Alzheimer's disease resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fahimeh Shojaei, M.D., Moises Romo M.D.

Synonyms and Keywords: Alzheimer's disease management, Alzheimer's disease workup, Alzheimer's disease approach, approach to Alzheimer's disease, Alzheimer's disease treatment

Overview

Alzheimer's disease is the most common cause of dementia among older people. Dementia is a loss of thinking, remembering, and reasoning skills that interfere with a person's daily life and activities. The diagnosis of Alzheimer's disease (AD) is made on the basis of clinical criteria described by either the National Institute on Aging and the Alzheimer's Association (NIA-AA) or DSM-V (Diagnostic and Statistical Manual of Mental Disorders, fifth edition). There is no known cure for Alzheimer's disease (AD). Available treatments offer relatively small symptomatic benefit but remain palliative in nature. Current treatments can be divided into pharmacological, psychosocial, and caregiving.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

  • Alzheimer's disease is not a life-threatening condition that may result in death or permanent disability within 24 hours if left untreated.

Common Causes

While there is no direct cause for the development of Alzheimer's disease, there are several factors that may contribute to its acquisition:

  • Unknown (includes genetic/environment interactions)

Diagnosis

Shown below is an algorithm summarizing the diagnosis of amnesia according to the the American Academy of Neurology guidelines:[1]

 
 
 
 
 
 
 
Patient with amnesia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute onset
 
 
 
 
 
 
 
Chronic onset
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Measure vitamin B12, and folate, and TSH
 
Abnormal?
 
Yes
 
Vitamin deficiency, hypothyroidism
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fluctuating course, inattention, disorganized thinking, or altered level of consciousness?
 
 
 
 
 
 
 
Positive for SIGE CAPS questionary?
 
Yes
 
Depression
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
No
 
Severe disimpairment in social functioning?
 
No
 
Normal aging
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Delirium
 
 
 
 
 
 
 
Dementia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Take history and perform physical examination
 
 
 
 
 
 
 
Take history and perform physical examination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History of head trauma?
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Concussion, post-concussive amnesia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Measure urine toxicology, CBC, creatinine, electrolites, and glucose to reveal cause
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initial short term memory loss
 
Vascular risk factors, imaging evidence of cerebrovascular involvement
 
Young age, behavioral symptoms or language impairment
 
 
Bradikinesia or features of parkinsonism,

fluctuating cognition, [[visual

hallucinations]]
 
 
 
Dementia occuring 1 year after onset of Parkinson disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Alzheimer disease
 
Vascular dementia
 
Frontotemporal dementia
 
 
Dementia with Lewy bodies
 
 
 
Parkinson's disease
 
 

Treatment

Shown below is an algorithm summarizing the treatment of Alzheimer's disease according to the the American Academy of Neurology guidelines:[2]

 
 
 
 
 
 
 
 
Patient with diagnosed Alzheimer's disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild to moderate
 
 
 
 
 
 
 
Moderate to severe
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initiate therapy
•Donepezil. 5 mg once daily; titrate 10 mg once daily
•Galantamine (solution). 4 mg twice daily; titrate to 8 mg twice daily
•Galantamine (ER capsules). 8 mg once daily; titrate to 16 mg once daily
•Rivastigmine (patch). 4.6 mg once daily; titrate to 9.5 mg once daily
•Rivastigmine (oral). 1.5 mg twice daily; titrate to 6 mg twice daily
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adverse event
Considere switch to a different ChEI
 
 
 
Disease progression
Considere high dose or switch to a different ChEI
 
 
 
 
Initiate therapy
•Donepezil. 5 mg once daily; titrate 10 mg once daily
•Rivastigmine (patch). 4.6 mg once daily; titrate to 9.5 mg once daily
•Memantine. 5 mg once daily; titrate to 10 mg twice daily or Memantine XR. 7 mg once daily; titrate to 28 mg once daily
•Combination ChEI+ Memantine. 7 mg twice daily or 10 mg once daily (ER); titrate to 10 mg twice daily or 28 mg once daily (ER)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Monitor and reevaluate therapy
Monitor every 3-4 months and titrate dose as needed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adverse event
Considere switch to a different therapy
 
 
 
Disease progression
Considere higher dose or switch to a different therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Discontinue therapy
When all cognitive function and functional abilities are lost at terminal stages of AD


Recommendations for maintaining brain health in elderly patients with and without Alzheimer's Disease
  • Consider following a Mediterranean-style diet, with fish, vegetables, legumes, fruit, cereals, unsaturated fatty acids (e.g., olive oil), and a limited amount of meat or dairy products.
  • Consider taking supplements containing omega-3 (particularly docosahexaenoic acid), B-complex vitamins (including B12, B6, folic acid), and vitamin E.
  • Keep alcohol intake to a low-to-moderate level (e.g., one glass of wine per day with dinner).
  • Engage in regular physical activity.
  • Maintain leisure and social activities – keep socially engaged.
  • Continue or take up activities that help to stimulate the brain, e.g., Tai Chi, dancing, puzzles.
  • Become educated about dementia and seek support from others with dementia, e.g., the Alzheimer's Association, Keep Memory Alive, and other community groups.
  • Include music in daily life – listening to music, playing an instrument, singing.
  • Maintain regular sleep patterns.
  • Manage stress – stop doing things if they are becoming too stressful (e.g., volunteer work, answering the telephone), keep to a regular daily schedule, and include relaxing activities (e.g., playing with pets, massage, and aromatherapy).

Do not modify

Do's

Don'ts

References

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  2. Grossberg, George T.; Tong, Gary; Burke, Anna D.; Tariot, Pierre N.; Fink, Anne (2019). "Present Algorithms and Future Treatments for Alzheimer's Disease". Journal of Alzheimer's Disease. 67 (4): 1157–1171. doi:10.3233/JAD-180903. ISSN 1387-2877.
  3. Folstein MF, Folstein SE, McHugh PR (November 1975). ""Mini-mental state". A practical method for grading the cognitive state of patients for the clinician". J Psychiatr Res. 12 (3): 189–98. doi:10.1016/0022-3956(75)90026-6. PMID 1202204.
  4. Borson S, Scanlan JM, Chen P, Ganguli M (October 2003). "The Mini-Cog as a screen for dementia: validation in a population-based sample". J Am Geriatr Soc. 51 (10): 1451–4. doi:10.1046/j.1532-5415.2003.51465.x. PMID 14511167.
  5. Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H (April 2005). "The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment". J Am Geriatr Soc. 53 (4): 695–9. doi:10.1111/j.1532-5415.2005.53221.x. PMID 15817019.
  6. Schmitt FA, Saxton JA, Xu Y, McRae T, Sun Y, Richardson S, Li H (2009). "A brief instrument to assess treatment response in the patient with advanced Alzheimer disease". Alzheimer Dis Assoc Disord. 23 (4): 377–83. doi:10.1097/WAD.0b013e3181ac9cc1. PMID 19571727.
  7. Schmitt FA, Saxton JA, Xu Y, McRae T, Sun Y, Richardson S, Li H (2009). "A brief instrument to assess treatment response in the patient with advanced Alzheimer disease". Alzheimer Dis Assoc Disord. 23 (4): 377–83. doi:10.1097/WAD.0b013e3181ac9cc1. PMID 19571727.
  8. Kaufer DI, Cummings JL, Ketchel P, Smith V, MacMillan A, Shelley T, Lopez OL, DeKosky ST (2000). "Validation of the NPI-Q, a brief clinical form of the Neuropsychiatric Inventory". J Neuropsychiatry Clin Neurosci. 12 (2): 233–9. doi:10.1176/jnp.12.2.233. PMID 11001602.
  9. Cummings JL, Isaacson RS, Schmitt FA, Velting DM (March 2015). "A practical algorithm for managing Alzheimer's disease: what, when, and why?". Ann Clin Transl Neurol. 2 (3): 307–23. doi:10.1002/acn3.166. PMID 25815358.
  10. Knopman DS, DeKosky ST, Cummings JL, Chui H, Corey-Bloom J, Relkin N, Small GW, Miller B, Stevens JC (May 2001). "Practice parameter: diagnosis of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology". Neurology. 56 (9): 1143–53. doi:10.1212/wnl.56.9.1143. PMID 11342678.
  11. Petersen RC, Stevens JC, Ganguli M, Tangalos EG, Cummings JL, DeKosky ST (May 2001). "Practice parameter: early detection of dementia: mild cognitive impairment (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology". Neurology. 56 (9): 1133–42. doi:10.1212/wnl.56.9.1133. PMID 11342677.
  12. Squire LR, Zouzounis JA (December 1988). "Self-ratings of memory dysfunction: different findings in depression and amnesia". J Clin Exp Neuropsychol. 10 (6): 727–38. doi:10.1080/01688638808402810. PMID 3235647.
  13. Hack, Jason B.; Hoffman, Robert S. (1998). "Thiamine Before Glucose to Prevent Wernicke Encephalopathy: Examining the Conventional Wisdom". JAMA. 279 (8): 583. doi:10.1001/jama.279.8.583a. ISSN 0098-7484.


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