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Key Clinical Updates in Management of Common Geriatric Problems
Aducanumab, a monoclonal antibody that targets amyloid-beta protein and promotes its clearance from the brain, became the first new drug approved by the FDA for the treatment of Alzheimer disease since 2003.
Lin GA et al. https://icer.org/assessment/alzheimersdisease-2021/
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ESSENTIALS OF DIAGNOSIS
Progressive decline of mental processes.
Acquired cognitive deficits severe enough to impair function.
Not due to delirium or another mental disorder.
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General Considerations
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Dementia is an acquired, persistent, and progressive impairment in mental processes, with compromise of one or more cognitive domains. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition, identifies these domains (with example deficits) as: (1) complex attention (easily distracted, difficulty performing calculations), (2) executive function (poor abstraction, mental flexibility, planning, and judgment), (3) learning and memory (difficulty recalling items from a list, forgetting recent events), (4) language (word finding and object naming difficulty), (5) perceptual-motor function (difficulty navigating in known environments, copying a drawing), and (6) social cognition (change in personality, trouble reading social cues). The diagnosis of dementia requires a significant decline in function that is severe enough to result in the loss of independence in IADLs.
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While dementia prevalence doubles every 5 years in the older population, reaching 30–50% at age 85, the prevalence among US adults 65 years or older has been declining. This improvement has been attributed to higher education levels and better control of cardiovascular risk factors. Women suffer disproportionately, both as patients and as caregivers. Alzheimer disease accounts for roughly two-thirds of dementia cases in the United States, with vascular dementia (either alone or combined with Alzheimer disease) and Lewy body dementia accounting for much of the rest. Some risk factors for Alzheimer disease are older age, hyperlipidemia, hypertension, depression, family history, lower education level, and female sex. Education, physical exercise, heart healthy diets, and social connectivity may be protective. Risk factors for vascular dementia are those for stroke, ie, older age, hypertension, cigarette use, atrial fibrillation, diabetes mellitus, and hyperlipidemia.
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Depression and delirium are also common in older adults, may coexist with dementia, and may also present with cognitive impairment. Major depressive disorder may occur in up to 20–50% of patients with dementia, and because they share common features, distinguishing the two can prove difficult. Delirium, characterized by acute confusion, occurs much more commonly in patients with underlying dementia.
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1. Cognitive impairment
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According to the USPSTF, there is insufficient evidence to recommend for or against screening all older adults for cognitive impairment. While there is logic in the argument that early detection may improve future planning and patient outcomes, empiric evidence that demonstrates a clear benefit for either patients or caregivers is lacking. It is important to note, however, that ...