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Diagnosing Alzheimer's - Professionals
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Reprinted from The Alzheimer’s Association: www.alz.org

 

·         Diagnostic Disclosure

 

 

Diagnostic Overview

 


Alzheimer’s is characterized primarily by a gradual onset of progressive symptoms, including:

·         memory loss

·         changes in personality

·         noticeable decline in cognitive abilities (including speech and understanding

·         loss of executive function (decision-making)

·         losses impairing activities of daily living (dressing, eating, toileting etc.)

Today, new diagnostic tools and criteria make it possible for all physicians (primary care as well as specialists) to make a positive clinical diagnosis of probable Alzheimer’s with an accuracy of approximately 90 percent.

Recognizing symptoms early and accurately diagnosing a patient with Alzheimer’s is important. Although the onset of Alzheimer’s disease cannot yet be stopped or reversed, an early diagnosis gives patients a greater chance of benefiting from existing treatments and allows them and their families more time to plan for the future.

Cognitive function should be assessed not only in those concerned about memory loss but also in patients who may not yet exhibit obvious symptoms but have risk factors for the disease, such as age and family history. The Alzheimer’s Association has established a list of 10 warning signs to look for when attempting to detect Alzheimer’s in a patient, before the disease progresses to the advanced stages.

 

 

 

Diagnostic Procedures

 


The actual diagnostic workup involves several steps — an initial evaluation including a medical history, a mental status evaluation, a clinical examination and laboratory tests — as outlined in the Differential Diagnosis of AD Algorithm appearing below. There is more information on each step below the diagram. 

Differential Diagnosis in AD Algorithm*

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Dementia
Dementia, according to the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV), is a syndrome that may be caused or characterized by:

Multiple cognitive deficits, which include memory impairment and at least one of the following: aphasia, apraxia, agnosia or disturbance in executive functioning. Social or occupational function is also impaired. A diagnosis of dementia should not be made during the course of a delirium. (A dementia and a delirium may both be diagnosed if the dementia is present at times when the delirium is not present.)

Alzheimer’s disease is the most common cause of dementia, accounting for between 50 and 60 percent of all cases, but there are many disorders that can cause or simulate dementia. Many of these are the result of degenerative diseases whose progression, at least at the present time, cannot be arrested. However, several causes of dementia are either potentially reversible or stoppable and may be responsive — either totally or in part — to treatment.

Medication-induced dementia
Medication-induced dementia is the most frequent cause of “reversible” dementia. The incidence of adverse drug reactions increases with age. Alterations in pharmacokinetics and pharmacodynamics, together with the presence of concomitant illnesses (especially renal, hepatic and cardiac) and the number of prescribed and over-the-counter medications taken, render older people more vulnerable to adverse events. To rule out a medication-induced dementia, a thorough drug history and a review of all current medication (both prescription and over-the-counter) should be undertaken. The “brown bag” test, wherein patients bring all their medication to the physician for inspection, is essential.

Metabolic / endocrine / nutritional / systemic disorders
Metabolic/endocrine/nutritional/systemic disorders (e.g., hypothyroidism, B12 deficiency and systemic infections) are additional causes of “reversible” dementias and can be diagnosed with routine laboratory tests. Tests recommended include blood count, sedimentation rate (if indicated), electrolytes (including calcium), liver and renal function tests, urinalysis, syphilis serology, B12 levels, thyroid function tests and a toxicity screen (if medical history and the physical exam so indicate). Most of these conditions respond favorably to treatment.

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Vascular dementia / hydrocephalus / tumors / hematoma
Vascular dementia (VaD) may arise as a sequel to any form of cerebrovascular disease. VaD is responsible for approximately 20 percent of dementia cases. As a comorbid condition, VaD may worsen the dementia of Alzheimer’s disease. A diagnosis of probable vascular dementia is adapted from the following National Institute of Neurological Disorders and Stroke (NINDS) criteria:

Cerebrovascular disease (CVD) is defined by the presence of focal signs on neurologic examination such as: hemiparesis, facial weakness, Babinski sign, sensory deficit, hemianopia, dysarthria consistent with stroke (with or without history of stroke) and evidence of relevant CVD by brain imaging, including multiple large-vessel infarcts or a single strategically placed infarct (angular gyrus, thalamus, basal forebrain), as well as multiple basal ganglia and white matter lacunas or extensive periventricular white matter lesions, or combinations thereof.

Other criteria include any combination of onset of dementia within three months following a recognized stroke; abrupt deterioration in cognitive functions; or fluctuating, stepwise progression of cognitive deficits.

Normal pressure hydrocephalus, brain tumors and subdural hematoma, the most common of the structural brain lesions, can also present with dementia. Confirmation or exclusion of their presence usually requires a CT or MRI scan.

Depression
Depression is another common cause of “reversible” dementia in the geriatric population. Unlike younger individuals, elderly depressed patients may present with cognitive impairment, i.e., confusion, memory disturbance, attention deficits, all of which can be mistaken for dementia. Depression may also coexist with dementia and exacerbate the problem, causing; “excess disability.” A good history and thorough mental-status examination should form the basis for a treatment plan to alleviate primary or secondary impairment from depressive symptoms.

DSM-IV criteria for a diagnosis of depression require that a patient experiences five (or more) of the following symptoms during the same two-week period (every day for most of the day, or nearly every day). At least one of the symptoms is either depressed mood or loss of interest or pleasure.

1.      Depressed mood most of the time, as indicated by either subjective report (e.g., feels sad) or observation by others (e.g., appears tearful).

2.      Diminished interest or pleasure in nearly all activities.

3.      Significant weight loss or weight gain (e.g., more than five percent of body weight in a month) or decrease or increase in appetite.

4.      Insomnia or hypersomnia.

5.      Psychomotor agitation or retardation.

6.      Fatigue or loss of energy.

7.      Feelings of worthlessness or guilt.

8.      Diminished ability to think or concentrate, or indecisiveness.

9.      Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

The symptoms:

·         must cause clinically significant distress or impairment in social and occupational functioning;

·         are not due to the direct physiological effects of a substance or a general medical condition;

·         are not better accounted for by bereavement;

·         persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms or psychomotor retardation.

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Alzheimer’s disease
Alzheimer’s disease is progressive, resulting in impairment in cognitive function. The clinical symptoms associated with this disease include memory loss, language disorders, visuospatial impairment and behavioral disturbances. Alzheimer's may present with a variety of symptoms, but difficulties with memory are common to all.

For a diagnosis of probable Alzheimer's, the criteria adapted from the National Institute of Neurological and Communicative Disorders and Stroke and Alzheimer’s Disease and Related Disorders Association (NINCDS-ADRDA) include:

·         Dementia established by examination and objective testing

·         Deficits in two or more cognitive areas

·         Progressive worsening of memory and other cognitive functions

·         No disturbance in consciousness

·         Onset between ages 40 and 90

Absence of systemic disorders or other brain diseases, which could account for the deficits in memory and cognition, should also be established. Atypical cases of dementia should be referred to specialists for assessment.

Resource list


This list below identifies sources for the Differential Diagnosis of Alzheimer’s Disease Algorithm diagnostic toolbox. Most of these resources can be found by calling your local library, contacting the publisher or calling the Alzheimer’s Association’s Green-Field Library at 312.335.9602.

· Mini-Mental Status Examination
Folstein, M.F., Folstein, S.E., and McHugh P.R. “Mini-Mental State”: a practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research (November 1975), vol. 12 (3): 189-98.

· Cockrell, J. R. and M.F. Folstein. Mini-Mental State Examination (MMSE). Psychopharmacology Bulletin (1988), vol. 24 (4): 689-92.

· Physical Self-Maintenance Scale
Lawton, M., Brody, E. “Assessment of Older People: Self-Maintaining and Instrumental Activities of Daily Living.” The Gerontologist. 1969, 9:179-86.

· DSM-IV Criteria
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Washington, D.C.: American Psychiatric Press, 1994.
For more information call American Psychiatric Press at 1.800.368.5777.

· AHRQ Guidelines (Agency for Healthcare Research and Quality)
Costa, P. T. Jr., et al. Early identification of Alzheimer’s disease and related dementias. Clinical practice guidelines, quick reference guide for clinicians, no. 19. Rockville, Md.: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1996.

· American Academy of Neurology (AAN) Guidelines
American Academy
of Neurology. Practice parameters for detection, diagnosis, and management of dementia (summary statements). Neurology (May 8, 2001), vol. 56: 1133-1142, 1143-1153, 1154-1166

· National Institute of Neurological Disorders and Stroke (NINDS) Criteria
Roman, G. C., et al. Vascular dementia: diagnostic criteria for research studies. Report of the NINDS-AIREN international workshop. Neurology (February 1993), vol. 43 (2): 250-60.

· National Institute of Neurological Communicative Disorders and Stroke (NINCDS) and the Alzheimer Disease and Related Disorders Association Criteria
McKhann, G., et al. Mental and clinical diagnosis of Alzheimer’s disease: report of the NINCDS-ADRDA Work Group under the auspices of the Department of Health and Human Services Task Force on Alzheimer’s Disease. Neurology (July 1984), vol. 34 (7): 939-44.

 

 

 

Diagnostic Disclosure

 

Introduction

Except in unusual circumstances, physicians and the care team should disclose the diagnosis to the individual with Alzheimer’s disease because of the individual’s moral and legal right to know. You may have to disclose the diagnosis to the families first in cases where the person with Alzheimer’s may have difficulty understanding.

Disclosing the diagnosis early in the disease process allows the individual to maximize quality of life and play an active role in planning for the future. If you disclose the diagnosis after the dementia has advanced, it may no longer be meaningful to the affected individual.

If the individual is informed of the diagnosis early on, he or she can also be involved in communicating and planning for end-of-life decisions. These plans can apply to issues such as life-prolonging measures and consenting to participate in Alzheimer research and can be expressed through the preparation of advance directives.

You should arrange a joint meeting with the individual and the family members to disclose the diagnosis. Telling families the diagnosis is Alzheimer’s can be difficult, since there is currently no promising prognosis for those affected. Because the initial meeting can be overwhelming, you may need to schedule a follow-up meeting to continue discussion of the diagnosis and available support services.

After disclosing the diagnosis, expect various responses from the individual and family, ranging from acceptance of what was suspected and relief at learning what is causing behavioral changes to denial or depression.

Disclosing the diagnosis

Consider the following before communicating the diagnosis:

·         Gain an understanding of family dynamics and cultural values.

  • When possible, include all of the professionals (nurses, social workers, psychologists and others ) involved in determining the diagnosis in the joint meeting to answer questions and provide specific recommendations.

·         Allow sufficient time to answer questions from the individual and family. A follow-up meeting may need to be scheduled to continue discussion.

·         Discuss how the disease might progress and agree upon a specific care plan that considers the person’s values and beliefs.

·         Provide written educational materials and a list of available community resources, including the Alzheimer’s Association.

Covering key issues

The individual and family should understand the following key issues:

·         Alzheimer’s disease is not a normal part of aging, but a degenerative disease of the brain that results in impaired memory, thinking and behavior.

·         Alzheimer’s disease affects every individual differently, so there is no exact way to determine how the disease will progress.

·         While there is no cure for the disease, some of its symptoms can be treated by medications and behavioral approaches.

·         Disclosure of the diagnosis allows the individual to maximize quality of life and be involved in planning future care decisions.

·         Assistance is available from the Alzheimer’s Association and other resources.

·         Progress is being made in research. One way to help that progress is by participating in clinical drug studies. To locate the clinical drug studies being conducted in the area, contact your local Alzheimer’s Association.

More information about clinical studies:

Participating in Clinical Studies

Clinical Trials Index

Throughout the diagnostic evaluation and treatment planning, you should involve the family and caregiver. As the disease progresses and patients become increasingly dependent on their caregivers, these individuals will become your primary source of information on the patient’s daily mental and physical health.

Finally, bear in mind that the primary caregiver and other members of the family ultimately will suffer from the stress that accompanies caregiving and need information and support, as well as attention to their own health needs.

 

Internet Citation: http://www.alz.org/professionals_and_researchers_diagnosing_alzheimers.asp

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