New Guidelines Update Alzheimer’s and Dementia Evaluations

A three-step process underscores new clinical practice guidelines for primary and specialty care clinicians to evaluate patients who may have cognitive impairment or dementia due to Alzheimer’s or a related disease.

In broad terms, the evaluation should establish a patient’s cognitive functional status, cognitive-behavioral syndrome, and the likely etiology of impairments, said Brad Dickerson, MD, of the Massachusetts General Hospital and Harvard Medical School in Boston, and colleagues of the Diagnostic Evaluation, Testing, Counseling, and Disclosure Clinical Practice Guideline (DETeCD-ADRD CPG) workgroup.

As part of a comprehensive evaluation, the clinician should set goals with a patient and care partner, obtain risk profile information including family and health history, describe symptom history and its effects on daily life, evaluate the patient’s performance on cognitive tests, and include a brain MRI or CT along with lab tests.

The diagnostic formulation should be disclosed clearly, Dickerson and colleagues wrote in Alzheimer’s & Dementia. If primary care clinicians do not have high confidence in the etiology, the patient should be referred to a dementia specialist.

The DETeCD-ADRD CPG — which outlines separate recommendations for primary care and specialty care — is the first update in decades, Dickerson and colleagues said.

“If clinicians use this guideline and healthcare systems provide adequate resources, outcomes should improve in most patients in most practice settings,” they wrote.

The guidance summarizes the process of characterizing and diagnosing people who may have Alzheimer’s, Lewy body disease, frontotemporal lobar degeneration, vascular cognitive impairment and dementia, or similar disorders. It does not propose new diagnostic or staging criteria for these diseases.

“With this guideline, we expand the scope of prior guidelines by providing recommendations for practicing clinicians on the process from start to finish,” Dickerson said in a statement.

“We recommend that medical professionals begin by making sure their thinking about the goals of the evaluation aligns with that of the patient, which usually requires a discussion to educate the patient on the specific steps of the process,” he pointed out. “Then we outline the steps involved in obtaining information about symptoms and examination, followed by a variety of diagnostic tests tailored to the patient, and summarize best practices regarding the diagnostic disclosure process.”

The guidance emphasizes the importance of having a care partner for most patients, since cognitive symptoms may compromise a patient’s ability to process the information discussed, Dickerson added.

The DETeCD-ADRD guidelines were developed by an expert workgroup from multiple disciplines convened by the Alzheimer’s Association. The group based its recommendations on a review of 133 publications.

“The workgroup provides rigorous, evidence- and practice-informed foundational steps that capture the core elements of a high-quality evaluation and disclosure process,” Dickerson said. “The guidelines are formulated into 19 practical recommendations that are applicable to any practice setting, including primary care, along with additional guidance for specialists and subspecialists.”

The guidelines were supported by companion articles in Alzheimer’s & Dementia that included a review of validated clinical assessment instruments and information about disclosing diagnoses of mild cognitive impairment and dementia.

The guidance provides a foundation for a “personalized process within which specific tests are slotted and can be updated as the field evolves,” noted co-author Alireza Atri, MD, PhD, of Banner Sun Health Research Institute and Banner Alzheimer’s Institute in Sun City, Arizona. Some guideline details may be modified as new tools and biomarkers become validated for clinical practice, he added.

The goal of the evaluation process is to provide timely and accurate diagnosis, disclosure, and counseling, the DETeCD-ADRD authors said. The recommendations help clinicians evaluate cognitive problems which could have a number of etiologies, observed co-author Maria Carrillo, PhD, chief science officer of the Alzheimer’s Association.

“That is the necessary start for an early and accurate Alzheimer’s diagnosis,” Carrillo pointed out. “In addition, these guidelines provide clinicians information about other underlying causes that may contribute to the memory complaints.”