Memory Loss, Alzheimer's Disease, and Dementia: A Practical Guide for Clinicians

283 Pages·2015·40.44 MB·English

by  Andrew E. Budson

Reviews for the First Edition
The cohesive text is an appealing blend of personal expe- Designed for easy reference to satisfy the real time
rience and clinical anecdotes, and is supported by a needs of clinicians in hectic clinical settings, I’m sure
firm command of the rapidly changing clinical literature. this volume will be dog-eared in short order given its
The writing is crisp, lucid and, above all, practice- clear no-nonsense style.
oriented . . . Budson and Solomon are especially adroit Neil W. Kowall, MD,
in identification of controversies, knowledge gaps, and Professor of Neurology and Pathology,
areas in which diagnostic criteria are ill-defined or diffi- Boston University School of Medicine, Director,
cult to apply (e.g., fluctuating cognition in dementia Boston University Alzheimer’s Disease Center,
with Lewy bodies). Readers are not abandoned without Chief, Neurology Service,
guidance; ambiguities are resolved by confident descrip- Boston VA Healthcare System
tions of personal approaches to specific situations . . . The
book is an incredible compilation of practical advice. This book summarizes complex material in a
Lancet Neurology, March 2012 manner that benefits clinical practitioners at all levels.
This is an excellent addition to the library of profes-
From the point of view of the busy clinician sionals serving older adults.
working in the trenches but looking for a practical and Maureen K. O’Connor, Psy.D.,
cutting-edge guide, Doraiswamy said he cannot think ABCN, Chief, Neuropsychology Service,
of a better book, noting, ‘This is the clinical book of Edith Nourse Rogers Memorial
the year in our field’. Veterans Hospital, Bedford, MA
Alzheimer’s Research Forum review,
December 2011 This is a very good addition to the books on
dementias. With this book, the authors provide a
Few books provide both a comprehensive review resource for clinicians who will be caring for the more
and a step-by-step guide. I strongly recommend this than 5 million individuals with memory loss, whether
book to all those who treat patients with memory loss— their degree is in medicine, psychology, nursing, social
physicians, social workers, psychologists, nurses—at work, or therapies. Primary care providers, nurses,
every level of training and experience. psychologists, and students will find this book a very
P. Murali Doraiswamy, MD, Professor & Head, practical, clinically oriented guide that helps them
Division of Biological Psychiatry, Duke University, know what to do when sitting in the office with a
and co-author of The Alzheimer’s Action Plan patient complaining of memory loss. Specialists will
find this book a wealth of up-to-date information
Memory Loss: A Practical Guide for Clinicians provides regarding the latest diagnostic tools and treatments for
the assessment, diagnostic and therapeutic insights clini- their patients with memory loss.
cians need to provide exemplary care to memory Eric Gausche, MD, University of Illinois
impaired patients. Don’t go to the clinic without it. at Chicago College of Medicine
Jeffrey L. Cummings, MD, Director, 4 Star-Doody Rating, March 2013
Cleveland Clinic Lou Ruvo Center for
Brain Health
i
Memory Loss, Alzheimer’s
Disease, and Dementia
A Practical Guide for Clinicians
2nd Edition
Memory Loss,
Alzheimer’s Disease,
and Dementia
A Practical Guide for Clinicians
Andrew E. Budson, M.D.
Neurology Service, Section of Cognitive & Behavioral Neurology,
Veterans Affairs Boston Healthcare System, Boston, MA;
Alzheimer’s Disease Center and Department of Neurology,
Boston University School of Medicine, Boston, MA;
Harvard Medical School, Boston, MA;
Division of Cognitive & Behavioral Neurology, Department of Neurology,
Brigham and Women’s Hospital, Boston, MA;
The Boston Center for Memory, Newton, MA;
The Memory Clinic, Bennington, VT
Paul R. Solomon, Ph.D.
Department of Psychology, Program in Neuroscience,
Williams College, Williamstown, MA;
The Boston Center for Memory, Newton, MA;
The Memory Clinic, Bennington, VT
For additional online content visit expertconsult.com
Edinburgh  London  New York  Oxford  Philadelphia  St Louis  Sydney  Toronto  2016
© 2016, Elsevier Inc. All rights reserved.
First edition 2011
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods they should be mindful of their own safety and the safety of others, including parties for whom they
have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient,
and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any
liability for any injury and/or damage to persons or property as a matter of products liability, negligence or
otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the
material herein.
ISBN: 978-0-323-28661-9
eISBN: 978-0-323-31610-1
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Cover Images
Images show 18F AV-1451 tau positron emission tomography (PET) imaging overlaid on T1 MRI scans in
three patients with the Alzheimer’s disease pathophysiological process. The top row is from a patient with
mild cognitive impairment (MCI) due to Alzheimer’s disease, with a mini-mental state examination (MMSE)
score of 26. The second row is from a patient with mild Alzheimer’s disease dementia, with an MMSE score of
23. The third row is from a patient with moderate Alzheimer’s disease dementia, with an MMSE score of 15.
The columns from left to right show three different axial slices through the brain: inferior temporal lobes
(left images); inferior frontal, superior temporal, and occipital lobes (middle images); and superior frontal and
parietal lobes (right images). The progression of tau pathology with the clinical severity of the patient can be
seen clearly. Images are courtesy of Avid Radiopharmaceuticals, Inc.
Content Strategist: Charlotta Kryhl
Content Development Specialist: Poppy Garraway, Joanne Scott
Content Coordinator: Trinity Hutton
Project Manager: Joanna Souch
Design: Christian Bilbow
Illustration Manager: Brett McNaughton
Illustrator: Robert Britton
Marketing Manager(s) (UK/USA): Deborah Davis
Foreword
Dementia and Alzheimer’s disease (AD) are becoming aphasia, frontotemporal dementia, progressive supra-
more prevalent by the minute. Every 68 seconds, nuclear palsy, corticobasal degeneration, normal pres-
someone in the United States transitions from mild sure hydrocephalus, Jakob-Creutzfeldt disease, and
cognitive impairment to AD type of dementia. Alzhe- chronic traumatic encephalopathy. These succinct
imer’s disease is now more costly to the US economy clinical, laboratory, and imaging descriptions are
than cancer or cardiovascular disease. Based on extremely helpful in providing clinical pearls and
autopsy figures, AD is the third most common cause imparting the wisdom of experienced clinicians in the
of dementia in the United States. The anticipated cost sometimes challenging process of differential diagno-
of the care for patients with AD and dementia by 2050 sis of causes of memory impairment.
is anticipated to be one trillion dollars annually if Pharmacologic and non-pharmacologic manage-
treatments are not found. ment of memory loss are central to why patients seek
Symptomatic treatments are available for AD and care. Patients and their families need clinicians who
Parkinson’s disease dementia. Disease modifying ther- can provide treatments and techniques that optimize
apies that defer the onset or slow the rate of progres- the remaining cognitive resources of their loved ones.
sion are in clinical trials. No disease modifying agents Memory Loss, Alzheimer’s Disease, and Dementia clearly
have been shown to be successful in any neurodegen- defines the goals of treatment, describes the use of
erative disease and development of new potential cholinesterase inhibitors and memantine, discusses
therapies is in the uncertain future. the informed use of vitamins and supplements, and
Optimal care of patients with dementia or AD provides perspective on non-pharmacologic manage-
depends on excellent deployment of our currently ment strategies that may be helpful to caregivers. A
available tools; Memory Loss, Alzheimer’s Disease, and chapter on future treatments looks ahead to emerging
Dementia: A Practical Guide for Clinicians is a terrific symptomatic and disease modifying therapies cur-
guide for engaging this process. Beginning with the rently in the AD pipeline.
justification of why to diagnose and treat disorders Among the most disabling features of AD and other
with memory loss, Drs. Budson and Solomon provide dementing disorders, are the behavioral and psycho-
ample justification in terms of reducing patient mor- logical symptoms that many patients exhibit. Over 90
bidity and caregiver suffering through good clinical percent of patients with AD eventually have behavioral
practices and sensitive management. They then take abnormalities of some type. Apathy, depression, agita-
us through the process of evaluating the patient with tion, psychosis, irritability, and sleep disorders are
memory loss with “how to” directions for the assess- particularly common. Drs. Budson and Solomon
ment of attention, memory, language, visual-spatial provide sage advice for educating the caregiver and
skills, and executive function. A helpful online appen- implementing non-pharmacologic treatment strate-
dix provides cognitive tests and questionnaire forms, gies. This is followed by a description of optimal
instructions, and normative data. pharmacologic management and use of psychotropics
Not all memory loss or dementia is due to when required to ameliorate the sometimes devastat-
AD. Optimal management depends on sophisticated ing effects of behavioral changes in patients with
differential diagnosis. Drs. Budson and Solomon take cognitive impairment.
us through the differential diagnostic process address- A plethora of challenges face the patient and caregiver
ing mild cognitive impairment, AD, dementia with with progressive memory decline and their clinicians.
Lewy bodies, vascular dementia, primary progressive In the final section of Memory Loss, Alzheimer’s Disease,
ix
x Foreword
and Dementia, Drs. Budson and Solomon discuss life comprehensive, and insightful. Clinicians will find
adjustments for memory loss, legal and financial issues this to be an extremely useful resource; don’t go to the
that inevitably arise, and special care issues such as clinic without it.
driving and conservatorship that comprise difficult
milestones in the journey of the AD patient. Jeffrey L. Cummings, M.D., Sc.D.
Memory Loss, Alzheimer’s Disease, & Dementia is an Director, Cleveland Clinic Lou Ruvo
excellent overview of the diagnosis and management Center for Brain Health
of patients with AD and other forms of memory Camille and Larry Ruvo Chair for Brain Health
impairment. Inclusion of the caregiver—critical to the Professor of Medicine, Cleveland Clinic Lerner College of
success of any management plan—is emphasized Medicine of Case Western Reserve University
throughout the book. The advice provided is practical, Las Vegas, Nevada
Preface
Although challenging, it is also an exciting time to specialists, students and experienced clinicians,
be a clinician treating individuals with memory loss, whether their degrees are in medicine, psychology,
Alzheimer’s disease, and dementia. In just the few nursing, social work, or the therapies. Primary care
years since the first edition of this book there has been providers, nurses, psychologists, and students will
a virtual explosion of new developments in the field. find this book a very practical, clinically oriented
New diagnostic criteria have been published for: guide that helps them know what to do when sitting
• Dementia of any cause, in the office with a patient complaining of memory
• Alzheimer’s disease dementia, loss. Specialists, including psychiatrists, neurologists,
• Mild cognitive impairment of any cause, neuropsychologists, geriatricians, and others, will find
• Mild cognitive impairment due to Alzheimer’s this book a wealth of up-to-date information regarding
disease, the latest diagnostic criteria, tools, and treatments
• Vascular dementia and vascular cognitive for their patients with memory loss, mild cognitive
impairment, impairment, and dementia.
• Primary progressive aphasia (including logopenic, In this second edition, now printed in full color,
semantic, and nonfluent/agrammatic variants), each and every chapter has been updated to include
• Behavioral variant frontotemporal dementia, the latest clinically relevant information. In Section I:
• Corticobasal degeneration, and Evaluating the Patient with Memory Loss or Dementia, we
• Traumatic encephalopathy syndrome. have included a new chapter entitled, Approach to the
The new Diagnostic and Statistical Manual of Mental Dis- Patient with Memory Loss, Mild Cognitive Impairment, or
orders, 5th Edition (DSM-5) has been published, with Dementia, which can help clinicians better determine
new criteria described for many of these disorders and whether the patient in their office has dementia,
others as well. New diagnostic techniques have been mild cognitive impairment, or age-associated memory
developed and approved by the US Food and Drug changes, and if impairment is present, which disease
Administration (FDA), including positron emission is likely responsible, and which other disorders to
tomography (PET) scans that can, for the first time, consider for the relevant differential diagnosis. In
detect the β-amyloid plaques that cause Alzheimer’s Section II: Differential Diagnosis of Memory Loss and
disease in the living brain. Lastly, there are many new Dementia, we have written two new chapters: one on
treatments for Alzheimer’s disease being developed, primary progressive aphasia and apraxia of speech,
including immunological therapies aimed at slowing and one on the evolving topic of chronic traumatic
neuronal loss and the progression of disease, that will encephalopathy. In Section II we have also added a case
likely come into clinical practice in the coming years. vignette at the beginning of each chapter to provide
It is in this vibrant setting that we have written the an example of how a patient with each disorder might
second edition of this book. With the explosion of new present. In several places in Sections I and II we have
criteria and diagnostic techniques, we believe that the taken advantage of technology to include videos to
frontline clinician needs a practical guide now more illustrate various aspects of the disorders that cannot
than ever. We have worked to ensure that—despite easily be translated into words, such as tremors,
the added complexity of the field—our book remains speech and language difficulties, and gait problems.
accessible to all clinicians who are and will be caring These videos can be viewed in the online, tablet, and
for the more than 44 million individuals throughout smartphone versions of the book.
the world with memory loss, mild cognitive impair- As was the first edition, this book is based upon
ment, or dementia due to Alzheimer’s disease or the most recent peer-reviewed published studies in the
another disorder. It is written for generalists and literature, combined with our opinions reflecting our
xi
xii Preface
experience in treating more than 4000 patients with caregiver (Section IV, Chapters 21–24). Finally Section V
memory loss and dementia over approximately 30,000 (Chapters 25–27) discusses life adjustments including
patient visits. Where our opinions are supported by driving, as well as legal, financial, and other issues.
the literature we have provided appropriate references, The web appendices provide additional useful infor-
and where our opinions differ from the literature we mation including cognitive test and questionnaire
have done our best to point out this discrepancy. forms that can be immediately used (Appendix A), an
There are, of course, large areas of clinical practice expanded discussion on screening for memory loss
for which there are no randomized, double-blind, (Appendix B), and other useful information.
placebo-controlled trials to guide one. It is here that
A NOTE ON ABBREVIATIONS
our training and experience proves most valuable.
Because we want this book to be accessible to a
wide variety of audiences from diverse fields, each
How To Use This Book
with their own standard abbreviations, we have
Everyone should read Chapters 1–4. Other chapters endeavored to eliminate abbreviations. This will
can then be read when there are relevant issues such often make sentences longer, but we hope that
as suspected diagnoses other than Alzheimer’s disease these sentences will be, on the whole, more easily
(Section II, Chapters 5–14), questions regarding understood.
medications for memory loss (Section III, Chapters
15–20), and issues with the behavioral and psycho- Andrew E. Budson, M.D.
logical symptoms of dementia as well as caring for the Paul R. Solomon, Ph.D.
Acknowledgments
This book is dedicated first to our patients and their Dr. Solomon receives or has received grant support
caregivers; we are indebted for all that they have from Abbott, Alzheimer’s Disease Cooperative Study,
taught us. We also dedicate this second edition to Astellas, AstraZeneca, Avid Radiopharmaceuticals,
those who supported, encouraged, and inspired us in Eisai, Elan, EnVivo EPIX, Forrest, Genentech, Glaxo-
more ways than we can list: Jessica and Todd Solomon; SmithKline, Eli Lilly and Compnay, Janssen, Novartis,
Danny, Leah, Sandra, and Richard Budson; and of Memory Pharmaceuticals Neurochem, Pfizer, Merck,
course to Elizabeth Vassey and Amy Null. We thank Myriad, Sanofi, Sonexa, Voyager, FORUM Pharmaceu-
you all. ticals, Hoffmann-La Roche, Neuronetrix, Onnit Labs,
A special thanks goes to Ann C. McKee, M.D., for and Wyeth. He consults or has consulted for Abbott,
providing the neuropathology figures. Astellas, Avid, Eisai, EPIX, Pfizer, and Toyoma.
Note: The content of this book has been derived
from the patients that Dr. Budson and Dr. Solomon
DISCLOSURES
have seen separately and together in the Boston Center
Disclosures (current and/or during the past 5 years): for Memory, Newton, Massachusetts, and in The
Dr. Budson receives grant support from the National Memory Clinic in Bennington, Vermont, along with
Institute on Aging, National Institutes of Health literature reviews conducted solely for the purpose of
(NIH), and from the Veterans Affairs Research & this book. These reviews and the writing of this
Development Service. He also receives or has received book have been conducted during early mornings,
grant support from the following pharmaceutical late nights, weekends, and vacations. Dr. Budson’s
companies: AstraZeneca, Avid Radiopharmaceuticals, contribution to this book was conducted outside of
Eli Lilly and Company, FORUM Pharmaceuticals, both his VA tour of duty and his Boston University/
Hoffmann-La Roche, Neuronetrix, and Onnit Labs. NIH research time.
xiii