New Alzheimer’s guidelines provide comprehensive framework for diagnosis

We have entered a new era of improved and emerging biologically based diagnostic biomarkers for Alzheimer’s disease (AD) and AD-related neurodegenerative disorders (ADRD) that are rapidly impacting assessment and care paradigms in every clinical setting: primary care, specialty care and dementia subspecialty care.

A comprehensive evaluation involves goal setting in collaboration with the patient and usually a care partner; obtaining information about the patient’s risk profile for AD or a related disease (e.g., age, family history of dementia, hypertension, smoking); describing the history of symptoms and their impact on daily life; evaluating the patient’s ability to perform tests of thinking skills; and obtaining an MRI or CT scan of the brain, along with laboratory tests for conditions that may contribute to cognitive impairment. The integration of new brain imaging, spinal fluid testing, or other specialized testing into this comprehensive evaluation will add critical value to the diagnostic formulation and care plan for individuals with clinical concern for AD or an ADRD.

A special edition of the magazine Alzheimer’s and Dementia: The Journal of the Alzheimer’s Association emphasizes the new Alzheimer’s Association Clinical Practice Guideline for the Diagnostic Evaluation, Testing, Counseling and Disclosure of Suspected Alzheimer’s Disease and Related Disorders (DETeCD-ADRD CPG) which summarizes the process of diagnostic evaluation and disclosure for individuals suspected of possibly having cognitive behavioral impairment as a result from AD or ADRD. Side effects include Lewy Body disease, frontotemporal lobar degeneration, vascular cognitive impairment and dementia (VCID), and a host of other diseases and conditions that can cause or substantially contribute to cognitive behavioral disorders. Similar American guidelines are more than twenty years old and are aimed at specialists or subspecialists in the field of dementia.

With this guideline, we expand the scope of previous guidelines by providing recommendations for practicing physicians about the process from start to finish. We recommend that medical professionals begin by ensuring that their thinking about the objectives of the evaluation aligns with that of the patient, which usually requires a discussion to inform the patient of the specific steps of the process. We then outline the steps involved in obtaining symptom and examination information, followed by a variety of diagnostic tests tailored to the patient, and summarize best practices regarding the diagnostic disclosure process.

Brad Dickerson, MD, director of the Frontotemporal Disorders Unit at Massachusetts General Hospital and professor of neurology at Harvard Medical School

“We emphasize the importance of having a care partner involved during this process for most patients, because cognitive symptoms often compromise a person’s ability to process all of this information on their own,” Dickerson added.

This guideline does not set diagnostic or staging criteria for these diseases, which continue to evolve. Instead, it provides a framework for a high-quality process that is tailored to each individual patient and allows physicians to create a three-step diagnostic formulation, including:

• Cognitive functional status -; the general level of impairment, such as mild cognitive impairment or dementia.
• Cognitive-behavioral syndrome -; the symptoms the person experiences (for example, progressive language problems and memory loss in depression).
• The likely brain disease(s) or condition(s) causing the symptoms.

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

In this special issue of Alzheimer’s and dementiathe three summaries* from the DETeCD-ADRD CPG Working Group distill these recommendations, briefly summarize the evidence supporting them, and operationalize them as a series of steps in an evaluation process. A comprehensive report hosted online provides extensive details on the methodology for developing guidelines, the evidence review process, the peer review process, the rationale and recommendations for implementation, and specific stories of evidence supporting each recommendation.

“The AD/ADRD field has entered a new era and is rapidly evolving, which is very exciting,” said Alireza Atri, MD, Ph.D., Chief Medical Officer, Banner Research and director of the Banner Sun Health Research Institute, Banner Health, Sun City and Phoenix, Arizona, and lecturer in neurology, Brigham and Women’s Hospital and Harvard Medical School. “This first U.S. interdisciplinary national assessment guideline, designed for broad clinical settings, provides a comprehensive foundation that summarizes a high-quality and personalized process within which specific tests can be performed and updated as the field evolves.”

“Some details of the guideline will likely need to be adjusted as new tools and biomarkers become sufficiently validated for appropriate clinical use in practice. The working group used the best evidence and practices to identify individuals with memory or thinking symptoms or concerns and their to empower loved ones, physicians and healthcare systems, to engage in a person-centered process that will increase knowledge, appreciation and autonomy for the person with a potential illness – and make it easier to do what is right for them,” said Atri.

The DETeCD-ADRD CPG working group consists of experts from multiple disciplines and multiple healthcare institutions, including primary care and specialized care. The guideline concludes that if physicians use the recommendations in this guideline and healthcare systems provide adequate resources, outcomes should improve for most patients in most practice settings.

We encourage physicians to review these guidelines and incorporate them into their practice. These guidelines are important because they guide physicians in evaluating memory complaints, which can have many underlying causes. That is the necessary start for an early and accurate diagnosis of Alzheimer’s disease. In addition, these guidelines provide physicians with information about other underlying causes that may contribute to memory complaints.”

Maria C. Carrillo, Ph.D., Alzheimer’s Association chief science officer and chief medical officer

Other co-authors are Carolyn Clevenger, DNP, AGPCNP-BC, GNP-BC (Emory University, Atlanta, GA), Jason Karlawish, MD (University of Pennsylvania, Philadelphia, PA), David Knopman, MD (Mayo Clinic, Rochester, MN), Pei-Jung Lin, PhD (Tufts Medical Center, Boston, MA), Mary Norman, MD (Cedars Sinai Medical Center, Culver City, CA), Chiadi Onyike, MBBS, MHS (Johns Hopkins University, Baltimore, MD), Mary Sano, PhD (Icahn School of Medicine at Mount Sinai, New York, NY), Susan Scanland, MSN, CRNP, GNP-BC, CDP (Dementia Connection, Clarks Summit, PA) .

This work was funded by the Alzheimer’s Association.