First Alzheimer's Guidelines for Clinical Practice Released

Megan Brooks

July 23, 2018

CHICAGO — The Alzheimer's Association has released the first clinical practice guidelines for the evaluation of cognitive impairment suspected to be a result of Alzheimer's disease and related dementias in both primary care and specialty care settings.

"These are the first US national guidelines aimed at multiple specialties. Most patients have 3 to 5 years of pretty serious symptoms before they are actually first evaluated, and that process can take over a year and a half, so hopefully these guidelines will improve that," Alireza Atri, MD, PhD, co-chair of the Alzheimer's Association Diagnostic Evaluation Clinical Practice Guideline workgroup, noted in an interview with Medscape Medical News.

At their core, the guidelines recommend that all middle-aged or older individuals who self-report or for whom their care partner reports cognitive, behavioral, or functional changes undergo a timely multitiered evaluation. The guidelines emphasize that concerns should not be dismissed as "normal aging" without a proper assessment.

The guidelines recognize the broader category of "cognitive behavioral syndromes," indicating that Alzheimer's disease and related dementias may lead to both behavioral and cognitive symptoms of dementia. As a result, these conditions can produce changes in mood, anxiety, sleep, and personality, as well as interpersonal, work, and social relationships, that are often noticeable before more familiar memory and thinking symptoms of Alzheimer's disease and related dementias appear.

The guidelines were previewed here July 22 at the Alzheimer's Association International Conference (AAIC) 2018. They will be published in full later this year in a peer-reviewed journal, along with detailed rationale behind them.

The guidelines aren't meant to burden the clinician. They should empower the clinician. Dr. Alireza Atri

The guidelines include 20 consensus recommendations, including 16 "A" recommendations, indicating that they must be done and that, in almost all circumstances, adhering to the recommendation will improve outcomes.

The "A" recommendations emphasize the importance of obtaining a history from the patient and someone who knows the patient well to establish the presence and characteristics of any substantial changes to categorize the cognitive behavioral syndrome, investigate possible causes and contributing factors to arrive at a diagnosis/diagnoses, and appropriately educate, communicate findings and diagnosis, and ensure ongoing management, care, and support.

"These recommendations really involve good practice of medicine, but unfortunately the data doesn't support this being done," said Atri, from the Center for Brain/Mind Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.

"When you read the guidelines, they look like common sense, but there is data to show that upwards of half the people who end up in nursing homes that are in later stages of dementia actually have never been given a formal diagnosis. That's not right," said Atri.

There are two "B" recommendations, indicating that they should be done and in most cases will improve outcomes. One states that magnetic resonance imaging or computed tomography should be obtained to help establish etiology in a patient being evaluated for a cognitive behavioral syndrome. The other advocates molecular imaging with fluorodeoxyglucose (FDG) positron emission tomography (PET) imaging when there is continued diagnostic uncertainty regarding etiology after structural imaging has been interpreted.

There are two "C" recommendations, indicating something that may be done and might improve outcomes. One suggests a dementia specialist obtain cerebrospinal fluid of amyloid beta-42 and tau/p-tau profiles to evaluate Alzheimer's disease pathology in a patient with an established cognitive behavioral syndrome in whom there is continued diagnostic uncertainty regarding etiology after structural imaging and/or FDG-PET. The other states that, if diagnostic uncertainty still exists, an amyloid PET scan may be obtained.

"The guidelines aren't meant to burden the clinician. They should empower the clinician and help guide them through the process. The guidelines might also help to reduce ambiguity and roadblocks encountered in health systems and insurance companies," said Atri.

The guidelines, he added, should also "empower patients and families to know that there is an established process in the US, and if they do have a concern, it empowers them to find the health provider that is willing to help them through the process. It will help patients get information early and make plans or mitigate risk factors for cognitive decline."

"This is really the first time that we've had clinical practice guidelines for the general healthcare professional," Heather Snyder, PhD, senior director of medical and scientific operations at the Alzheimer's Association, told Medscape Medical News.

"The big takeaway is that if a patient comes in with a complaint themselves about their cognition or memory, or their caregiver or spouse does, they should be evaluated and the healthcare professional should identify the overall level of impairment the person might be experiencing, define what the clinical syndrome might be, and also the cause and if they are able to treat that," said Snyder.

"The plan is to work toward implementation of these guidelines with the physician community, physician groups, healthcare systems and beyond," said Snyder.

This research had no commercial funding. The authors have disclosed no relevant financial relationships.

Alzheimer's Association International Conference (AAIC) 2018: Abstract O1-07-02. Presented July 22, 2018.

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