.”
“In all cases, there is something we can do to help and support those who entrust us with the privilege of advising and caring for them,” said Alireza Atri, MD, PhD, Cochair of the AADx-CPG. “The guidelines can empower patients, families, and clinicians to expect that symptoms will be evaluated in a patient-centered, structured, and collaborative manner. In addition, they help to ensure that, regardless of the specific diagnosis, the results are communicated in a timely and compassionate way to help patients and families live the best lives possible.”