Chapter 66

This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #3, #26, #46, #49, #55, #56, #58, #59, #60, #61, #62

### LEARNING OBJECTIVES

Learning Objectives

• Describe the current diagnostic criteria for dementia, Alzheimer disease (AD), and mild cognitive impairment (MCI) and how these conditions differ from normal cognitive aging.

• Understand the effects of age and other genetic and nongenetic risk factors on risk of developing AD.

• Identify key neuropathologic features and mechanistic pathways associated with AD.

• Recognize common reversible causes of cognitive dysfunction.

• Describe an effective dementia care management plan across care settings and stages of disease, integrating use of pharmacologic and nonpharmacologic interventions, education, and community resources.

Key Clinical Points

1. AD is the most common neurodegenerative disorder affecting older adults with prevalence rates increasing with advancing age.

2. While aging is the most established risk factor for late-onset AD, various other genetic, lifestyle, and environmental factors also influence dementia risk.

3. The diagnostic evaluation for dementia, AD, and MCI depends heavily on a careful assessment of an individual’s change in functional status, a structured cognitive assessment, a thorough clinical examination, and exclusion of other competing causes of cognitive decline.

4. As there are no proven preventive or disease-modifying therapies for AD, current standard-of-care management plans integrate use of pharmacologic therapies to delay symptom progression; nonpharmacologic strategies to optimize function, behavior, and safety; and education and support for patients and their care partners.

5. Advanced care planning prior to loss of decisional capacity is of critical importance in developing patient-centered goals of care in persons with cognitive impairment.

AD is the most common neurodegenerative disorder affecting older adults, projected to affect more than 13 million Americans and 115 million individuals worldwide by 2050. Compared to projections in high-income countries, the number of individuals with AD in low- and middle-income nations is increasing at an even greater rate. The disease is characterized by diffuse functional and structural abnormalities in the brain that lead to progressive cognitive and behavioral deficits and functional decline. AD is associated with significant morbidity and mortality and is among the 10 most common causes of death in the United States. The physical, psychological, functional, and socioeconomic impact of AD substantially affects the well-being and quality of life of patients and their caregivers. Caring for patients with AD places heavy financial burden on patients, families, communities, and the health care system at large. In the United States in 2015, the average annual health care and long-term care cost for an older adult with AD ranged from $28,000 to$75,000, depending on whether the person lived in the community or a residential facility. The total cost of caring for Americans with AD exceeds \$225 billion annually. Evidence is just beginning to emerge on the economic impact of dementia care in low- and middle-income countries as most of the costs in these nations are related to informal care.

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