New Principles of Care for Patients with Alzheimer's Disease

June 3, 2007
David S. MacDougall

Internal Medicine World Report, October 2006, Volume 0, Issue 0

Delay Progression, Enhance Quality of Life

The American Association for Geriatric Psychiatry (AAGP) has released a new position statement outlining therapeutic interventions designed to delay disease progression and improve quality of life and dignity for patients with Alzheimer's disease (AD) (Am J Geriatr Psychiatry. 2006; 14:561-573).

More than 4.5 million Americans have AD, currently the most common type of dementia in the United States.

"There is good evidence now that while we cannot cure Alzheimer's, we can treat it in ways that are very beneficial to patients and their caregivers," said Constantine G. Lyketsos, MD, MHS, codirector, Division of Geriatric Psychiatry and Neuropsychiatry, Johns Hopkins School of Medicine, and chair of the AAGP task force that created the position statement.

"Despite this, rates of recognition and treatment are low, without much change from 20 years ago, so that practice guidelines are not being implemented," said Dr Lyketsos, reiterating the need to focus on the recognition of the early signs and symptoms of the disease.

The definitions of dementia associated with AD are listed in Table 1.

The position statement highlights key elements of dementia care, encompassing pharmacologic and nonpharmacologic treatments for AD (Table 2).

Current evidence suggests that the key initial event in the complex pathophysiology of AD is misprocessing of the amyloid precursor protein in brain neurons, followed by the deposition of insoluble beta amyloid plaques, synaptic failure, neuronal injury, and apoptotic neuronal death.

The focus of new AD treatments is on preventing amyloid plaque deposition, inhibiting the formation of insoluble forms of beta amyloid, and removing beta amyloid from the brain.

Potential "accelerators" of AD progression include:

? Postmenopausal estrogen loss

? Hypercholesterolemia

? Inflammatory responses

? Oxidative free radicals.

The evidence of direct associations between these factors and AD progression is limited, and treatment recommendations for these factors have not yet been developed.

Cognitive deficits are the clinical hallmark of AD and other dementing diseases, but noncognitive neuropsychiatric symptoms, such as depression and agitation, affect >90% of patients. Treating these symptoms in patients with AD can have a significant impact on patients and their caregivers.

"In addition to the medications used to treat the cognitive symptoms, treatment of the neuropsychiatric symptoms and several supportive care interventions are key parts of the dementia care package," Dr Lyketsos told IMWR.

"We encourage primary care physicians to become proficient in how to deliver these or to affiliate with specialists who can help them," he said. Try nonpharmacologic interventions first in patients with AD and neuropsychiatric symptoms. Successful measures that have shown particular efficacy are:

? Cognitive stimulation

? Improved socialization

? Music therapy

? Sensory stimulation

? Behavior management techniques.

Tailor supportive care to individual conditions and circumstances and develop checklists that will help you to systematically address:

? Safety issues (eg, driving, living alone, medication use)

? Monitoring general medical health

? Planning for advanced care

? Maximizing patients' ability to perform daily activities independently.

Support to the family and caregivers of patients with AD has been shown to en?hance quality of life and delay patient institutionalization.