Addressing Alzheimer’s: A pragmatic approach

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Applied Evidence

Addressing Alzheimer’s: A pragmatic approach

J Fam Pract. 2015 January;64(1):10-18

Marisa Menchola, PhD

Barry D. Weiss, MD

Family physicians are ideally positioned to support patients with Alzheimer’s and their families through all facets of the disease, from initial diagnosis to end-of-life care.

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References

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5. Centers for Medicare & Medicaid Services. The guide to Medicare preventive services. 4th ed. 2011. Available at: http://www.curemd.com/fqhc/The%20Guide%20to%20Medicare%20Preventative%20Services%20for%20Physicans,%20Providers%20and%20Suppliers.pdf. Accessed December 2, 2014.

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8. Cordell CB, Borson S, Boustani M, et al; Medicare Detection of Cognitive Impairment Workgroup. Alzheimer’s Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimers Dement. 2013;9:141-150.

9. McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of dementia due to Alzheimer’s disease: recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimers Dement. 2011;7:263-269.

10. The American Geriatrics Society. A guide to dementia diagnosis and treatment. The American Geriatrics Society Web site. Available at: http://dementia.americangeriatrics.org/documents/AGS_PC_Dementia_Sheet_2010v2.pdf. Accessed December
2, 2014.

11. Jack CR, Knopman DS, Jagust WJ, et al. Tracking pathophysiological processes in Alzheimer’s disease: an updated hypothetical model of dynamic biomarkers. Lancet Neurol. 2013;12:207-216.

12. Johnson KA, Minoshima S, Bohnen NI, et al; Alzheimer’s Association; Society of Nuclear Medicine and Molecular Imaging; Amyloid Imaging Taskforce. Appropriate use criteria for amyloid PET: a report of the Amyloid Imaging Task Force, the Society of Nuclear Medicine and Molecular Imaging, and the Alzheimer’s Association. Alzheimers Dement. 2013;9:e1-e16.

13. Centers for Medicare and Medicaid Services. National coverage determination (NCD) for FDG PET for dementia and neurodegenerative diseases (220.6.13). Centers for Medicare and Medicaid Services Web site. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=288&ncdver=3&bc=BAABAAAAAAAA&. Accessed December 2, 2014.

14. Albert MS, DeKosky ST, Ruckson D, et al. The diagnosis of mild cognitive impairment due to Alzheimer’s disease: recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimers Dement. 2011;7:270-179.

15. Mitchell AJ, Shiri-Feshki M. Rate of progression of mild cognitive impairment to dementia—meta-analysis of 41 robust inception studies. Acta Psychiatr Scand. 2009;119:252-265.

16. Farias ST, Mungas D, Reed BR, et al. Progression of mild cognitive impairment to dementia in clinic- vs community-based cohorts. Arch Neurol. 2009;66:1151-1157.

17. Bensadon BA, Odenheimer GL. Current management decisions in mild cognitive impairment. Clin Geriatr Med. 2013;29:847-871.

18. Ngo-Metzger Q, August KJ, Srinivasan M, et al. End-of-life care: guidelines for patient-centered communication. Am Fam Physician. 2008;77:167-174.

19. Sayegh P, Knight BG. Cross-cultural differences in dementia: the Sociocultural Health Belief Model. Int Psychogeriatr. 2013;25:517-530.

20. McDaniel SH, Campbell TL, Hepworth J, et al. Family-Oriented Primary Care. 2nd ed. New York, NY: Springer; 2005.

21. Bensadon BA, Odenheimer GL. Current management decisions in mild cognitive impairment. Clin Geriatr Med. 2013:29;847-871.

22. Russ TC, Morling JR. Cholinesterase inhibitors for mild cognitive impairment. Cochrane Database Syst Rev. 2012;9:CD009132.

23. Sadowsky CH, Galvin JE. Guidelines for the management of cognitive and behavioral problems in dementia. J Am Board Fam Med. 2012;25:350-366.

24. Birks J. Cholinesterase inhibitors for Alzheimer’s disease. Cochrane Database Syst Rev. 2006;(1):CD005593.

25. Fillit HM, Doody RS, Binaso K, et al. Recommendations for best practices in the treatment of Alzheimer’s disease in managed care. Am J Geriatr Pharmacother. 2006;4(suppl A):S9-S24;quiz S25-S28.

26. Schneider LS, Tariot PN, Dagerman KS, et al; CATIE-AD Study Group. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med. 2006;355:1525-1538.

27. US Food and Drug Administration. Public health advisory: Deaths with antipsychotics in elderly patients with behavioral disturbances. US Food and Drug Administration Web site. Available at: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm053171.htm. Published April 11, 2005. Updated August 16, 2013. Accessed December 2, 2014.

28. The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60:616-631.

29. Brummel-Smith K. It’s time to require written informed consent when using antipsychotics in dementia. Br J Med Pract. 2008;1:4-6.

30. Huckans M, Hutson L, Twamley E, et al. Efficacy of cognitive rehabilitation therapies for mild cognitive impairment (MCI) in older adults: working toward a theoretical model and evidence-based interventions. Neuropsychol Rev. 2013;23:63-80.

31. Woods B, Aguirre E, Spector AE, et al. Cognitive stimulation to improve cognitive functioning in people with dementia. Cochrane Database Syst Rev. 2012;2:CD005562.

32. McLaren AN, Lamantia MA, Callahan CM. Systematic review of non-pharmacologic interventions to delay functional decline in community-dwelling patients with dementia. Aging Ment Health. 2013;17:655-666.

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PRACTICE RECOMMENDATIONS

› Refer patients for formal neuropsychological testing when dementia is suspected but the history, clinical interview, and brief cognitive tests do not result in a definitive diagnosis. C
› Use non-drug therapies as first-line treatment for behavioral symptoms of Alzheimer’s disease (AD), as the adverse effects of drug therapy generally offset any benefit. B
› Recommend against feeding tubes for patients with late-stage AD as they are more apt to cause discomfort than to provide benefit. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Alzheimer’s disease (AD), the most common form of dementia, affects more than 5 million Americans.¹ Estimates suggest that by 2050, the prevalence could triple, reaching 13 to 16 million.¹ To effectively care for patients with AD and their families, family physicians need to be familiar with the latest evidence on all facets of care, from initial detection to patient management and end-of-life care.

This evidence-based review will help you toward that end by answering common questions regarding Alzheimer’s care, including whether routine screening is advisable, what tests should be ordered, which interventions (including nonpharmacologic options) are worth considering, and how best to counsel patients and families about end-of-life care.

Routine screening? Still subject to debate

In considering routine dementia screening in primary care, the key question is whether screening improves outcomes. Advocates note that individuals with dementia may appear unimpaired during office visits and may not report symptoms due to lack of insight; they point out, too, that waiting for an event that makes cognitive impairment obvious, such as a driving mishap, is risky.² Those who advocate routine screening also note that only about half of those who have dementia are ever diagnosed.³

Others, including the US Preventive Services Task Force (USPSTF), disagree. In its 2014 evidence review, the USPSTF indicated that there is “insufficient evidence to assess the balance of benefits and harms of screening for cognitive impairment in older adults.”⁴

Mixed messages

The dearth of evidence is also reflected in the conflicting recommendations of the Affordable Care Act (ACA) and the Centers for Medicare and Medicaid Services (CMS). The ACA requires physicians to assess the cognitive function of Medicare patients during their annual wellness visits. CMS, however, instructs providers to screen for dementia only if observation or concerns raised by the patient or family suggest the possibility of impairment, and does not recommend any particular test.⁵

Cost-effectiveness analyses raise questions about the value of routine screening, as well. Evidence suggests that if a primary care physician screens 300 older patients, 39 will have a positive screen. But only about half of those 39 will agree to a diagnostic evaluation, and no more than 9 will ultimately be diagnosed with dementia. The estimated cost of identifying 9 cases is nearly $40,000—all in the absence of a treatment to cure or stop the progression of the disorder.⁶

The bottom line: Evidence does not support routine dementia screening of older adults. When cognitive impairment is suspected, however, physicians should conduct a diagnostic evaluation—and consider educating patients and families about the Alzheimer’s Association (AA)’s 10 warning signs of AD.⁷ (See “Is it Alzheimer’s? 10 warning signs”⁷ below.) A longer version, available at http://www.alz.org/national/documents/checklist_10signs.pdf, outlines the cognitive changes that are characteristic of healthy aging and compares them to changes suggestive of early dementia.⁷

Is it Alzheimer’s? 10 warning signs⁷

1. Memory loss that disrupts daily life
2. Challenges in planning or solving  problems
3. Difficulty completing familiar tasks
4. Confusion with time or place
5. Trouble understanding visual images  and spatial relationships
6. New problems with words in  speaking or writing
7. Misplacing things and losing the  ability to retrace steps
8. Decreased or poor judgment
9. Withdrawal from work or social  activities
10. Changes in mood and personality

How to proceed when you suspect AD

Step 1: Screening instrument. The first step in the diagnostic evaluation of a patient with suspected AD is to determine if, in fact, cognitive impairment is present. This can be done by screening with in-office screening instruments, such as the Mini-Cog (available at alz.org/documents_custom/minicog.pdf) or Mini-Mental State Examination (MMSE; health.gov.bc.ca/pharmacare/adti/clinician/pdf/ADTI%20SMMSE-GDS%20Reference%20Card.pdf), among others.⁸

Step 2: Clinical evaluation. If observation and test results suggest cognitive impairment, the next step is to determine whether clinical findings are consistent with the diagnostic criteria for AD (TABLE 1)⁹ developed by workgroups from the National Institute on Aging (NIA)/AA in 2011. A work-up is necessary to identify conditions that can mimic dementia (eg, depression) and behaviors that suggest another type of dementia, such as frontotemporal or Lewy body dementia.¹⁰ Lab testing should be included to rule out potentially reversible causes of cognitive dysfunction (eg, hypothyroidism, vitamin D deficiency).