New Guidelines for Alzheimer's Disease are a Step in the Right Direction

Contributed by: Dennis Fortier, President, Medical Care Corporation

The announcement of new guidelines for diagnosing Alzheimer's disease is being widely covered in the press today.  The move is a solid step in the right direction, but is spawning some confusion about why the change is necessary, and how it might help.

Biggest Change: AD starts prior to Dementia
The most important change is that we will now recognize Alzheimer's disease in its early stages, prior to the patient suffering massive brain damage and becoming demented.  This is a more difficult diagnosis to make and, as such, requires a thoughtful approach.

I wrote more extensively about the benefits, and the ensuing confusion about new diagnostic guidelines for Alzheimer's disease, when the draft versions of these documents were first discussed in the summer of 2010.   I encourage you to click back and read those thoughts, but the short summary is below.

Perspective on Former Guidelines
According to the former guidelines, put in place nearly 30 years ago, Alzheimer's disease was defined in part by the presence of dementia.  As readers of this blog know, dementia requires impairment so severe that a person cannot independently care for themselves.  In this regard, the term "mild Alzheimer's" means "barely demented due to Alzheimer's pathology"'  This is a misnomer because, even in its "mild" stages, dementia is a severe condition.

To put that in perspective, imagine if we could note the high blood sugar and blurry vision caused by diabetes, but we couldn't diagnose and treat it until the patient's kidneys failed.  Any guideline, suggesting that symptoms must be severe before diagnosis, is in direct conflict with early intervention.

The former guidelines were problematic as illustrated by this example:  Suppose a 75 year old person, with a family history of Alzheimer's, noticed subtle signs of memory loss and visited a physician.  The physician then confirmed the declining memory and sought the cause of the problem.  After ruling out depression, sleep disorders, medications, thyroid malfunction, poorly controlled diabetes, vitamin deficiency, and stroke as possible causes, he noted on an MRI scan of the brain that the patient's hippocampus was shrinking.  This would be a strong indication of Alzheimer's disease.

However, since the patient in this example had only subtle memory loss, not severe cognitive impairment meeting the criteria for dementia, the physician could not diagnose Alzheimer's and initiate treatment.  According to the old guidelines, the physician would let the Alzheimer's pathology progress for months or years, until the patient suffered enough irreversible brain damage to become demented, and then they could diagnose Alzheimer's and initiate treatment.  That clearly makes no sense.

New Guidelines
Under the new guidelines, if a patient has memory loss or other cognitive deficits, and common causes of such deficits are ruled out, and pathology is consistent with Alzheimer's, then we should recognize the condition as early stage Alzheimer's disease and begin treating it.  This holds even if the patient's cognitive problem is subtle and does not meet the criteria for dementia.

Since earlier intervention bodes well for better treatment outcomes, this is a solid step in the right direction.

1 comment :

  1. The new guidelines present a three stage categorization. It's great to see progress in this area. A lot of what is ultimately achieved in science is consequential to how we categorize and organize our thoughts and approaches to scientific (and medical) discovery. Whilst AD immediately conjures up a sense of inevitability and hopelessness in most people, there were two thoughts that occurred to me that readers might take hope from:
    1. During the mid-stage (MCI), fighting against the plaque has not proved successful to date. Companies such as Amarin, who it was hoped might develop beyond Phase III clinical trials, came close but ultimately through in the towel and moved on to other medical problems (though that's not to say that many other researchers are still aggressively pursuing a cure). There is an alternative strategy which may help for a while. Use of scientifically proven nutraceuticals, such as neurapex (, may help the existing cognitive processing environment (PFC) to perform better than it would normally do so. Though this wouldn't prevent the consequences of the plaque build-up, it may offer some 'counter measures' in the fight against AD;
    2. Re. the third stage, some very good work has been done on appreciating the 'lifeworld' (an expression taken from phenomenology) experience and social psychologists are now presenting research that shows that the AD sufferer may experience their cognitions in as appreciative a manner as they did pre-AD. Even though their daily living is obviously impacted, the internal experience may not be (hopefully) as harrowing as non-AD observers perceive it to be.