First ever practice guidelines for clinical evaluation of Alzheimer's disease

A work group convened by the Alzheimer's Association has developed 20 recommendations for physicians and nurse practitioners that cater to the urgent need for more timely and accurate diagnosis and improvement in the care of patients with Alzheimer's disease.

The recommendations were presented by Alireza Atri, Director of the Banner Sun Health Research Institute, Sun City, AZ, at the Alzheimer's Association International Conference (AAIC) 2018.

“Too often cognitive and behavioral symptoms due to Alzheimer’s disease and other dementias are unrecognized, or they are attributed to something else,” said James Hendrix, Alzheimer’s Association Director of Global Science Initiatives. “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.

1. For patients who self-report or whose care partner or clinician report cognitive, behavioral or functional changes, the clinician should initiate a multi-tiered evaluation focused on the problem.


2. For patients with atypical or rapidly progressive cognitive-behavioral symptoms, the clinician should expedite a multi-tiered evaluation and should strongly consider referral to a specialist.


3. The evaluation process should use tiers of assessments and tests based on individual presentation, risk factors and profile to first establish the presence and characteristics of a Cognitive Behavioral Syndrome (CBS); and second, investigate possible causes and contributing factors to arrive at an etiologic diagnosis.


4. The clinician should establish a collaborative dialogue with the patient and care partner throughout the evaluation process to appropriately educate; communicate findings; and disclose the syndromic and etiologic diagnosis(es); and ensure ongoing management, care, and support.


5. During history taking for a patient being evaluated for cognitive-behavioral symptoms, the clinician should obtain reliable information involving an informant regarding changes in
   
   
   
   • cognition
   
   
   • activities of daily living (IADL and ADL)
   
   
   • mood and other neuropsychiatric symptoms
   
   
   • sensory and motor function.
   
   
   
   


6. During history taking for a patient being evaluated for cognitive-behavioral symptoms, the clinician should obtain reliable information about individualized risk factors for cognitive decline.


7. In a patient being evaluated for cognitive behavioral symptoms, the clinician should perform an examination of cognition, mood, and behavior (mental status exam), and dementia focused neurological examination, aiming to diagnose the Cognitive Behavioral Syndrome.


8. In a patient being evaluated for cognitive behavioral symptoms, clinicians should use validated tools to assess cognition.


9. A patient with an atypical presentation by history or examination, or in whom there is diagnostic uncertainty, should be referred to a specialist.


10. A specialist evaluating a patient with cognitive-behavioral symptoms should perform a comprehensive history and office-based examination of cognitive, neuropsychiatric, and neurological functions, aiming to diagnose the Cognitive Behavioral Syndrome.


11. A neuropsychological evaluation is recommended when an office-based cognitive assessment is not sufficiently informative.


12. Laboratory tests in the evaluation of cognitive-behavioral symptoms should be multi-tiered and
    individualized to the patient’s medical risks and profile.


13. In a patient being evaluated for a Cognitive Behavioral Syndrome, the clinician should obtain a magnetic resonance imaging (MRI) (as a first tier approach) to aid in establishing etiology. If MRI is not available or is contraindicated, computed tomography (CT) should be obtained.


14. When diagnostic uncertainty remains, the clinician can obtain additional (Tier 2-4) laboratory tests guided by the patient’s individual medical, neuropsychiatric, and risk profile.


15. In a patient with an established Cognitive Behavioral Syndrome in whom there is continued diagnostic uncertainty regarding etiology after structural imaging has been interpreted, a dementia specialist can obtain molecular imaging with FDG-PET to improve diagnostic accuracy.


16. In a patient with an established Cognitive Behavioral Syndrome in whom there is continued diagnostic uncertainty regarding etiology after structural imaging and/or FDGPET has been interpreted, a dementia specialist can obtain CSF according to appropriate use criteria for analysis of aβ42 amyloid and tau/p-tau profiles to evaluate for Alzheimer’s disease pathology.


17. If diagnostic uncertainty still exists after obtaining structural imaging and FDG-PET and/or CSF aβeta and tau/p-tau is unavailable or uninterpretable, the dementia specialist can obtain amyloid PET scan according to the appropriate use criteria.


18. In a patient with an established Cognitive Behavioral Syndrome and a likely autosomal dominant family history, the dementia specialist should consider whether genetic testing is warranted. A genetic counselor should be involved throughout the process.


19. Throughout the evaluation process, the clinician should establish a dialogue with the patient and care partner to assess the understanding (knowledge of facts) and appreciation (recognition that facts apply to the person) of the presence and severity of the Cognitive Behavioral Syndrome.


20. In communicating diagnostic findings the clinician should honestly and compassionately inform both the patient and their care partner of the following information using a structured process: the name, characteristics and severity of the Cognitive Behavioral Syndrome; the disease(s) likely causing the Cognitive Behavioral Syndrome; the stage of the disease; what can be reasonably expected in the future; treatment options and expectations; potential safety concerns; and medical, psychosocial and community resources for education, care planning and coordination, and support services.

"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 clinical practice guidelines," Hendrix concludes.