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October 22, 1997, Vol 278, No. 16 >
ARTICLE | October 22, 1997

Diagnosis and Treatment of Alzheimer Disease and Related Disorders: Title and subTitle BreakConsensus Statement of the American Association for Geriatric Psychiatry, the Alzheimer's Association, and the American Geriatrics Society FREE

Gary W. Small, MD; Peter V. Rabins, MD; Patricia P. Barry, MD; Neil S. Buckholtz, PhD; Steven T. DeKosky, MD; Steven H. Ferris, PhD; Sanford I. Finkel, MD; Lisa P. Gwyther, MSW; Zaven S. Khachaturian, PhD; Barry D. Lebowitz, PhD; Thomas D. McRae, MD; John C. Morris, MD; Frances Oakley, OTR; Lon S. Schneider, MD; Joel E. Streim, MD; Trey Sunderland, MD; Linda A. Teri, PhD; Larry E. Tune, MD
[+] Author Affiliations

A complete list of author affiliations and financial disclosures appears at the end of this article.

Reprints: Gary W. Small, MD, University of California at Los Angeles, Neuropsychiatric Institute and Hospital, 760 Westwood Plaza, Room 37-432, Los Angeles, CA 90024-1759.


JAMA. 1997;278(16):1363-1371. doi:10.1001/jama.1997.03550160083043
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References

Objective.  —A consensus conference on the diagnosis and treatment of Alzheimer disease (AD) and related disorders was organized by the American Association for Geriatric Psychiatry, the Alzheimer's Association, and the American Geriatrics Society on January 4 and 5, 1997. The target audience was primary care physicians, and the following questions were addressed: (1) How prevalent is AD and what are its risk factors? What is its impact on society? (2) What are the different forms of dementia and how can they be recognized? (3) What constitutes safe and effective treatment for AD? What are the indications and contraindications for specific treatments? (4) What management strategies are available to the primary care practitioner? (5) What are the available medical specialty and community resources? (6) What are the important policy issues and how can policymakers improve access to care for dementia patients? (7) What are the most promising questions for future research?

Participants.  —consensus panel members and expert presenters were drawn from psychiatry, neurology, geriatrics, primary care, psychology, nursing, social work, occupational therapy, epidemiology, and public health and policy.

Evidence.  —The expert presenters summarized data from the world scientific literature on the questions posed to the panel.

Consensus Process.  —The panelists listened to the experts' presentations, reviewed their background papers, and then provided responses to the questions based on these materials. The panel chairs prepared the initial drafts of the consensus statement, and these drafts were read by all panelists and edited until consensus was reached.

Conclusions.  —Alzheimer disease is the most common disorder causing cognitive decline in old age and exacts a substantial cost on society. Although the diagnosis of AD is often missed or delayed, it is primarily one of inclusion, not exclusion, and usually can be made using standardized clinical criteria. Most cases can be diagnosed and managed in primary care settings, yet some patients with atypical presentations, severe impairment, or complex comorbidity benefit from specialist referral. Alzheimer disease is progressive and irreversible, but pharmacologic therapies for cognitive impairment and nonpharmacologic and pharmacologic treatments for the behavioral problems associated with dementia can enhance quality of life. Psychotherapeutic intervention with family members is often indicated, as nearly half of all caregivers become depressed. Health care delivery to these patients is fragmented and inadequate, and changes in disease management models are adding stresses to the system. New approaches are needed to ensure patients' access to essential resources, and future research should aim to improve diagnostic and therapeutic effectiveness.

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Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Advisory Panel on Alzheimer's Disease. Alzheimer's Disease and Related Dementias: Acute and Long-term Care Services . Washington, DC: US Dept of Health and Human Services; 1996;. NIH publication. 96-4136.
2 +
Evans DA.  Estimated prevalence of Alzheimer's disease in the US . Milbank Q . 1990;;68:267-289.
3 +
American Academy of Neurology.  Practice parameter for diagnosis and evaluation of dementia (summary statement): report of the Quality Standards Subcommittee of the American Academy of Neurology . Neurology . 1994;;44:2203-2206.
4 +
Costa PT Jr, Williams TF, Somerfield M, et al. Recognition and Initial Assessment of Alzheimer's Disease & Related Dementias . Rockville, Md: US Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; November 1996;. AHCPR publication 97-0702.
5 +
US Dept of Veterans Affairs, University Health-System Consortium. Dementia Identification and Assessment: Guidelines for Primary Care Practitioners . Oak Brook, Ill: University Health System Consortium; 1997;.
6 +
Evans DA, Funkenstein HH, Albert MS, et al.  Prevalence of Alzheimer's disease in a community population of older persons is higher than previously reported . JAMA . 1989;;262:2551-2556.
7 +
Dartigues JF, Gagnon M, Michel P, et al.  The Paquid research program on the epidemiology of dementia: methods and initial results . Rev Neurol (Paris) . 1991;;147:225-230.
8 +
Heeren TJ, Lagaay AM, Hijmans W, Rooymans HG.  Prevalence of dementia in the 'oldest old' of a Dutch community . J Am Geriatr Soc . 1991;;35:755-759.
9 +
Hendrie HC, Osuntokun BO, Hall KS, et al.  Prevalence of Alzheimer's disease and dementia in two communities: Nigerian Africans and African Americans . Am J Psychiatry . 1995;;152:1485-1492.
10 +
Ritchie K, Kildea D.  Is senile dementia 'age related' or 'aging related'? evidence from a metaanalysis of dementia prevalence in the oldest old . Lancet . 1995;;346:931-934.
11 +
Bachman DL, Wolf PA, Linn RT, et al.  Incidence of dementia and probable Alzheimer's disease in a general population: the Framingham Study . Neurology . 1993;;43:515-519.
12 +
Jorm AF. The Epidemiology of Alzheimer's Disease and Related Disorders . London, England: Chapman & Hall; 1990;.
13 +
Barrett JJ, Haley WE, Harrell LE, Powers RE.  Knowledge about Alzheimer disease among primary care physicians, psychologists, nurses, and social workers . Alzheimer Dis Assoc Disord . 1997;;11:99-106.
14 +
Hoffman RS.  Diagnostic errors in the evaluation of behavioral disorders . JAMA . 1982;;248:964-967.
15 +
McDaniel LD, Lukovits T, McDaniel KD.  Alzheimer's disease: the problem of incorrect clinical diagnosis . J Geriatr Psychiatry Neurol . 1993;;6:230-234.
16 +
Ryan DH.  Misdiagnosis in dementia: comparisons of diagnostic error rate and range of hospital investigation according to medical specialty . Int J Geriatr Psychiatry . 1994;;9:141-147.
17 +
Callahan CM, Hendrie HC, Tierney WM.  Documentation and evaluation of cognitive impairment in elderly primary care patients . Ann Intern Med . 1995;;122:422-429.
18 +
Ross GW, Abbott RD, Petrovich H, et al.  Frequency and characteristics of silent dementia among elderly Japanese-American men: the Honolulu-Asia Aging Study . JAMA . 1997;;277:800-805.
19 +
McCartney JR, Palmateer LM.  Assessment of cognitive deficit in geriatric patients: a study of physician behavior . J Am Geriatr Soc . 1985;;33:467-471.
20 +
German PS, Shapiro S, Skinner EA, et al.  Detection and management of mental health problems of older patients by primary care providers . JAMA . 1987;;257:489-493.
21 +
Pinholt EM, Kroenke K, Hanley JF, et al.  Functional assessment of the elderly: a comparison of standard instruments with clinical judgments . Arch Intern Med . 1987;;147:484-488.
22 +
Mant A, Eyland EA, Pond DC, Saunders NA, Chancellor AH.  Recognition of dementia in general practice: comparison of general practitioners' opinions with assessments using the Mini-Mental State Examination and Blessed dementia rating scale . Fam Pract . 1988;;5:184-188.
23 +
Mohs RC, Breitner JCS, Silverman JM, Davis KL.  Alzheimer's disease: a morbid risk among first-degree relatives approximates 50 percent by 90 years of age . Arch Gen Psychiatry . 1987;;44:405-408.
24 +
Breitner JCS, Silverman JM, Mohs RC, Davis KL.  Familial aggregation in Alzheimer's disease: comparison of risk among relatives of early- and late-onset cases, and among male and female relatives in successive generations . Neurology . 1988;;38:307-312.
25 +
Goate A, Chartier-Harlin MC, Mullan M, et al.  Segregation of a missense mutation in the amyloid precursor protein gene with familial Alzheimer's disease . Nature . 1991;;349:704-706.
26 +
Levy-Lahad E, Wasco W, Poorkaj P, et al.  Candidate gene for the chromosome 1 familial Alzheimer's disease locus . Science . 1995;;269:973-977.
27 +
Sherrington R, Rogaev EI, Liang Y, et al.  Cloning of a gene bearing missense mutations in earlyonset familial Alzheimer's disease . Nature . 1995;;375:754-760.
28 +
Corder EH, Saunders AM, Strittmatter WJ, et al.  Gene dose of apolipoprotein E type 4 allele and the risk of Alzheimer's disease in late onset families . Science . 1993;;261:921-923.
29 +
American College of Medical Genetics/American Society of Human Genetics Working Group on APOE and Alzheimer's Disease.  Statement on the use of apolipoprotein E testing for Alzheimer's disease . JAMA . 1995;;274:1627-1629.
30 +
Relkin NR, Tanzi R, Breitner J, et al.  Apolipoprotein E genotyping in Alzheimer's disease: position statement of the National Institute on Aging/ Alzheimer's Association Working Group . Lancet . 1996;;347:1091-1095.
31 +
Stephenson J.  Researchers find evidence of a new gene for late-onset Alzheimer disease . JAMA . 1997;;277:775.
32 +
National Institute on Aging. Progress Report on Alzheimer's Disease 1996 . Bethesda, Md: National Institute on Aging; 1996;. NIH publication 96-4137.
33 +
Ernst RL, Hay JW.  The U.S. economic and social costs of Alzheimer's disease revisited . Am J Public Health . 1994;;84:1261-1264.
34 +
Schulz R, O'Brien AT, Bookwala J, Fleissner K.  Psychiatric and physical morbidity effects of dementia caregiving: prevalence, correlates, and causes . Gerontologist . 1995;;35:771-791.
35 +
Russell LB, Gold MR, Siegel JE, Daniels N, Weinstein MS.  The role of cost-effectiveness analysis in health and medicine: Panel on Cost-Effectiveness in Health and Medicine . JAMA . 1996;;276:1172-1177.
36 +
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders . 4th ed. Washington, DC: American Psychiatric Association; 1994;.
37 +
McKeith LG, Galasko D, Kosaka K, et al.  Consensus guidelines for the clinical and pathologic diagnosis of dementia with Lewy bodies (DLB): report of the consortium on DLB international workshop . Neurology . 1996;;47:1113-1124.
38 +
Mega MS, Cummings JL, Fiorello T, Gornbein J.  The spectrum of behavioral changes in Alzheimer's disease . Neurology . 1996;;46:130-135.
39 +
Stern Y, Alpert M, Brandt J, et al.  Utility of extrapyramidal signs and psychosis as predictors of cognitive and functional decline, nursing home admission and death in Alzheimer's disease: prospective analysis from the Predictors Study . Neurology . 1994;;44:2300-2307.
40 +
Lerner AJ, Hedera P, Koss E, Stuckey J, Friedland RP.  Delirium in Alzheimer disease . Alzheimer Dis Assoc Disord . 1997;;11:16-20.
41 +
Francis J, Kapoor WN.  Prognosis after hospital discharge of older medical patients with delirium . J Am Geriatr Soc . 1992;;40:601-606.
42 +
Alexopoulos GS, Meyers BS, Young RC, Mattis S, Kakuma T.  The course of geriatric depression with 'reversible dementia': a controlled study . Am J Psychiatry . 1993;;150:1693-1699.
43 +
Rasmusson DX, Brandt J, Steele C, et al.  Accuracy of clinical diagnosis of Alzheimer disease and clinical features of patients with non-Alzheimer neuropathology . Alzheimer Dis Assoc Disord . 1996;;10:180-188.
44 +
Larson EB, Edwards JK, O'Meara E, Nochlin D, Sumi SM.  Neuropathologic diagnostic outcomes from a cohort of outpatients with suspected dementia . J Gerontol . 1996;;51:M313-M318.
45 +
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