Alzheimer’s Association guidelines emphasize establishing cognitive behavioral syndrome
Establishing that a patient has cognitive behavioral syndrome was the first priority in identifying new guidelines related to that syndrome, as well as mild cognitive impairment, Alzheimer’s disease and related dementia, according to data recently presented at the Alzheimer’s Association International Conference.
Currently, there are 5.7 million Americans with Alzheimer’s, a number that could triple by 2050, Alzheimer’s Association data suggest. The U.S. will spend $277 billion a year treating those aged 65 years and older with Alzheimer’s in 2018, and that number could increase to $1.1 trillion by 2050. Despite efforts by scientific researchers and the pharmaceutical community, there have been no new drug therapies for the disease for more than a decade.
“The recommendations delineate utilization of 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]; second, to investigate possible causes and contributing factors to arrive at an etiologic diagnosis based on established disease criteria; and third, to appropriately educate, communicate findings, and disclose the syndromic and etiologic diagnosis(es), and ensure ongoing management, care and support,” wrote Alireza Atri, MD, PhD, of the Center for Brain/Mind Medicine at Brigham and Women’s Hospital and Harvard Medical School.
The guidelines cover patient process and type, history of present illness, office-based examination of each patient, neuropsychological evaluation of patient, imaging and laboratory tests, and communication of diagnostic findings and recommended follow-up.
The guidelines to receive an “A” level recommendation in each of these categories are:
- Clinicians with patients who self-report or whose care partner report behavioral, cognitive, or functional should begin a multitiered evaluation focused on the problem; accelerate such evaluations and strongly consider referring the patient to specialist when a fast-moving progressive or nontypical behavioral symptoms are present or if there is diagnostic uncertainty.
- Clinician should conduct cognition exam, dementia-focused neurological test, mood and behavior (mental status exam), with the intent of diagnosing the cognitive behavioral syndrome and validated tools to assess cognition in a patient being evaluated for cognitive behavioral symptoms.
- Clinicians should utilize tiers of assessments and tests based on individual presentation, risk factors and profile to first ascertain the presence and traits of a cognitive behavioral syndrome; and second, look into potential causes and contributing factors to come to at an etiologic diagnosis in their evaluation process.
- Clinicians should initiate a collaborative dialogue with the patient and care partner to correctly teach, convey findings; reveal the etiologic and/or syndromic diagnosis(es); and assure ongoing care, management, and support throughout the evaluation process. During this process, the clinician should establish a dialogue with the patient and care partner to evaluate the patient and caregiver’s appreciation — recognition that facts apply to the person — and understanding — knowledge of facts — of the presence and severity of the cognitive behavioral syndrome. These findings should steer education, communicating and documenting diagnostic findings, assessment and diagnostic disclosure.
- History taking for cognitive behavioral symptoms, should include reliable information involving an informant regarding changes in sensory and motor function; cognition; daily living activities; and mood and other neuropsychiatric symptoms. Utilizing structured instruments for evaluating each such domain is helpful and about risk factors for cognitive decline unique to the patient.
- Specialists examining patients with cognitive behavioral symptoms should conduct a comprehensive history and office-based examination of neuropsychiatric, cognitive and neurological functions, with the intent of diagnosing the cognitive behavioral syndrome.
- Neuropsychological evaluation is recommended when office-based cognitive assessment is not sufficiently informative, such as when a patient/informant reports concerning symptoms in daily life but the patient acts within normal limits on a cognitive examination, or when the examination of cognitive behavioral function is not normal but there is uncertainty about interpretation of results due to a complex clinical profile or confounding demographic characteristics. Such evaluations should include normed neuropsychological testing of the domains of learning and memory —especially delayed free and cued recall/recognition — language, visuospatial and executive function, and language.
- Laboratory tests to assess cognitive behavioral symptoms should be multitiered and unique to the patient’s medical risks and profile. Clinicians should obtain routine tier 1 laboratory studies in all patients, and if uncertainty about the diagnosis remains, clinicians can obtain additional (tier 2 through 4) laboratory tests guided by the patient’s risk, medical, and neuropsychiatric profile.
- Genetic testing should be considered in patients with an established cognitive behavioral syndrome and a likely autosomal dominant family history, and a genetic counselor should be involved in every component of these tests when they occur.
- Clinicians should compassionately and honestly advise the patient and their caregiver specific details of the cognitive behavioral syndrome, including the likely cause, stage, future expectations, treatment options and expectations; possible safety concerns; and support services available.
According to Atri, “A” level guidelines “must be done” and “will improve outcomes.”
The recommendations are based on literature searches and systematic reviews and are applicable in both primary and specialty settings, he added. – by Janel Miller
Atri A. Alzheimer’s Association Best Clinical Practice Guidelines for the Evaluation of Neurodegenerative Cognitive Behavioral Syndromes, Alzheimer’s Disease and Dementias in the United States.
Atri A. Details of the New Alzheimer’s Association Best Clinical Practice Guidelines for the Evaluation of Neurodegenerative Cognitive Behavioral Syndromes, Alzheimer’s Disease and Dementias in the United States.
Both presented at: Alzheimer’s Association International Conference; July 22-26, 2018; Chicago.
For more information: Consult the Alzheimer’s Association website: www.alz.org.
Disclosure: Healio Family Medicine could not confirm relevant financial disclosures at the time of publication.