Alzheimers Disease The Challenge of Early Diagnosis

1
Alzheimers Disease The Challenge of Early
Diagnosis

• Overview and Introduction

2
Benefits of Early Diagnosis and Treatment of
Alzheimers Disease

• Alzheimers disease can be diagnosed
  approximately 90 of the time with a general
  medical and psychiatric evaluation1,2
• Early diagnosis has many advantages3,4
• Allows time for planning
• Empowers the patients to make treatment decisions
  early on
• Facilitates caregiver participation
• May slow the progression of symptoms2
• Offers the patient potential for greater
  functioning and independence2,3
• Can help ease the stress for caregivers2,3

Sources 1. Small GW, et al. JAMA.
19972781363-1372. 2. National
Institute on Aging. National Institutes of
Health 2000. NIH publication 00-4859l-62. 3.
Doraiswamy PM, et al. J Clin Psychiatry.
199859(suppl 13)6-18. 4. Knopman DS. In
Early Diagnosis of Alzheimers Disease. Totowa,
NJ Humana Press, Inc 2000298.
3
Discussion Points

• Dementia is underrecognized (even with
• behavioral symptoms) and undertreated
• 67.7 of residents have dementia
• Of those with dementia
• 73 were adequately evaluated
• 52 were adequately treated
• 70 had clinically significant behavioral
  symptoms
• Used 262 min/d of staff time vs no dementia 126
  min/d (Plt.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. 2004521618-1625.
4
Barriers to Early Diagnosis

• Stigma
• First-degree relatives of AD patients reluctant
  to approve cognitive status examination
• Those of patients with more behavioral problems
  show greater reluctance
• Misconceptions
• Perception of uselessness of examination
• Perception of limited treatment options
• Early Stages
• Patients maintain social skills in mild stages

Source Werner P, Heinik J. Int J Geriatr
Psychiatry. 200419479-486.
5
Barriers to Early Diagnosis (cont)

• Failure to Recognize the Importance of
• Cognitive/Functional Changes
• Racial Barriers
• Racial bias in screening tools
• Duality of respect for the patient
  normalization
• Cultural ignorance or insensitivity

Source Cloutterbuck J, et al. Dementia.
20032221-243.
6
Discussion Points

• Dementia Screening Tools Effect of Ethnicity
• Brief screening tests often incorrectly classify
  African Americans with dementia (42) compared
  to Caucasians (6)
• The specificity of standardized cognitive
  assessments for dementia is particularly bad for
  African Americans
• Comparison of the utility of the Clock Drawing
  Test (CDT), Cognitive Abilities Screening
  Instrument, and MMSE
• All tests were affected by education level
• CDT was most sensitive to poorly educated
  non-English speakers

Sources Stephenson J. JAMA. 2001286779-780.
Lampley-Dallas VT. J Natl Med Assoc.
200193323-328. Fillenbaum G, et al. J Clin
Epidemiol. 199043651-660. Borson S, et al.
J Gerontol A Biol Sci Med Sci. 199954M534-M540.
7
Discussion Points

• Ethnic Differences in Knowledge and Perception of
  AD
• Elderly have misperceptions about the prevalence,
  etiology, diagnosis, and financial coverage for
  AD treatments
• Older Hispanic and Asian adults frequently
  consider AD a contagious but curable disease
• Hispanic, Asian, and African Americans more often
  consider AD a form of insanity
• Education levels partially explain differences in
  AD knowledge between Caucasians and Hispanics
• For Asians, the number of years speaking English
  is correlated with better knowledge of AD

Source Ayalon L, et al. Int J Geriatr
Psychiatry. 20041951-57.
8
Barriers to Early Diagnosis (cont)

• Barriers associated with PCPs
• Differential diagnosis
• Vascular dementia, frontotemporal dementia,
  Lewy body dementia
• Comorbid conditions
• Differentiating dementia, delirium, and
  depression
• Time
• 1 hour required for diagnosis, but only 15
  minutes reimbursed
• Knowledge of appropriate reimbursement codes
• Overabundance of tests

9
Discussion PointsVascular Dementia (VaD) - Key
Elements

• Cognitive impairment caused by cerebrovascular
  disease or cerebrovascular accident
• Mixed dementia VaD AD
• Stairstep progression of illness
• May have motor impairment early in the course of
  illness
• Care Notes
• Treat hypertension, diabetes, ? lipids
• May be associated with severe or refractory
  depression
• Accommodate hemiplegia in interactions with
  staff/environment

Source Black SE. Postgrad Med.
2005117(1)15-16,19-25.
10
Discussion PointsDementia With Lewy Bodies - Key
Elements

• Wide fluctuations in cognition, responsiveness,
  and function
• Vivid visual hallucinations and paranoid
  delusions
• Parkinsonism occurs early
• Care notes
• Some antipsychotics will cause severe
  parkinsonism at low doses
• Quetiapine, aripiprazole, or clozapine may be
  tolerated best
• Cholinesterase inhibitors are helpful
• Levodopa and Parkinsons disease medications have
  limited effectiveness for movement disorders

Sources McKeith IG, et al. Neurology.
1996471113-1124. McKeith IG,
et al. Neurology. 199953902-905.
11
Discussion PointsFrontotemporal Dementia - Key
Elements

• Frontal lobe dementia, Picks disease
• Earlier age of onset than AD
• Gradual decline
• Early problems with memory and language
  expression
• Prominent personality changessocially
  inappropriate, disinhibited, and compulsive
  (sexualized, eating) behaviors often observed
• Care notes
• Cholinesterase inhibitors not very effective
• Safe environment for harmful compulsive behaviors

Source McKhann GM, et al. Arch Neurol.
2001581803-1809.
12
Alzheimers Disease

• Multiple cognitive deficits, with both memory
  impairment and 1 or more of the following
  deficits
• Aphasia (language)
• Apraxia (learned motor skills)
• Agnosia (visuospatial/sensory)
• Executive functioning (planning, insight
  anticipation)
• Impairment in social or occupational
  functioning, representing a significant decline
  from a previous level of functioning
• Gradual onset and progressive cognitive decline

Adapted from American Psychiatric Association.
Diagnostic and Statistical Manual of Mental
Disorders. 4th ed. Washington,
DC American Psychiatric Association
1994142-143.
13
Overcoming Barriers to AD Diagnosis

• Time
• Schedule high-risk patients at end of day
• AD does not have to be diagnosed in a single
  visit
• Reimbursement
• Know appropriate codes for AD diagnosis and for
  extra time
• Coexisting illnesses
• AD treatments may permit sustained
  self-management of other illnesses
• Depression
• Evaluate patients using Geriatric Depression
  Scale (15 questions)
• Screening tools
• Start slowly in gathering information, eg, MMSE
  (10-15 minutes) and CDT (1-5 minutes)
• FAQ 10 questions completed by family

14
Targeted Screening

• Patients at least 65 years of age, when clinical
  presentation suggests the possibility of
  dementia (eg, forgetfulness, poor hygiene, poor
  compliance)
• All patients at least 80 years of age, with
  regular 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/feat
ure/247clinicalpracguide/CMI_
DementiaGuideline_public_web_020604.pdf. Accessed
August 17, 2005. Knopman DS, et
al. Neurology. 2001561143-1153.
15
Discussion Points

• Is there a relationship between mild cognitive
  impairment (MCI) and AD? (16 of MCI patients
  convert to AD per year)
• How do we differentiate MCI from AD?
• Government recommendation not to screen (Agency
  for Healthcare Research and Quality)

16
The Case for UniversalCognitive Screening

• Memory complaints are common and can be
  associated with subsequent dementia
• Early dementia symptoms can be difficult to
  recognize
• Cognitive impairment affects how medical care is
  provided
• Management (and costs) of other diseases
• Follow through with medical recommendations
• Prevention of complications

17
Discussion Points

• Which screening tools do you recommend?
• A dialogue on the utility of screening tools
• Educational preceptorshipwarning signs and
  public awareness
• Community
• Doctors
• Consumers
• Alzheimers Association

18
Dementia Diagnostic Process

• General screen
• Signs of acute/chronic disease how well
  controlled?
• Common conditions
• Weight loss, dehydration, subnutrition
• Include obstructive sleep apnea, insomnia,
  depression
• Neurologic screen
• Vascular or Parkinsons dementia, frontal signs
• Gait, balance, and falls
• Neuropathy
• Laboratory screen
• Vitamin B12 deficiency, hypothyroidism
• Associated problems, secondary complications,
  andadditional causes
• Brain structural screen
• Noncontrast CT or MRI
• Surgical and vascular lesions

19
Evaluation of the AD Patient

• In approximately 90 of patients who have AD,
  the diagnosis can be made on the basis of
• Detailed medical history obtained from the
  patient and a reliable informant
• Medical examination
• Mental status examination
• A 15-minute office visit is insufficient for
  fully evaluating the AD patient. For patients
  seen regularly, a 3-stage assessment may be more
  appropriate

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


20
The Office History

• Memory impairment repetitive trouble
  remembering recent conversations, events,
  appointments frequently misplaces objects
• Executive impairment deterioration of complex
  task performance decreased ability to solve
  problems impaired driving
• Drugs alcohol, prescriptions, over-the-counter
  (OTC) medications
• Focal motor or sensory neurologic symptoms

21
Evaluation of the AD Patient (cont)
First Visit

• Take comprehensive history
• Medical history, medications (including OTC drug
  use)
• Interview immediate family member/caregiver
• If time permits and patient is cooperative,
  perform MMSE
• Assess family needs and caregiver stress

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


22
Evaluation of the AD Patient (cont)
Second 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.
23
Evaluation of the AD Patient (cont)
Third Visit

• Review laboratory findings and resultsof testing
• Discuss treatment options, follow-up plans for
  patient
• Readdress family and caregiver needs

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



24
Discussion Points

• What Is the Place for Imaging?
• Noncontrast CT or MRI scan in the initial
  evaluation is appropriate (American Academy of
  Neurology Guideline)
• The use of positron emission tomography
• Value of imaging is to rule out other forms of
  intracranial pathology that may be contributing
  to cognitive change or for unusual presentations
• Rapid onset (duration lt3 months), subdural
  hematoma, cerebral neoplasms, head trauma,
  history of cerebrovascular accident(s), seizures,
  new-onset urinary or fecal incontinence, abnormal
  gait, postural instability, focal signs, visual
  field deficit, headaches, suspect malignant tumor

Sources American Academy of Neurology.
Neurology. 2001561133-1142.
American Academy of Neurology. Neurology.
2001561143-1153.
25
Practical Consequences of Improved Diagnostic
Accuracy

• Accurate diagnostic information and education
  reduce family/caregiver burden
• Decreased likelihood of repeated diagnostic
  assessments and testing
• AD label improves caregiver attitudes
• Information about the disease improves quality of
  life for family/patient and delays nursing home
  placement

Sources Mittelman M, et al. JAMA.
19962761725-1731. Wadley
V, et al. J Gerontol B Psychol Sci Soc Sci.
200156P244-P252.
26
Stages of Alzheimers Disease
27
Summary

• Marked changes in memory are not a normal part of
  aging and may signal a developing dementia
• Universal screening for AD is important
• Effective diagnosis and management take time
• Three separate visits may be required
• It is important to recognize and overcome the
  barriers to early diagnosis of AD