The American Association for Geriatric Psychiatry, the Alzheimer's Association and the American Geriatrics Society convened a consensus conference on the diagnosis and treatment of Alzheimer's disease. The members of the consensus panel and expert presenters were from the fields of psychiatry, neurology, geriatrics, primary care, psychology, nursing, social work, occupational therapy, epidemiology, and public health policy. The 18-member panel was charged with the task of developing recommendations for the diagnosis and treatment of Alzheimer's disease in the primary care setting. Co-chairs of the panel were Gary W. Small, M.D., University of California at Los Angeles, and Peter V. Rabins, M.D., the Johns Hopkins University, Baltimore. A consensus statement titled “Diagnosis and Treatment of Alzheimer's Disease and Other Related Disorders” was prepared and published in the October 22/29, 1997, issue of JAMA.
According to the statement, Alzheimer's disease affects about 4 million persons in the United States. It is the most common of the dementing disorders. By the year 2040, an estimated 14 million persons in this country will have Alzheimer's disease.
The consensus statement addresses the following questions about the disease:
How prevalent is Alzheimer's disease and what are its risk factors?
What is its impact on society?
What are the different forms of dementia and how can they be recognized?
What constitutes safe and effective treatment for Alzheimer's disease?
What management strategies are available to the primary care practitioner?
What are the available medical specialty and community resources?
What are the important policy issues and how can policy makers improve access to care for dementia patients?
What are the most promising questions for future research?
The main risk factors, according to the statement, are age and family history. Approximately 6 to 8 percent of all persons older than 65 years have Alzheimer's disease. The panel reports that the prevalence of the disease doubles every five years after the age of 60 years. By the age of 90 years, some studies show that almost 50 percent of persons with a first-degree relative with Alzheimer's disease develop the disease themselves.
Alzheimer's disease is characterized by gradual onset and progressive decline in cognition. Changes in behavior and mood frequently occur. Motor skills, sensory function and social skills usually remain intact until late in the course of the disease.
The panel notes that recent progress in understanding the diagnosis and treatment of Alzheimer's disease has helped many patients and their caregivers. Treatments include pharmacologic and nonpharmacolgic methods, and the panel emphasizes that a nonpharmacologic approach is preferred. If nonpharmacologic therapy fails, pharmacologic therapy should be introduced. Pharmacologic therapy can also be used if there is a risk of danger or if the patient is very distressed. The statement discusses the use of cholinesterase inhibitors, such as tacrine and donepezil, and other agents, such as estrogen, nonsteroidal anti-inflammatory drugs and botanical agents, such as ginkgo biloba. Before any treatment is started, it is recommended that patients undergo a thorough medical examination.
The panel lists a number of strategies available to the primary care practitioner to minimize the problems of function and independence and help the patient with a safe environment. The following five strategies are presented in the statement:
Schedule regular patient surveillance and health maintenance visits every three to six months.
Work closely with family and caregivers. This strategy includes a thorough discussion of long-term care and the necessary emotional adjustments.
Establish programs to improve patient behavior and mood.
Encourage caregivers to modulate the environment.
Warn families of the hazards of the patient wandering and driving.
Conclusions and Recommendations
The following is a list of the conclusions and recommendations made by the expert panel:
Alzheimer's disease is underreported and underrecognized. Patients often do not see their physician for an evaluation when they experience cognitive deficits. Also, physicians may not recognize the early signs of the disease. Because there is no definitive test for the disease, physicians must conduct a focused clinical assessment and interview with their patients who are suspected of having Alzheimer's disease.
Diagnosis is primarily one of inclusion, not exclusion, and usually can be made using standardized clinical criteria. Physicians need to be alert to concerns about cognitive decline in their patients who present for treatment of another medical problem.
Most cases of Alzheimer's disease can be managed in a primary care environment. Patients with severe impairment or those with complex comorbidity should be referred to a subspecialist. Regular health examinations are essential. Pharmacologic therapies for cognitive impairment and nonpharmacologic and pharmacologic treatments for behavioral problems can help the quality of life. Drug treatment should be used cautiously in elderly patients.
Education, counseling and support for the family and/or caregivers is important. Some relatives may need their own neuropsychologic evaluation.
The nation's current system of care for patients with Alzheimer's disease is inadequate and fragmented. New approaches need to be initiated to assure necessary medical, psychosocial and community resources.
Future research should focus on barriers to care and improvement of diagnostic and therapeutic effectiveness.