Alzheimer Disease: Appropriate Diagnosis and Management

AUGUST 20, 2019
MD Magazine

Jeffrey L. Cummings, MD, ScD: Why is early diagnosis such a challenge to clinicians, and what’s the importance of timely diagnosis and early recognition? Dr Atri, could I ask you to address this question?

Alireza Atri, MD, PhD: Sure. Thanks, Jeff. I think it has to do with…a misperception about the value that diagnosis and treatment can provide. There’s an issue of proficiency for clinicians. There are issues with knowledge, time, and resources. I think that all those things are actually surmountable with better education and appreciation.… When you look at Alzheimer disease and related dementias in a spectrum and when you add family education; care of the caregiver; detection early when individuals are at their highest peak to be able to make their own decisions and are able to have autonomy and be empowered to make decisions about their own lives, get on medications, change lifestyles, and have a supportive environment, these are actually meaningful. This is something that cannot be addressed by 1 demographic or 1 stakeholder. It requires health care systems to be involved, as well as clinicians, educators, and family members.

Over time…we’ll have a bit more clarity regarding…the pathways for best practices. I’ll put in a plug, because we’ve been working on this in a multidisciplinary work group for the Alzheimer’s Association for clinical best practices. Nineteen recommendations will come out later this year regarding the whole process of evaluation in a primary care setting…, specialty setting, or subspecialty setting, including how to take concerns, how to do the evaluation, what testing to do, what are the recommendations regarding imaging and other biomarkers, and how to actually disclose the diagnosis. I’m actually really hopeful that we can reach primary care clinicians and help them implement these recommendations. But it’s going to require multiple stakeholders to make this happen.

Jeffrey L. Cummings, MD, ScD: That’s great. I’m looking forward to those. Dr Sabbagh, let me ask you to address the question of when a health care provider should refer to a neurologist when the question is Alzheimer disease.

Marwan Sabbagh, MD: The answer is very simple in that when the health care provider takes the time to detect that there is a cognitive issue to begin with—when they don’t know what they’re dealing with, their comfort level is not where it needs to be, and they need a confirmatory approach to their diagnosis—they should not dismiss it. So, in other words, I think that most of the time when a primary care physician detects any incidence of cognitive impairment, they should order a neurological evaluation. Of course, we want to make sure. It might not be Alzheimer disease, it might be something else. But our best approach is to push the patients into the specialty practice sooner than later.

Jeffrey L. Cummings, MD, ScD: Thank you. Dr. Isaacson, I want to talk a little bit about nonpharmacologic approaches to Alzheimer disease. We talk a lot about drug therapies. But what about the nonpharmacologic therapies? How do you think about them? When would you integrate them?

Richard Isaacson, MD: There are now multiple randomized controlled trials that have evaluated whether lifestyle interventions may reduce the risk of cognitive decline. The totality of evidence is building for taking a multidomain intervention. For example, there’s a study called the FINGER [Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability]. This trial involves nutritional intervention and exercise on a regular basis, as well as cognitive training. When you use all 3 of these, there is less cognitive decline 2 years later. This was found in a very large multicountry…randomized study. Other studies, such as the SPRINT-MIND [Systolic Blood Pressure Intervention Trial–Memory and Cognition in Decreased Hypertension] study showed that blood pressure reductions can actually reduce the incidence of mild cognitive impairment. These are preliminary results, but they are convincing. These are randomized studies. Many studies are looking at whether exercise, nutrition, and cognitive training could have a benefit.

But there are other interventions as well that may be evidence based and safe. The totality of evidence may not be as strong, but things to take into consideration include minding someone’s sleep, understanding going to bed at the same time every day, taking away some of the sedative sleep medications, and maybe using something like sleep hygiene. Music interventions have a very interesting body of evidence that’s evolving in terms of stress reduction. These are all nonpharmacological approaches that can help in the treatment of Alzheimer disease. Whether or not they’re effective may depend on the person.

Also, the one-size-fits-all approach isn’t going to work in a situation like this. Additionally, just telling someone, “Go exercise—it’s good for your brain,” that may not work either. What if someone has a physical limitation? What if someone has low muscle mass? Well, then maybe they need to do strength training once or twice a week. But if someone is not fit from a cardiovascular perspective, they need targeted advice on how to do cardiovascular exercise in a way that’s appropriate for them. Maybe they need a personal trainer. Maybe they need to see a nutritionist. I believe that the take-home point for using nonpharmacological strategies is that this should be common—an everyday part of the treatment strategy and the treatment armamentarium for Alzheimer disease.

Jeffrey L. Cummings, MD, ScD: Is there a place to go to get information about these criteria? It seems complicated to me as I listen to you.

Richard Isaacson, MD: Sure. It’s quite complicated. There are a variety of websites out there, and there are a variety of resources. We actually created a free resource for the public. It’s called Alzheimer’s Universe. It’s a free website that has just over 2½ hours of course work—interactive education about brain health and what is and what is not in our control when it comes to risk reduction for Alzheimer disease. The site again is Alzheimer’s Universe, and it’s at AlzU.org. There are courses for high school students, college studies, and the general public, as well as health care providers, medical students, and neurology trainees.

Jeffrey L. Cummings, MD, ScD: Very good. Thank you for that. Elaine, what do primary care physicians need to know about treating patients with Alzheimer disease? What are the critical things?

Elaine R. Peskind, MD: I think there are some things that they need to know even in a sphere larger than just treatment. First of all, primary care physicians need more confidence with making the diagnosis. This is making the diagnosis of Alzheimer disease that presents in the typical fashion: insidious onset and gradual progression of memory and other cognitive impairments in the absence of stroke or parkinsonism. You have ruled out vitamin B12 deficiency and thyroid deficiency. You’ve stopped medications that may be causing cognitive impairment. The vast majority of those cases will be Alzheimer disease. In later life, in the late 70s or 80s, it will be Alzheimer disease maybe with another 1 or 2 comorbid pathologies.

I think that it’s important to engage the “caregiver” early on in the course. In the case of mild cognitive impairment, it may not be in the caregiving role, but rather a role of providing information and implementing your recommendations. Again, patients with Alzheimer disease may have insight affected early, and they need to have that other source of information for taking their medications and for complying with all the nonpharmacologic approaches…. Not only will their Alzheimer disease be better managed, or managed at all, but all of their other concurrent medical conditions will also be better managed.

Jeffrey L. Cummings, MD, ScD: Very good. Thank you and thank you for watching. Thank you to our great panel.

Transcript edited for clarity.

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