Geriatric Psychiatrists Issue Alzheimer's Care Principles

In a sweeping new position statement, the American Association for Geriatric Psychiatry (AAGP) has affirmed that “there now exists a minimal set of care principles for patients with [Alzheimer's disease] and their caregivers.”

Consequently, AAGP says, “the detection and treatment of Alzheimer's must now be considered part of the typical care practices for any physician and other licensed clinicians who interact with patients with this disease.”

The new position statement, developed by a task force convened by AAGP last year, was published in the July American Journal of Geriatric Psychiatry. The chair of the task force, Constantine Lyketsos, M.D., a professor of psychiatry at John Hopkins University School of Medicine, is the lead author of the position statement.

The position statement is not a practice guideline, stressed Christopher Colenda, M.D., M.P.H., AAGP president and dean of the Texas A&M Health Sciences Center College of Medicine. Rather, the aim of the statement, Colenda told Psychiatric News, is to “assert where the organization and its experts stand” with respect to specific points of treatment for Alzheimer's patients and to outline how experts in geriatric psychiatry can“ be supportive of clinicians in the field by giving them advice on how to approach the care of these patients, which they are now seeing in everyday practice.”

Colenda is a co-author of the AAGP position statement, which he said is targeted to nongeriatric specialists.

In developing the statement, AAGP recognized that existing scientific evidence, coupled with clinical experience and common sense, provided sufficient information to create the principles of care.

The care model consists of a series of therapeutic interventions, including both pharmacologic and nonpharmacologic, that address the following clinical goals:

In addition, the statement addresses clinical care for Alzheimer's patients across a range of clinical settings such as primary care, specialist care, and long-term care, including assisted-living environments.

Colenda noted, however, that the principles do not address diagnosis and initial assessment of patients with Alzheimer's. Other practice guidelines are available that cover screening and diagnostic workups, he said.

AAGP, he added, is participating in the review and updating of APA's Practice Guideline for the Treatment of Patients With Alzheimer's Disease and Other Dementias of Late Life. That guideline, first published in 1997, was the subject of a Guideline Watch published in April 2006, and a revised guideline is targeted for publication during the first half of 2007.

It is important to note, Colenda said, that the principles of care focus solely on dementia associated with Alzheimer's, and are not necessarily applicable to patients with other types of dementia.

The AAGP's position statement includes five sections (see box). The first section discusses current understanding of the pathophysiology of Alzheimer's and the primarily pharmacologic interventions aimed at changing the progressive pathophysiological trajectory that defines the disease. Symptomatic therapies are covered in the second section, including cholinesterase inhibitor therapy to slow cognitive decline.

The third section addresses neuropsychiatric symptoms that affect over 90 percent of patients with Alzheimer's, including agitation, aggression, delusions, and hallucinations. A discussion of supportive care for patients follows, addressing safety issues and modifications to daily routine and structure that have been found to be beneficial.

In the final section, the provision of supportive care to family and caregivers is discussed, including the critical need to educate caregivers on realistic assessments and prognosis for Alzheimer's patients. Assisting caregivers in accessing resources and long-range planning is also covered.

“The care of patients with Alzheimer's dementia presents a number of challenges,” Colenda explained. “First and foremost, people are not being diagnosed early enough. If we could have a real sensitivity within the primary care setting to doing a cognitive assessment in all folks over the age of 65, we could perhaps identify those who have mild cognitive impairment [MCI] earlier.”

While some patients with MCI never progress to a dementia-related illness, Colenda added, many do. If screening was done regularly, patients with MCI could be monitored more closely, and perhaps treatment could be started earlier.

“Of course, we don't yet know if treatment early in the course of MCI can change outcomes,” Colenda conceded. “However, the potential is there.” Good cardiovascular health can reduce risk of developing progressive vascular dementia, and it is reasonable to hypothesize, he said, that intervening earlier in the trajectory of progressive cases of MCI could improve outcomes.

As research begins to define the pathophysiological basis of Alzheimer's and other dementias more clearly, Colenda noted, “we can design compounds that will directly address that pathophysiology, and we may be able to have significant treatments that preserve cognitive health and reduce the disability associated with dementia.”

“Position Statement of the American Association for Geriatric Psychiatry Regarding Principles of Care for Patients With Dementia Resulting From Alzheimer Disease” is posted at<www.ajgponline.org>.▪