Critical Challenges in Critical Challenges in Alzheimer’s Disease: A Global Alzheimer’s Disease: A Global

Approach for Optimizing Approach for Optimizing Patient CarePatient Care

Patient Identification and Patient Identification and Initial StrategiesInitial Strategies

Alzheimer’s Disease (AD): Alzheimer’s Disease (AD): More Than Just Memory LossMore Than Just Memory Loss

► AD is a progressive, degenerative disease AD is a progressive, degenerative disease involving:involving: Loss of memory and other cognitive Loss of memory and other cognitive

functionsfunctions Decline in ability to perform activities Decline in ability to perform activities

of daily livingof daily living Changes in personality and behaviorChanges in personality and behavior Increases in resource utilizationIncreases in resource utilization Eventual nursing home placementEventual nursing home placement

Alzheimer’s Disease OverviewAlzheimer’s Disease Overview

► Progressive, degenerative brain disease Progressive, degenerative brain disease characterized by an increasing loss of characterized by an increasing loss of memory & other cognitive functionsmemory & other cognitive functions

► Characterized by changes in activities of Characterized by changes in activities of daily living (ADL), behavior & personality, daily living (ADL), behavior & personality, cognition including judgment – ABCscognition including judgment – ABCs

► Most common cause of dementia among Most common cause of dementia among people aged 65 or overpeople aged 65 or over

1. Murphy SL. Natl Vital Stat Rep. 2000;48:1-106.2. Evans DA et al. Milbank Quarterly. 1990;68:267-289.

Current Prevalence of ADCurrent Prevalence of AD

► AD is the fourth leading cause of death AD is the fourth leading cause of death due to disease for people > 65 years of age due to disease for people > 65 years of age in the United Statesin the United States11

► Approximately 4 million people in the Approximately 4 million people in the United States have ADUnited States have AD22

AD Is the Most Prevalent AD Is the Most Prevalent Type of Irreversible DementiaType of Irreversible Dementia

Guttman R et al. Arch Fam Med. 1999;8:347-353.McKeith IG et al. Neurology. 1996;47:1113-1124.Cherrier MM et al. J Am Geriatr Soc. 1997;45:579-583.

VaD, vascular dementia;VaD, vascular dementia;DLB, dementia with Lewy bodies;DLB, dementia with Lewy bodies;FTD, frontotemporal dementia.FTD, frontotemporal dementia.reflects difficulties diagnosing/reporting reflects difficulties diagnosing/reporting dementias; only dementias; only estimationsestimations of prevalence of prevalencecan be made.can be made.

0

20

40

60

80

100

ADAD VaDVaD DLBDLB FTDFTD OtherOther

Irre

vers

ible

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enti

as (

%)

Irre

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ible

dem

enti

as (

%)

Mortality Due to AD: Impact of AgeMortality Due to AD: Impact of Age

Reprinted with permission from Hoyert DL et al. Natl Vital Stat Rep. 1999;47:1-104.

1,000

100

10

1

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0.01

Under45

45–54 55–64 65–74 75–84 85+

Age (years)

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Cost of AD in the USCost of AD in the US

► Annual treatment costs ~ $100 billionAnnual treatment costs ~ $100 billion $18,408/patient per year for mild AD$18,408/patient per year for mild AD $30,096/patient per year for $30,096/patient per year for

moderate ADmoderate AD $36,132/patient per year for severe $36,132/patient per year for severe

ADAD

Leon J et al. Health Aff (Millwood). 1998;17:206-216.

Does Treatment Affect the Cost of AD?Does Treatment Affect the Cost of AD?

► Savings are small for mild and very severe ADSavings are small for mild and very severe AD

► Prevention of even a small Prevention of even a small declinedecline in cognition for in cognition for patients with moderate AD would save patients with moderate AD would save ~ $3,700 per patient annually~ $3,700 per patient annually

► Relatively small Relatively small improvementsimprovements in patients with in patients with moderate AD would save ~ $7,100 per patient moderate AD would save ~ $7,100 per patient annuallyannually

Ernst RL et al. Arch Neurol. 1997;54:687-693.

Who Are the Caregivers?Who Are the Caregivers?

► The overwhelming majority of patients live at The overwhelming majority of patients live at home and are cared for by family and friendshome and are cared for by family and friends

77% are women77% are women 73% are over 50 years of age73% are over 50 years of age 33% are the sole providers33% are the sole providers 45% are children of the patient45% are children of the patient 49% are spouses49% are spouses Remainder are close family members or Remainder are close family members or

friendsfriends

Consumer Health Sciences, LLC. Princeton, NJ; December 1999.

Caregiver Burden Caregiver Burden

► Caregivers spend from 40–100 hours per week Caregivers spend from 40–100 hours per week with the patientwith the patient

► 90% are affected emotionally (frustrated, 90% are affected emotionally (frustrated, drained)drained)

► 75% report feeling depressed; 66% have 75% report feeling depressed; 66% have significant depressionsignificant depression

► Half say they do not have time for themselves Half say they do not have time for themselves and that the stress affects family relations and that the stress affects family relations

► Many experience a significant loss of incomeMany experience a significant loss of income

Coping. Available at: http://www.alzheimers.com. Accessed September 2000.

Factors That Create Factors That Create “Breaking Point”for Caregiver “Breaking Point”for Caregiver

► Amount of time spent caring for the Amount of time spent caring for the patientpatient

► Loss of identityLoss of identity

► Patient misidentifications and clinical Patient misidentifications and clinical fluctuationsfluctuations

► Nocturnal deterioration of patientNocturnal deterioration of patient

Annerstedt L et al. Scand J Public Health. 2000;28:23-31.

AP = amyloid plaques NFT = neurofibrillary tangles

Neuropathological ChangesNeuropathological ChangesCharacteristic of ADCharacteristic of AD

Normal

AP

AD

NFT

Courtesy of George T.Grossberg M.D.; St. Louis University

Key Risk Factors for ADKey Risk Factors for AD

► Primary risk factorsPrimary risk factors AgeAge Family history Family history Genetic marker such as APOE-4, trisomy 21, mutations in Genetic marker such as APOE-4, trisomy 21, mutations in

presenilin 1,2presenilin 1,2 Cardiovascular risk factors e.g. hyperlipidemia/Cardiovascular risk factors e.g. hyperlipidemia/

hypertension (the role of statins and omega 3 fatty acids)hypertension (the role of statins and omega 3 fatty acids)

► Possible risk factorsPossible risk factors Head trauma Head trauma Low level of education Low level of education Depression Depression Increased zinc?Increased zinc? Increased homocysteine (the role of B-vitamins, e.g. Folic acid)Increased homocysteine (the role of B-vitamins, e.g. Folic acid)

AD Is Often MisdiagnosedAD Is Often Misdiagnosed

Patient initially diagnosed Patient initially diagnosed with ADwith AD

Patient’s first diagnosis other Patient’s first diagnosis other than ADthan AD

Yes 28%

NoNo 72% 72%

21%

7%

9%

14%

14%

35%

Normal aging

Depression No diagnosis

Dementia (not AD) Stroke

Other

Source: Consumer Health Sciences, LLC. Alzheimer’s Caregiver Project. 1999.

Treatment AlternativesTreatment Alternatives

► SymptomsSymptoms Non-pharmacologicalNon-pharmacological NeurolepticsNeuroleptics Anti-depressantsAnti-depressants Anti-convulsantsAnti-convulsants ChEIsChEIs NMDA receptor antagonistsNMDA receptor antagonists

AD Treatment AlgorithmAD Treatment Algorithm

Stage of ADStage of AD Mild Mild ModerateModerate Severe Severe

TreatmentTreatment

OptionsOptions ChEIChEI ChEI/ChEI/ MemantineMemantine Memantine Memantine

(alone or in(alone or in (alone or in (alone or in combination)combination) combination) combination)

Alzheimer’s Disease Alzheimer’s Disease The Challenge of Early The Challenge of Early

DiagnosisDiagnosis

Overview and IntroductionOverview and Introduction

Benefits of Early Diagnosis and Benefits of Early Diagnosis and Treatment of Alzheimer’s DiseaseTreatment of Alzheimer’s Disease

► Alzheimer’s disease can be diagnosed approximately 90% Alzheimer’s disease can be diagnosed approximately 90% of the time with a general medical and psychiatric of the time with a general medical and psychiatric evaluationevaluation1,21,2

► Early diagnosis has many advantagesEarly diagnosis has many advantages3,43,4

Allows time for planningAllows time for planning Empowers the patients to make treatment decisions early onEmpowers the patients to make treatment decisions early on Facilitates caregiver participation Facilitates caregiver participation

► May slow the progression of symptomsMay slow the progression of symptoms22

► Offers the patient potential for greater functioning and Offers the patient potential for greater functioning and independenceindependence2,32,3

► Can help ease the stress for caregiversCan help ease the stress for caregivers2,32,3

Sources: 1. Small GW, et al. JAMA. 1997;278:1363-1372. 2. National Institute on Aging. National Institutes of Health; 2000. NIH publication 00-4859:l-62.

3. Doraiswamy PM, et al. J Clin Psychiatry. 1998;59(suppl 13):6-18.4. Knopman DS. In: Early Diagnosis of Alzheimer’s Disease. Totowa, NJ: Humana Press, Inc;

2000:298.

Discussion PointsDiscussion Points

Dementia is underrecognized (even withDementia is underrecognized (even with

behavioral symptoms) and undertreatedbehavioral symptoms) and undertreated

► 67.7% of residents* have dementia67.7% of residents* have dementia Of those with dementia Of those with dementia

73% were adequately evaluated73% were adequately evaluated52% were adequately treated52% were adequately treated70% had clinically significant 70% had clinically significant

behavioral symptomsbehavioral symptomsUsed 262 min/d of staff time vs no Used 262 min/d of staff time vs no

dementia 126 min/d (dementia 126 min/d (PP<.005)<.005)*The results are based on a randomized cohort of assisted living (AL) residents of 22 randomly selected AL facilities in Baltimore and 7 Maryland counties.

Source: Rosenblatt A, et al. J Am Geriatr Soc. 2004;52:1618-1625.

Barriers to Early DiagnosisBarriers to Early Diagnosis

Stigma Stigma ► First-degree relatives of AD patients reluctant to First-degree relatives of AD patients reluctant to

approve cognitive status examinationapprove cognitive status examination► Those of patients with more behavioral problems Those of patients with more behavioral problems

show greater reluctanceshow greater reluctance

MisconceptionsMisconceptions ► Perception of uselessness of examinationPerception of uselessness of examination► Perception of limited treatment optionsPerception of limited treatment options

Early StagesEarly Stages ► Patients maintain social skills in mild stagesPatients maintain social skills in mild stages

Source: Werner P, Heinik J. Int J Geriatr Psychiatry. 2004;19:479-486.

Barriers to Early Diagnosis Barriers to Early Diagnosis (cont)(cont)

Failure to Recognize the Importance ofFailure to Recognize the Importance of

Cognitive/Functional ChangesCognitive/Functional Changes

Racial BarriersRacial Barriers► Racial bias in screening toolsRacial bias in screening tools► Duality of respect for the patientDuality of respect for the patient——

“normalization”“normalization”► Cultural ignorance or insensitivityCultural ignorance or insensitivity

Source: Cloutterbuck J, et al. Dementia. 2003;2:221-243.

Discussion PointsDiscussion Points

Dementia Screening Tools: Effect of EthnicityDementia Screening Tools: Effect of Ethnicity

► Brief screening tests often incorrectly classify Brief screening tests often incorrectly classify African Americans with dementia (42%) compared African Americans with dementia (42%) compared to Caucasians (6%)to Caucasians (6%)

► The specificity of standardized cognitive assessments for The specificity of standardized cognitive assessments for dementia is particularly bad for African Americans dementia is particularly bad for African Americans

► Comparison of the utility of the Clock Drawing Test (CDT), Comparison of the utility of the Clock Drawing Test (CDT), Cognitive Abilities Screening Instrument, and MMSECognitive Abilities Screening Instrument, and MMSE

All tests were affected by education levelAll tests were affected by education level CDT was most sensitive to poorly educated CDT was most sensitive to poorly educated

non-English speakersnon-English speakers

Sources: Stephenson J. JAMA. 2001;286:779-780. Lampley-Dallas VT. J Natl Med Assoc. 2001;93:323-328.Fillenbaum G, et al. J Clin Epidemiol. 1990;43:651-660. Borson S, et al. J Gerontol A Biol Sci Med Sci. 1999;54:M534-M540.

Ethnic Differences in Knowledge and Perception of ADEthnic Differences in Knowledge and Perception of AD

► Elderly have misperceptions about the prevalence, etiology, Elderly have misperceptions about the prevalence, etiology,

diagnosis, and financial coverage for diagnosis, and financial coverage for

AD treatmentsAD treatments

► Older Hispanic and Asian adults frequently consider AD a Older Hispanic and Asian adults frequently consider AD a

contagious but curable diseasecontagious but curable disease

► Hispanic, Asian, and African Americans more often consider AD Hispanic, Asian, and African Americans more often consider AD

a form of insanity a form of insanity

► Education levels partially explain differences in AD knowledge Education levels partially explain differences in AD knowledge

between Caucasians and Hispanicsbetween Caucasians and Hispanics

► For Asians, the number of years speaking English is correlated For Asians, the number of years speaking English is correlated

with better knowledge of ADwith better knowledge of AD

Source: Ayalon L, et al. Int J Geriatr Psychiatry. 2004;19:51-57.

Discussion PointsDiscussion Points

Barriers to Early Diagnosis Barriers to Early Diagnosis (cont)(cont)

Barriers associated with PCPsBarriers associated with PCPs

► Differential diagnosisDifferential diagnosis Vascular dementia, frontotemporal dementia, Lewy Vascular dementia, frontotemporal dementia, Lewy

body dementiabody dementia

► Comorbid conditionsComorbid conditions Differentiating dementia, delirium, and depressionDifferentiating dementia, delirium, and depression

► TimeTime 1 hour required for diagnosis, but only 15 minutes 1 hour required for diagnosis, but only 15 minutes

reimbursedreimbursed Knowledge of appropriate reimbursement codesKnowledge of appropriate reimbursement codes

► Overabundance of testsOverabundance of tests

Discussion PointsDiscussion PointsVascular Dementia (VaD) - Key ElementsVascular Dementia (VaD) - Key Elements

► Cognitive impairment caused by cerebrovascular disease or Cognitive impairment caused by cerebrovascular disease or

cerebrovascular accidentcerebrovascular accident

► Mixed dementia = VaD + ADMixed dementia = VaD + AD

► ““Stairstep” progression of illnessStairstep” progression of illness

► May have motor impairment early in the course of illnessMay have motor impairment early in the course of illness

► Care NotesCare Notes

Treat hypertension, diabetes, Treat hypertension, diabetes, ↑ lipids ↑ lipids

May be associated with severe or refractory depressionMay be associated with severe or refractory depression

Accommodate hemiplegia in interactions with Accommodate hemiplegia in interactions with

staff/environmentstaff/environment

Source: Black SE. Postgrad Med. 2005;117(1):15-16,19-25.

Discussion PointsDiscussion PointsDementia With Lewy Bodies - Key ElementsDementia With Lewy Bodies - Key Elements

► Wide fluctuations in cognition, responsiveness, and functionWide fluctuations in cognition, responsiveness, and function► Vivid visual hallucinations and paranoid delusionsVivid visual hallucinations and paranoid delusions► Parkinsonism occurs early Parkinsonism occurs early ► Care notesCare notes

Some antipsychotics will cause Some antipsychotics will cause severesevere parkinsonism at parkinsonism at low doseslow doses

Quetiapine, aripiprazole, or clozapine may be tolerated Quetiapine, aripiprazole, or clozapine may be tolerated bestbest

Cholinesterase inhibitors are helpfulCholinesterase inhibitors are helpful Levodopa and Parkinson’s disease medications have Levodopa and Parkinson’s disease medications have

limited effectiveness for movement disorderslimited effectiveness for movement disorders

Sources: McKeith IG, et al. Neurology. 1996;47:1113-1124. McKeith IG, et al. Neurology. 1999;53:902-905.

Discussion PointsDiscussion PointsFrontotemporal Dementia - Key ElementsFrontotemporal Dementia - Key Elements

► Frontal lobe dementia, Pick’s diseaseFrontal lobe dementia, Pick’s disease► Earlier age of onset than ADEarlier age of onset than AD► Gradual declineGradual decline► Early problems with memory and language Early problems with memory and language

expressionexpression► Prominent personality changesProminent personality changes——socially socially

inappropriate, disinhibited, and compulsive inappropriate, disinhibited, and compulsive (sexualized, eating) behaviors often observed(sexualized, eating) behaviors often observed

► Care notesCare notes Cholinesterase inhibitors not very effectiveCholinesterase inhibitors not very effective Safe environment for harmful compulsive behaviorsSafe environment for harmful compulsive behaviors

Source: McKhann GM, et al. Arch Neurol. 2001;58:1803-1809.

Adapted from: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994:142-143.

Alzheimer’s DiseaseAlzheimer’s Disease

► Multiple cognitive deficits, with both memory Multiple cognitive deficits, with both memory impairment impairment andand 1 or more of the following deficits: 1 or more of the following deficits:

● Aphasia (language)Aphasia (language)● Apraxia (learned motor skills)Apraxia (learned motor skills)● Agnosia (visuospatial/sensory) Agnosia (visuospatial/sensory) ● Executive functioning (planning, insight anticipation)Executive functioning (planning, insight anticipation)

► Impairment in social or occupational functioning, Impairment in social or occupational functioning, representing a significant decline from a previous level representing a significant decline from a previous level of functioningof functioning

► Gradual onset and progressive cognitive declineGradual onset and progressive cognitive decline

Overcoming Barriers to AD DiagnosisOvercoming Barriers to AD Diagnosis

► Time Time Schedule high-risk patients at end of daySchedule high-risk patients at end of day AD does not have to be diagnosed in a single visitAD does not have to be diagnosed in a single visit

► ReimbursementReimbursement Know appropriate codes for AD diagnosis and for extra timeKnow appropriate codes for AD diagnosis and for extra time

► Coexisting illnessesCoexisting illnesses AD treatments may permit sustained self-management of AD treatments may permit sustained self-management of

other illnessesother illnesses► DepressionDepression

Evaluate patients using Geriatric Depression Scale (15 Evaluate patients using Geriatric Depression Scale (15 questions)questions)

► Screening toolsScreening tools Start slowly in gathering information, eg, MMSE (10-15 Start slowly in gathering information, eg, MMSE (10-15

minutes) and CDT (1-5 minutes)minutes) and CDT (1-5 minutes) FAQ 10 questions completed by familyFAQ 10 questions completed by family

Targeted ScreeningTargeted Screening

► Patients at least 65 years of age, when clinical Patients at least 65 years of age, when clinical presentation suggests the possibility of dementia presentation suggests the possibility of dementia (eg, forgetfulness, poor hygiene, poor compliance)(eg, forgetfulness, poor hygiene, poor compliance)

► All patients at least 80 years of age, with regular All patients at least 80 years of age, with regular frequency frequency

Sources: Kaiser Permanente Care Management Institute. Guidelines for the diagnosis and management of dementia in primary care. Available at: http://members.kaiserpermanente.org/kpweb/pdf/feature/247clinicalpracguide/CMI_ DementiaGuideline_public_web_020604.pdf. Accessed August 17, 2005. Knopman DS, et al. Neurology. 2001;56:1143-1153.

Screening assesses quantitative and objective measures rather than qualitative responses.

Discussion PointsDiscussion Points

► Is there a relationship between mild cognitive Is there a relationship between mild cognitive impairment (MCI) and AD? (16% of MCI patients impairment (MCI) and AD? (16% of MCI patients convert to AD per year)convert to AD per year)

► How do we differentiate MCI from AD?How do we differentiate MCI from AD?

► Government recommendation not to screen Government recommendation not to screen (Agency for Healthcare Research and Quality)(Agency for Healthcare Research and Quality)

The Case for UniversalThe Case for UniversalCognitive ScreeningCognitive Screening

► Memory complaints are common and can be Memory complaints are common and can be associated with subsequent dementiaassociated with subsequent dementia

► Early dementia symptoms can be difficult to Early dementia symptoms can be difficult to recognizerecognize

► Cognitive impairment affects how medical care is Cognitive impairment affects how medical care is providedprovided

Management (and costs) of other diseasesManagement (and costs) of other diseases Follow through with medical recommendationsFollow through with medical recommendations Prevention of complicationsPrevention of complications

Discussion PointsDiscussion Points

► Which screening tools do you recommend?Which screening tools do you recommend? A dialogue on the utility of screening tools A dialogue on the utility of screening tools

► Educational preceptorshipEducational preceptorship——warning signs and warning signs and public awarenesspublic awareness CommunityCommunity DoctorsDoctors ConsumersConsumers Alzheimer’s AssociationAlzheimer’s Association

Dementia Diagnostic ProcessDementia Diagnostic Process

► General screen General screen Signs of acute/chronic disease: how well controlled?Signs of acute/chronic disease: how well controlled? Common conditionsCommon conditions Weight loss, dehydration, subnutritionWeight loss, dehydration, subnutrition

Include obstructive sleep apnea, insomnia, depressionInclude obstructive sleep apnea, insomnia, depression

► Neurologic screenNeurologic screen Vascular or Parkinson’s dementia, frontal signsVascular or Parkinson’s dementia, frontal signs Gait, balance, and fallsGait, balance, and falls NeuropathyNeuropathy

► Laboratory screenLaboratory screen Vitamin BVitamin B1212 deficiency, hypothyroidism deficiency, hypothyroidism Associated problems, secondary complications, andAssociated problems, secondary complications, and

additional causesadditional causes► Brain structural screenBrain structural screen

Noncontrast CT or MRINoncontrast CT or MRI Surgical and vascular lesions Surgical and vascular lesions

Evaluation of the AD PatientEvaluation of the AD Patient

► In approximately 90% of patients who have AD, In approximately 90% of patients who have AD, the diagnosis can be made on the basis of:the diagnosis can be made on the basis of:

Detailed medical history obtained from the Detailed medical history obtained from the patient and a reliable informantpatient and a reliable informant

Medical examinationMedical examination

Mental status examinationMental status examination

► A 15-minute office visit is insufficient for fully A 15-minute office visit is insufficient for fully evaluating the AD patient. evaluating the AD patient. For patients seen For patients seen regularly, a 3-stage assessment may be more regularly, a 3-stage assessment may be more appropriateappropriate

Source: Cefalu C, Grossberg GT. Diagnosis and Management of Dementia. American Family Physician Monograph, No. 2. Leawood, Kan: American Academy of Family Physicians; 2001.

The Office HistoryThe Office History

► Memory impairment: repetitive; trouble Memory impairment: repetitive; trouble

remembering recent conversations, events, remembering recent conversations, events,

appointments; frequently misplaces objectsappointments; frequently misplaces objects

► Executive impairment: deterioration of Executive impairment: deterioration of

complex task performance; decreased ability complex task performance; decreased ability

to solve problems; impaired drivingto solve problems; impaired driving

► Drugs: alcohol, prescriptions, over-the-Drugs: alcohol, prescriptions, over-the-

counter (OTC) medicationscounter (OTC) medications

► Focal motor or sensory neurologic symptomsFocal motor or sensory neurologic symptoms

► Take comprehensive historyTake comprehensive history Medical history, medications (including Medical history, medications (including

OTC drug use)OTC drug use)

► Interview immediate family member/caregiverInterview immediate family member/caregiver

► If time permits and patient is cooperative, perform If time permits and patient is cooperative, perform MMSEMMSE

► Assess family needs and caregiver stressAssess family needs and caregiver stress

First VisitFirst Visit

Source: Cefalu C, Grossberg GT. Diagnosis and Management of Dementia. American Family Physician Monograph, No. 2. Leawood, Kan: American Academy of Family Physicians; 2001.

Evaluation of the AD PatientEvaluation of the AD Patient (cont)(cont)

Second VisitSecond Visit

► CBC, electrolytes, LFTs, TSH, B12, folate, UA, EKG, HIV, VDRL, ESR, homocysteine

► Neuroimaging► Perform MMSE if not performed on first visit► Reassess family needs and caregiver stress► Consider neuropsychological testing

CBC = complete blood count; LFTs = liver function tests; TSH = thyroid-stimulating hormone; UA = unstable angina; EKG = electrocardiogram; HIV = human immunodeficiency virus; VDRL = Venereal Disease Research Laboratory test; ESR = erythrocyte sedimentation rate. Source: Cefalu C, Grossberg GT. Diagnosis and Management of Dementia. American Family Physician Monograph, No. 2. Leawood, Kan: American Academy of Family Physicians; 2001.

Evaluation of the AD PatientEvaluation of the AD Patient (cont)(cont)

► Review laboratory findings and resultsReview laboratory findings and resultsof testingof testing

► Discuss treatment options, follow-up plans Discuss treatment options, follow-up plans for patientfor patient

► Readdress family and caregiver needsReaddress family and caregiver needs

Third VisitThird Visit

Source: Cefalu C, Grossberg GT. Diagnosis and Management of Dementia. American Family Physician Monograph, No. 2. Leawood, Kan: American Academy of Family Physicians; 2001.

Evaluation of the AD PatientEvaluation of the AD Patient (cont)(cont)

Discussion PointsDiscussion Points

What Is the Place for Imaging?What Is the Place for Imaging?► Noncontrast CT or MRI scan in the initial evaluation is Noncontrast CT or MRI scan in the initial evaluation is

appropriate (American Academy of Neurology Guideline)appropriate (American Academy of Neurology Guideline)

► The use of positron emission tomography The use of positron emission tomography

► Value of imaging is to rule out other forms of intracranial Value of imaging is to rule out other forms of intracranial pathology that may be contributing to cognitive change or for pathology that may be contributing to cognitive change or for unusual presentations:unusual presentations:

Rapid onset (duration Rapid onset (duration <<3 months), subdural hematoma, 3 months), subdural hematoma, cerebral neoplasms, head trauma, history of cerebral neoplasms, head trauma, history of cerebrovascular accident(s), seizures, new-onset urinary cerebrovascular accident(s), seizures, new-onset urinary or fecal incontinence, abnormal gait, postural instability, or fecal incontinence, abnormal gait, postural instability, focal signs, visual field deficit, headaches, suspect focal signs, visual field deficit, headaches, suspect malignant tumormalignant tumor

Sources: American Academy of Neurology. Neurology. 2001;56:1133-1142. American Academy of Neurology. Neurology. 2001;56:1143-1153.

Practical Consequences of Improved Practical Consequences of Improved Diagnostic AccuracyDiagnostic Accuracy

► Accurate diagnostic information and education Accurate diagnostic information and education reduce family/caregiver burdenreduce family/caregiver burden

► Decreased likelihood of repeated diagnostic Decreased likelihood of repeated diagnostic assessments and testingassessments and testing

► ““AD label” improves caregiver attitudes AD label” improves caregiver attitudes

► Information about the disease improves quality of Information about the disease improves quality of life for family/patient and delays nursing home life for family/patient and delays nursing home placement placement

Sources: Mittelman M, et al. JAMA. 1996;276:1725-1731. Wadley V, et al. J Gerontol B Psychol Sci Soc Sci. 2001;56:P244-P252.

Stages of Alzheimer’s DiseaseStages of Alzheimer’s Disease

Mild Moderate Severe

Cognition

• Difficulty recognizing family and friends

• Chronic loss of recent memory

• Loss of speech

• Misidentifies or is unable to recognize familiar people

Confusion andConfusion andmemory loss, eg:memory loss, eg:

Needs help with basic ADL (eg, feeding, dressing, bathing)

Progresses to total dependence on caregiver (eg, feeding, toileting)

Problems withProblems withroutine tasksroutine tasks

Activities of daily living (ADL)

BehaviorAnxiety, suspicion, pacing, insomnia, agitation, wandering

Crying, screaming, groaning

Changes inChanges inpersonalitypersonality

– – Misplacing objectsMisplacing objects

– – Forgetting namesForgetting names

– – DisorientationDisorientation

Sources: National Institute on Aging. National Institutes of Health; 2003. NIH publication 02-3782. Available at:

http:www.alzheimers.org/unraveling/index.htm. Accessed January 10, 2005.

Alzheimer’s Association. Available at: http://www.alz.org/AboutAD/Stages.asp. Accessed January 13, 2005.

SummarySummary

► Marked changes in memory are not a normal part of Marked changes in memory are not a normal part of aging and may signal a developing dementiaaging and may signal a developing dementia

► Universal screening for AD is importantUniversal screening for AD is important

► Effective diagnosis and management take timeEffective diagnosis and management take time

Three separate visits may be requiredThree separate visits may be required

► It is important to recognize and overcome the barriers to It is important to recognize and overcome the barriers to early diagnosis of ADearly diagnosis of AD