Current Series: Advances Treatment Alzheimers Disease

Jeffrey L. Cummings, MD, ScD: Ali, I want to move to the next question.

Alireza Atri, MD, PhD: Sure.

Jeffrey L. Cummings, MD, ScD: What’s the importance of timely diagnosis and early recognition? Why do it?

Alireza Atri, MD, PhD: It dovetails with what Marwan was saying, that individuals, clinicians, and the public should know the value of that and why it makes a difference. I think accurate diagnosis delayed is basically autonomy, care, and justice denied. And there are many, many benefits for early and timely detection. And 1 of them is really autonomy and empowerment of the individual when they’re at their maximum ability to make decisions about their own care and to appreciate that and to get the care environment, right? Get their care plan in the right direction, to reduce harm, so they don’t get in a situation where they’re making bad financial decisions or something happens with a car. So that’s another model. Really, to participate in advanced care planning and for individuals is to be the mistresses and masters of their own fate. I think that’s really, really important.

Jeffrey L. Cummings, MD, ScD: Any other reasons for early diagnosis that you didn’t hear from Ali? That was a very exhaustive list.

Richard Isaacson, MD: From my perspective, the future of Alzheimer disease is clinical trials. And the earlier the diagnosis, the earlier you can treat, and the earlier you can get a screen for a trial. Sometimes trials have cutoffs, meaning if you’re too progressed, you’re not going to qualify. And I empathize with primary care doctors. I have so much time compared with a primary care doctor on the frontlines, with boots on the ground, seeing patient after patient. When in doubt, refer but also think about clinical trials.

Jeffrey L. Cummings, MD, ScD: Yes, that’s a great point.

Alireza Atri, MD, PhD: For them to appreciate the benefit of this multifactorial approach to care, it is not just medicines but really a whole environment. And part of it is, again—as Richard is a big proponent of—changes in lifestyle that can actually interact and maybe add to the benefit. But for people to understand that actually making the diagnosis and putting the care plans in place is really meaningful on multiple levels. 

Jeffrey L. Cummings, MD, ScD: Marwan, we’d like to talk a little about the assessment scales. When you’re taking the history and you’re going to turn toward that more structured assessment, how do you approach that? What are the tools you use?

Marwan Sabbagh, MD: Actually, Jeff, I like to use scales and assessment tools. I use a structured interview as part of my initial HPI, history of present illness. I use an instrument called the AQ, which is Alzheimer questionnaire, but there’s also the AD8 and IQCODE [Informant Questionnaire for Cognitive Decline in the Elderly]. These are informant-based questionnaires and allow the informant to tell me if they’re flagging for something, and I can explore that further.

The second thing, as a cognizant screening measure, I will do always a MoCA [Montreal Cognitive Assessment] if I can. Or if I’m doing a Mini-Mental State Exam, my team knows which 1 to do. I’ll add a clock draw. I also do a recall task. I will do an assessment of their fluency prosody, thought content, things like that.

In the medical practice, these are the things that are pretty standard. In clinical trials, of course, we use a whole different set of instruments, particularly the Clinical Dementia Rating [CDR] scale and the ADAS, Alzheimer Disease Assessment Scale. The issue, of course, is that we don’t translate well clinical trial instruments into clinical practice. Because nobody in clinical practice does an ADAS or a CDR. But then we have to translate that affect into a clinically meaningful change in medical practice. The research scales and the clinical scales are actually quite far apart, and they’re not necessarily easy to translate.

Jeffrey L. Cummings, MD, ScD: Very good point. Any favorite scales, Richard or Elaine, that you use? One of the ones that I didn’t hear you mention was the Mini-Cog, which people often find useful because it is so brief, yet it gives some information about the cognitive function of the individual.

Richard Isaacson, MD: I think the AD8 is helpful because it could be done in the waiting room, it takes no time at all. It’s an 8-question scale that the patient can fill out. That way, as you’re doing your cholesterol management and blood pressure, you see in several questions, “Uh oh, wait a minute, this may be a sign that something is going on,” and you may not have even remembered to ask because of everything else going on in the visit. So I think the AD8 has been helpful for us.

Jeffrey L. Cummings, MD, ScD: Yes, that’s a good point, that it’s done by the caregiver in the waiting room, and that can alert the clinician to the presence of problems.

Alireza Atri, MD, PhD: I’d like to add a couple of things to that. I would say that breaking it down by the formal structured interviews is really, really good, as well as having this pathway where maybe the individual is getting some kind of testing or the care partner’s providing information. Again, I think about it in multiple domains. What are the symptoms that the individual can tell, whether it’s a function index or something else to evaluate daily function like a second questionnaire or something to that effect?

Some questions—like the Neuropsychiatric Inventory, which think about mood and behavioral change—are really important. I try to assess how the care partner is also doing. Some impact scale, like the Zarit Burden scale or something like that, is also something that I use.

As far as the objective tests go, there’s no number that gives me an answer. It’s always at the end of it, coming in and interviewing for that information in the context of this individual presenting it that way.