A Look At The New Guidelines For Diagnosing Alzheimer's Disease

Question: What is the difference between dementia and

Alzheimer’s disease?

Answer: Dementia is the umbrella term for brain disorders

that cause a person to lose their ability to function normally

in daily life. Alzheimer’s disease is the most common, but

there are other dementias, such as vascular, Lewy body, etc.

Although we know Alzheimer’s dementia is distinct from

these other forms, in the early stages it may be difficult to

differentiate among them. Additionally, many older people

may have more than one condition, such as Alzheimer’s

disease combined with vascular disease and sometimes small

strokes. 

That is one of the reasons why researchers hope one day to

develop an easy-to-administer, reliable and inexpensive

biomarker—a test that indicates harmful changes taking

place in the brain—that can be used in a doctor’s office. For

example, eventually there may be a simple blood test to help

diagnose Alzheimer’s disease.

Question: How was dementia diagnosed before these new

guidelines and what has changed? 

Answer: The new guidelines do not dramatically alter the

current process doctors use to diagnose Alzheimer’s disease.

Dementia is still diagnosed based on significant and chronic

changes in a person’s thinking processes, or as a professional

would state, cognition. Healthcare providers speak with the

patient and family or caregivers, seeking observations about

changes in how the patient thinks, learns and remembers and

taking into consideration other potential causes of cognitive

decline—for example, medications, malnutrition,

dehydration, depression. 

However, the new guidelines ask doctors to look beyond

just memory loss for additional symptoms that may mark

onset of the disorder, such as problems with judgment.  And

the revised guidelines outline ways the healthcare provider

should approach evaluating the causes and progression of

cognitive decline. For example, healthcare providers are

made aware that mild cognitive impairment (MCI) may in

many cases progress to Alzheimer’s disease and that memory

impairment is not always the first symptom of Alzheimer’s. 

Question:  Where and how are biomarkers and new imaging

tests being used?

Answer: At this time, they are being used by researchers

investigating how brain imaging and body fluid analysis relate

to the changes taking place in the brain and whether the

tests can predict who is at risk for developing the clinical

symptoms associated with the disease. For clinicians in

research centers or with access to large medical centers,

fluid biomarker and imaging tests may be used in certain

cases. For example, they may be used to increase or

decrease the level of certainty about a diagnosis of

Alzheimer’s dementia and to distinguish Alzheimer’s

dementia from other dementias. But at this stage, the tests

are not available to primary care doctors because

investigators are still standardizing and evaluating their use.

Question: Why were the diagnostic criteria for Alzheimer’s

disease revised and who led the effort? 

Answer: The diagnostic criteria had been in place for more

than 27 years and did not reflect the new knowledge that has

been gained regarding the progression of the disease. Thus,

the National Institute on Aging (NIA) at the National

Institutes of Health and the Alzheimer’s Association brought

together experts in clinical neuro- and behavioral science to

revise the criteria. 

The new guidelines will help guide research and hopefully

speed the discovery of treatments to delay and/or prevent

Alzheimer’s disease. The guidelines also explain to clinicians

and the public our deeper understanding of the disease—that

it develops over decades, long before the first signs of

dementia appear; and for that reason, clinicians need to be

sensitive to early changes that may be associated with the

development of mild cognitive impairment. 

Question: How will doctors use the updated guidelines to

better diagnose Alzheimer’s disease? 

Answer: For the most part, doctors will consider Alzheimer’s

disease in an office setting pretty much as they have in the

past, but with updated knowledge about what to look for. A

major change for physicians is the consideration of mild

cognitive impairment, or MCI. People with MCI have

problems with memory or other cognitive functions that are

greater than normal for their age and education. 

Some doctors may use the guidelines to better inform

patients with MCI about their increased risk for developing

Alzheimer’s disease.  For clinicians with access to researchers

conducting biomarker and/or imaging studies, such

tests—while experimental—may be used to affirm suspicions

of Alzheimer’s disease. 

Question: Can doctors use the guidelines to diagnose other

kinds of dementia besides Alzheimer’s disease?

Answer: The guidelines are specifically for Alzheimer’s

dementia.

Question: Should these new guidelines be used to

“re-diagnose”—that is, for those who already have a diagnosis

of Alzheimer’s disease?

Answer: As a physician, I do not see a role for the guidelines

being used to re-diagnose an individual who already has a

confirmed diagnosis. People who currently have the diagnosis

of Alzheimer’s disease are those with evident functional and

cognitive impairment. With lesser impairments, patients and

doctors might ask about mild cognitive impairment.

In any case, if you or a family member is worried about

changes in cognition, you may want to see a healthcare

professional such as a geriatrician, geriatric psychiatrist or a

neurologist. Early diagnosis aids in planning for the future,

from learning about available drugs that treat the symptoms,

to making financial decisions, to exploring ways to get

involved in clinical trials. 

Question: Will these criteria impact current or future treatment?

Answer: It is the hope that these criteria will guide future

research and advance our discovery of the changes taking place

in the brain that lead to the development of Alzheimer’s disease.

With that discovery, we should be better positioned to develop

effective treatments.

Question: Are these the only guidelines doctors will be using now?

Answer: The NIA-Alzheimer’s Association guidelines have been

developed based on evidence by leading scientists in the

behavioral and clinical neuroscience fields. Thus, it is hoped

that clinicians will become aware of them and utilize them to

enhance how they think about patients with cognitive

impairment. 

Question: Should primary care clinicians refer their patients to

a neurologist for a preclinical evaluation?

Answer: There currently is not a role for biomarkers in routine

care. The guidelines for preclinical Alzheimer’s disease are

exclusively for research purposes. Researchers will use new

advances in imaging and biomarkers to evaluate research

participants for buildup of abnormal proteins.

Primary care clinicians should consider referring patients who

wish to volunteer for research projects related to Alzheimer’s

disease.  Research centers can be identified through the

Alzheimer’s Disease Education and Referral (ADEAR) Center

Web site maintained by NIA, at http://www.nia.nih.gov/Alzheimers/. 

Question: Will insurance companies pay for biomarker tests?

Answer: Currently, it is common for Medicare to compensate

for a CT scan or MRI to help establish a clinical diagnosis of

Alzheimer’s disease and rule out other causes of dementia.

Testing for preclinical disease is only being conducted in

research settings. Looking ahead, a component of the new

Medicare Annual Wellness Visit (AWV) allows the clinician

compensation for an assessment for cognitive impairment on an

annual basis, along with multiple other preventive health

assessments. As better screening procedures are developed and

the guidelines become better [distributed] we expect clinicians

will increasingly recognize and monitor patients with MCI

during AWVs-- especially those patients who report memory

loss problems that often progress to Alzheimer’s disease.

Hopefully, this will be accompanied by counseling regarding

long-range planning, and education regarding available

community resources.

For more info go to: http://www.afacareadvantage.org