Am Fam Physician. 1999 Nov 15;60(8):2432-2435.
The Council on Scientific Affairs of the American Medical Association (AMA) has reviewed the different guidelines on Alzheimer's disease. The review article is published in the July/August 1999 issue of Archives of Family Medicine. Included in the report are summaries of the content of Alzheimer's disease guidelines published by the Agency for Health Care Policy and Research (AHCPR), the American Academy of Neurology (AAN), the Veterans Health Administration (VHA) and the American Psychiatric Association (APA). In addition, the report contains a review of the epidemiology, etiology and neuropathology, caregiver issues, pharmacologic treatment and future research directions.
The following highlights the information in the section that discusses the published guidelines from the AHCPR, the AAN, the VHA and the APA.
The AMA review of the AHCPR guideline on Alzheimer's disease notes that recognition of early-stage disease is emphasized. According to the AMA, the following areas are discussed in the AHCPR guideline:
Triggers that signal the need for assessment for early-stage dementia.
The components of an initial assessment, including history and physical examination, mental status tests and tests of functional performance.
A flowchart for early recognition and assessment, including assessment for delirium and depression.
Guidelines for interpretation of test results and appropriate interventions.
An algorithm for reassessment and referral.
The role of neuropsychologic testing in patients with mixed test results.
Collaborative continuity of care for the patient and caregivers.
Knowledge of the individual patient for accurate assessment of changes.
The AAN guideline is noted to contain recommendations that are designated as “standards,” “guidelines” and “options” based on the strength of the evidence. The recommendations are as follows:
Indications for evaluation for dementia include memory loss or other cognitive problems. Evaluation is indicated in elderly patients whose competency is questioned, in anxious or depressed patients with cognitive complaints and in patients with no complaints but who are suspected of having cognitive impairment.
Cognitive and functional deficits should be substantiated by a reliable informant.
Cognitive or mental status testing should include assessment of attention, level of arousal, orientation, recent and remote memory, language, visuospatial function, calculations and judgment.
Neurologic history and examination, with special attention to gait disorders, focal abnormalities and extrapyramidal signs.
Diagnostic tests to exclude metabolic or structural causes of dementia depend on the suspected diagnosis. Tests may include complete blood cell count, serum electrolyte levels, glucose level, blood urea nitrogen and creatinine levels, liver and thyroid function tests, serum vitamin B12 and folate levels, and syphilis serology.
Neuroimaging should be considered based on the clinical manifestations.
According to the AMA review, the VHA guideline provides specific recommendations for procedures at each step of the assessment. Formulated questions, flowcharts and a list of laboratory tests are included. This guideline advocates referral for neuropsychologic testing to aid in defining cognitive deficits, differential diagnosis and treatment planning. Referral for neuropsychologic testing is recommended in the following circumstances:
Complaints of memory loss and other cognitive impairment without functional impairment.
Report of functional change with normal performance on cognitive screening tasks.
The diagnosis of Alzheimer's disease is established but additional information is needed to aid in decision making, treatment and counseling.
Lack of physician experience with cognitive screening tests.
Insight into techniques for behavioral and environmental intervention, and information for caregivers are needed.
According to the AMA, the APA guideline emphasizes the management of behavioral symptoms. The areas covered in this guideline are as follows:
Psychiatric management, including ongoing assessment, monitoring of symptoms at four- to six-month intervals, prompt intervention, and patient and family counseling about driving, supportive services, and legal and financial planning.
Behavioral management, including pet and art therapy, environmental interventions, behavior modification and reality orientation.
Treatment with psychoactive agents and other medications.
Treatment of cognitive symptoms with cholinesterase inhibitors, vitamin E and seligilene.
Treatment of depression and sleep disorders.
Copyright © 1999 by the American Academy of Family Physicians.
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