Table Of ContentClinical Practice Guideline
Number 19
ecognitron and Initia
Assessment of Alzheimer's Disease
and Related Dementias
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U.S. Department of Health and Human Servicei^^p^
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Public Health Service
Agency for Health Care Policy and Research
TheAgency for Health Care PoUcy and Research (AHCPR) was estab-
hshed in December 1989 under Public Law 101-239 (Omnibus Budget
ReconciliationAct of 1989) to enhance the quality, appropriateness, and
effectiveness ofhealth care services and access to these services. AHCPR
carries out its mission by conducting and supporting general health services
research, including medical effectiveness research, facilitating development
ofclinical practice guidelines, and disseminating research findings and guide-
lines to health care providers, policymakers, and the public.
The legislation also established withinAHCPR the Office ofthe Forum for
Quality and Effectiveness in Health Care (the Forum). The Forum has primary
responsibility for facilitating the development, periodic review, and updating of
clinical practice guidelines. The guidelines will assist practitioners in the pre-
vention, diagnosis, treatment, and management ofclinical conditions.
Guidelines are available in formats suitable for health care practitioners,
the scientific community, educators, and consumers. AHCPR invites com-
ments and suggestions from users. Please send written comments to Director,
Office ofthe Forum for Quality and Effectiveness in Health Care, AHCPR,
MD
Willco Building, Suite 310, 6000 Executive Boulevard, Rockville, 20852.
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Errata: Recognition andInitialAssessmentofAlztieimer's
Disease andRelatedDementias: ClinicalPractice Guideline
No. 19
Title page: Douglas J. Lanska, MD, MS, MSPH, should be
included in the list of panel members
Page 103, Contributors: Should include, in alphabetical order,
the following entry:
Douglas J. Lanska, MD, MS, MSPH
Associate Professor
Departments of Neurology, Preventive Medicine, and
Environmental Health, and Sanders Brown Center on Aging
University of Kentucky
Lexington, KY
Specialty: Neurology and Preventive Medicine
Dr. Lanska is a diplomate of the American Board of Psychiatry
and Neurology, an academic neurologist and epidemiologist,
and a specialist in neurodegenerative diseases and dementia.
He has served as Director of the Memory Disorders Clinic of
the University of Kentucky Alzheimer's Disease Research
Center, and as an advisor or consultant to numerous Federal
agencies and medical organizations, as well as to the
American Board of Psychiatry and Neurology. He has published
more than 125 scientific articles and book chapters, most
concerned with dementia, the epidemiology of neurologic
disorders, and health policy. Dr. Lanska also serves on the
editorial board of Neurologyand is a member of the American
Academy of Neurology, the American Neurological Association,
and the American College of Physician Executives.
Page 106, Consultants: Delete Dr. Lanska
Page 123, Attachment D, Resources for Health Professionals,
Patients, and Families: Change the phone number for the Elder
Care Locator to 800-677-1 116.
AHCPR Pub. No. 97-0702-e T*rU.S. GPO:1997-516-521/83773
Clinical Practice Guideline
Number 19
Recognition and
Initial
Assessment of Alzheimer's
Disease and Related
Dementias
Alzheimer's Disease and Related Dementias
Guideline Panel
Paul T. Costa, Jr., PhD (Cochair)
T. Franklin Williams, MD, FACP (Cochair)
Marilyn S. Albert, PhD
Nelson M. Butters, PhD (Deceased)
MD
Marshal F. Folstein,
MD
Sid Gilman,
Barry J. Gurland, FRCPhys, FRCPsych
Lisa P Gwyther, MSW, CCSW, ACSW
Albert Heyman, MD
Alfred W. Kaszniak, PhD, ABPP
Ira R. Katz, MD, PhD
Linda L. Levy, MA, OTR/L, FACTA
Nancy Emerson Lombardo, PhD
Nancy K. Orr-Rainey, MSG
Linda R. Phillips, PhD, RN, FAAN
Martha Storandt, PhD
Eric G. Tangalos, MD, FACP
May L. Wykle, PhD, RN, FAAN
U.S. Department of Health and Human Services
Public Health Service
Agency for Health Care Policy and Research
Rockville, Maryland
AHCPR Publication No. 97-0702
November 1996
Guideline Development and Use
Guidelines are systematically developed statements to assist practitioner
and patient decisions about appropriate health care for specific clinical condi-
tions. This guideline was developed by a private-sector panel convened by the
Agency for Health Care PoUcy and Research (AHCPR). The guideline
reflects the state ofknowledge, current at the time ofpublication, on effective
and appropriate care.
The panel employed an explicit science-based methodology and expert
clinicaljudgment to develop specific statements on patient assessment and
management for the clinical condition selected. Extensive literature searches
were conducted, and critical reviews and syntheses were used to evaluate
empirical evidence and significant outcomes. Peer review was undertaken to
evaluate the reliability and utility ofthe guideline in clinical practice. The
panel's recommendations are primarily based on the published scientific liter-
ature. When the scientific literature was incomplete or inconsistent in a
particular area, the recommendations reflect the professionaljudgment of
panel members and consultants.
We believe that this AHCPR-assisted clinical practice guideline will
make positive contributions to the quality ofcare in the United States. We
encourage practitioners and patients to use the information provided in the
guideline. The recommendations may not be appropriate for use in all cir-
cumstances. Decisions to adopt any particular recommendation must be made
by the practitioner based on available resources and circumstances presented
by individual patients.
Clifton R. Gaus, ScD
Administrator
AgencyforHealth Care Policy andResearch
Publication ofthis guideline does not necessarily represent endorsement by
the U.S. Department ofHealth andHuman Services.
i
Abstract
Dementia in the adult U.S. population is a devastating disorder that is
often unrecognized or misdiagnosed in its early stages. Despite the current
lack ofunequivocally effective treatment, recognition ofearly-stage dementia
may offer substantial benefits. These include avoidance ofinappropriate treat-
ment related to misdiagnosis and time for the patient and family to address
issues offinancial, legal, and medical care planning.
This Clinical Practice Guideline is intended to help primary care
providers recognize and assess Alzheimer's disease and related dementias in
their early stages. Differential diagnosis is beyond the scope ofthe guideline;
however, the guideline contains a list ofresources for further clinical evalua-
tion once probable dementia has been identified.
Guideline recommendations focus on the following areas:
Triggers that should prompt a clinician to undertake an assessment for
early-stage dementia.
The components ofan initial assessment, including tests ofmental status
and functional performance.
A
flow chart for early recognition and initial assessment, including
assessment for delirium and depression.
Interpretation oftest results and appropriate actions.
The role ofneuropsychological testing.
Knowledge ofthe individual patient is emphasized, including change in
ability from baseline, as is the value ofreliable informant reports to initial
assessment and clinicaljudgment.
This guideline should help clinicians recognize symptoms ofpossible
dementia and decrease underrecognition and misdiagnosis ofthis devastating
condition.
This documentisintliepublic domainandmaybeusedandreprintedwithoutspecial
permission,exceptforthosecopyrightedmaterialsnotedforwhichfurtherreproductionis
prohibitedwithoutthespecificpermissionofcopyrightholders.AHCPRappreciatescitation
asto source,andthesuggestedformatisprovidedbelow:
CostaPTJr,WilliamsTF, SomerfieldM,etal.RecognitionandInitialAssessmentof
Alzheimer'sDiseaseandRelatedDementias. ClinicalPractice GuidelineNo. 19. Rockville,
MD: U.S. DepartmentofHealthandHumanServices,PublicHealth Service,Agencyfor
HealthCarePolicy andResearch.AHCPRPublicationNo. 97-0702. November 1996.
Ill
Acknowledgments
Many people and professional organizations contributed importantly to
the development ofthis Clinical Practice Guideline, from its earliest stages
through two review cycles. The consultants, technical advisors, and reviewers
listed at the end ofthis guideline devoted considerable time and effort to this
collaborative effort and greatly helped the panel. Several persons helped
immeasurably in identifying key issues, compiling relevant literature, and
critiquing manuscript drafts ofthe guideline. These persons wereAlan
Zonderman, PhD, and Jeffrey Herbst ofthe Gerontology Research Center,
National Institute onAging; Andrea Pinkham ofthe University ofIowa; and
Gary VandenBos, PhD, executive director ofpublications and communica-
tions, American PsychologicalAssociation.
Special acknowledgment goes to Mark Somerfield, PhD, who served with
great dedication and competence as project coordinator, overseeing the litera-
ture reviews and data coding and extraction for the meta-analyses and without
whom this guideline would not have been possible.
The methodological and statistical expertise ofLawrence Hedges, PhD,
ofthe University ofChicago, andVictor Hasselblad, PhD, ofDuke Univer-
sity School ofMedicine, made possible the meta-analyses that led to several
ofthe guideline's key recommendations.
The Cochairs also thank Barbara J. Shapiro, panel editor, for her superb
writing and editing skills and Carole Sherman, panel manager, for her deft
supervision ofthe support services provided by Technical Resources
International, Inc.
Finally, thanks are due to theAgency for Health Care Policy and
Research for its continuing support ofthe panel's work and its commitment
to an evidence-based approach to improving clinical practice.
IV
Contents
Executive Summary
1
1. Overview 5
Purpose and Scope 6
Methods for Guideline Development 7
History ofGuideline Focus 8
Literature Search and Review 8
Meta-Analysis 10
Panel Recommendations and Strength ofEvidence 12
Public Comment and Peer Review 12
Recommendations for Further Research 12
Public and Professional Education 14
Organization ofthe Guideline 14
2. Characteristics, Epidemiology, and Costs 17
Characteristics ofDementia 17
Cognitive Impairment 17
Functional Impairment 20
Behavioral Symptoms 22
Prevalence, Incidence, and Survival 26
Costs ofDementia 28
Estimates ofDirect Costs 28
Estimates ofTotal Costs 29
3. Risk Factors and Causes ofDementia 31
Risk Factors 31
Family History ofDementia 31
Presence ofDown Syndrome 32
Other Possible Risk Factors 32
Causes ofDementia 33
Reversible Dementias 36
Nonreversible Dementias 43
4. Recommendations for Recognition and InitialAssessment of
Dementia 45
Triggers for Recognition and Initial Assessment for the Presence
ofDementia 45
Initiating an Assessment forAlzheimer's Disease and
Related Dementias 47
Focused History 50
Focused Physical Examination 51
.
Alzheimer's Disease and RelatedDementias
Functional Status Assessment 52
Mental StatusAssessment 53
Confounding and Comorbid Conditions 57
Assessing for Delirium and Depression 57
Delirium 58
Depression 61
Interpretation ofFindings and RecommendedActions 64
Age and Educational Influences 67
Cultural Influences 67
Neuropsychological Testing 69
Objectives ofNeuropsychological Testing 69
Role ofNeuropsychological Testing 70
Importance ofFollowup 72
Conclusion 73
References 75
Acronyms 93
Glossary 95
Contributors 99
Attachments 115
Index 141
Tables
1 Five-phase scheme for evaluation ofmental status tests 11
2. Diagnostic criteria for dementia ofthe Alzheimer's type 18
3. Causes ofpotentially reversible dementias 34
4. Causes ofnonreversible dementias 35
5. Some medications that may cause cognitive impairment 38
6. Symptoms that may indicate dementia 46
7. Components ofcommonly used briefmental status tests and
requirements for testing 54
8. Diagnostic criteria for delirium due to general medical
condition 58
9. Diagnostic criteria for major depressive episode 60
Figure
Flow chart for recognition and initial assessment ofAlzheimer's
disease and related dementias 48
VI
