What are the guideline sources, guidelines and references for Alzheimer_s disease ?
Guideline sources The following summarized guidelines for the evaluation and management of Alzheimer's disease are prepared by our editorial team based on guidelines from the European Neurological Society (ENS/EAN/EFNS 2015), the American Association of Family Physicians (AAFP 2011), and the European Federation of Neurological Societies (EFNS 2010). 1 2 3 Guidelines 1. Screening and diagnosis Screening for comorbidities: assess patients with Alzheimer's disease for comorbidity, both at the time of diagnosis and throughout the course of the illness E and always consider it as a possible cause of behavioral and psychological symptoms of dementia. B 2. Diagnostic investigations https://web.pathway.md/diseases/recUuM8OqQfI3m3Ej 1/5 6/23/23, 2:19 AM Alzheimer's disease Pathway History and physical examination: elicit a clinical history supplemented by an informant. A Show 2 more Cognitive assessment: assess for impairment of activities of daily living due to cognitive decline in the diagnostic evaluation as it is an essential part of the diagnostic criteria for dementia. A Show 4 more Laboratory studies: Obtain the following tests in patients with Alzheimer's disease at the time of diagnosis: complete blood cell count LFTs renal function tests folate vitamin B12 thyroid stimulating hormone calcium glucose. E Consider serological testing for the following disorders in patients with atypical presentation of Alzheimer's disease or clinical features suggestive of these disorders: syphilis borelia HIV. E Imaging: consider CT and MRI to exclude treatable causes of dementia. Consider multislice CT and coronal MRI to assess hippocampal atrophy to support a clinical diagnosis of Alzheimer's disease. C Show 3 more Electroencephalography: consider electroencephalography in the differential diagnosis of atypical clinical presentations of Alzheimer's disease (good practice point) and when Creutzfeldt- Jakob disease or transient epileptic amnesia is suspected. C Genetic testing: Consider screening for known pathogenic mutations in patients with appropriate phenotype or a family history of an autosomal dominant dementia. Do not routinely obtain Apolipoprotein E genotyping in patients with Alzheimer's disease. 3. Diagnostic procedures Cerebrospinal fluid analysis: Obtain routine CSF analysis in the differential diagnosis of atypical clinical presentations of Alzheimer's disease. E https://web.pathway.md/diseases/recUuM8OqQfI3m3Ej 2/5 6/23/23, 2:19 AM Alzheimer's disease Pathway Obtain CSF 14-3-3 or total tau protein measurements for the identification of Creutzfeldt-Jakob disease in patients with rapidly progressive dementia. Alterations in CSF total tau, phospho-tau and Ab42 support diagnosis of Alzheimer's disease. B 4. Medical management Cholinesterase inhibitors: As per AAFP 2011 guidelines, offer cholinesterase inhibitors for patients with mild-to-moderate Alzheimer's disease based on their modest effectiveness, although limited by their adverse effects. A As per EFNS 2010 guidelines, consider cholinesterase inhibitors (donepezil, galantamine, or rivastigmine) in patients with Alzheimer's disease at the time of diagnosis, taking into account expected therapeutic benefits and potential safety issues. Benefits on cognitive and non- cognitive symptoms have been demonstrated in patients with mild, moderate and severe disease. B Memantine: As per EFNS 2015 guidelines, consider memantine in patients with moderate-to-severe Alzheimer's disease, taking into account expected therapeutic benefits and potential safety issues B . Benefits on cognitive and non-cognitive symptoms are apparent, some non-cognitive symptoms - agitation, delusions - may respond better than others. C As per AAFP 2011 guidelines, consider combination therapy with a cholinesterase inhibitor and memantine in patients with moderate-to-severe Alzheimer's disease. C Antipsychotics: As per AAFP 2011 guidelines, consider atypical antipsychotics to improve some behavioral manifestations in patients with Alzheimer's disease, but take into account that these agents are associated with increased mortality in older patients. C As per EFNS 2010 guidelines, reserve antipsychotics only for patients with moderate-to-severe behavioral and psychological symptoms of dementia causing significant distress which have either not responded to other treatments (such as nonpharmacological measures or cholinesterase inhibitors) or when other treatments are not appropriate. A Show 2 more Other medications: As per AAFP 2011 guidelines, do not prescribe NSAIDs, vitamin E, testosterone, estrogen, statins, and insulin sensitizers for the treatment of patients with Alzheimer's disease. D As per EFNS 2010 guidelines, do not use aspirin for the treatment of patients with Alzheimer's disease , though it can be used in patients with Alzheimer's disease who also have other indications for its use (for example, to prevent cardiovascular events). (Level A). D Show 2 more https://web.pathway.md/diseases/recUuM8OqQfI3m3Ej 3/5 6/23/23, 2:19 AM Alzheimer's disease Pathway 5. Nonpharmacologic interventions Cognitive stimulation: consider cognitive stimulation or rehabilitation in patients with mild-to- moderate Alzheimer's disease. E Occupational therapy: consider occupational therapy in patients with Alzheimer's disease to improve patients functioning and reduce need for informal care. C Addressing behavioral and psychological symptoms of dementia: carefully search for triggers and causative factors for behavioral and psychological symptoms of dementia (such as physical illness). Initiate treatment with nonpharmacological measures, where possible. B 6. Specific circumstances Patients with depression: offer SSRIs rather than TCAs for the treatment of depression in patients with Alzheimer's disease. B 7. Patient education Diagnosis disclosure: disclose the diagnosis of Alzheimer's disease to patient (and caregivers as appropriate), which should be individually tailored and accompanied by information and counseling, as well as useful contacts such as Alzheimer's disease patient organizations. B Patient and caregiver education: Provide education and support to patients with Alzheimer's disease and their caregivers. A Discuss realistic expectations for treatment effects and potential side effects with patients with Alzheimer's disease and their caregivers. E Addressing patient needs and preferences: Consider driving, medico-legal issues and the need for other support services in patients with Alzheimer's disease. E Consider encouraging patients with Alzheimer's disease, if possible, to draw up advance directives containing future treatment and care preferences. E 8. Preventative measures Prevention: Insufficient evidence to support the use of any drugs purely for the primary prevention of dementia. I Insufficient evidence to support the use of anti-inflammatory drugs, nootropics (including piracetam, nicergoline), selegiline, estrogens, pentoxyphylin, statins, EGb 761 and Cerebrolysin for the prevention of Alzheimer's disease. I https://web.pathway.md/diseases/recUuM8OqQfI3m3Ej 4/5 6/23/23, 2:19 AM Alzheimer's disease Pathway 9. Follow-up and surveillance Discontinuation of medical therapy: consider discontinuing treatment for patients with Alzheimer's disease who continue to experience decline despite maximal therapy. C Follow-up: Regular patient follow-up, which should include scales like the MMSE to monitor response to treatment and disease progression, should be an integral part of management. E Consider follow-up with serial MRI in a clinical setting to document disease progression. E References 1. Bradford T Winslow, Mary K Onysko, Christian M Stob et al. Treatment of Alzheimer Disease. Am Fam Physician. 2011 Jun 15;83 12 1403 12. Open 2. J Hort, J T O'Brien, G Gainotti et al. EFNS guidelines for the diagnosis and management of Alzheimers disease. Eur J Neurol. 2010 Oct;17 10 1236 48. Open 3. R Schmidt, E Hofer, F H Bouwman et al. EFNS ENS/EAN Guideline on concomitant use of cholinesterase inhibitors and memantine in moderate to severe Alzheimer's disease. Eur J Neurol. 2015 Jun;22 6 889 98. Open 4. APA Work Group on Alzheimer's Disease and other Dementias, Rabins PV, Blacker D et al. American Psychiatric Association practice guideline for the treatment of patients with Alzheimer's disease and other dementias. Second edition. Am J Psychiatry. 2007 Dec;164 12 Suppl):5 56. Open 5. American College of Medical Genetics. Choosing Wisely ACMG recommendations. Choosing Wisely. 2015. Open 6. Jeff Sevigny, Ping Chiao, Thierry Bussi re et al. The antibody aducanumab reduces A plaques in Alzheimer's disease. Nature. 2016 Sep 1;537 7618 50 6. Open 7. S Budd Haeberlein, P S Aisen, F Barkhof et al. Two Randomized Phase 3 Studies of Aducanumab in Early Alzheimer's Disease. J Prev Alzheimers Dis. 2022;9 2 197 210. Open 8. Christopher H van Dyck, Chad J Swanson, Paul Aisen et al. Lecanemab in Early Alzheimer's Disease. N Engl J Med. 2023 Jan 5;388 1 9 21. Open https://web.pathway.md/diseases/recUuM8OqQfI3m3Ej 5/5