An Update on Alzheimer Disease: Developments Are Shaping the Future

Things are happening in Alzheimer disease (AD) research and there seems to be a lot of excitement in the AD research community. The big news is that recent developments are shaping the future for AD assessment and diagnosis and allowing for early detection and treatment of the disease.

In his presentation at the 2013 US Psychiatric and Mental Health Congress, Mark E. Agronin, MD, Affiliate Associate Professor of Psychiatry and Neurology at the University of Miami Miller School of Medicine in Florida and Medical Director for Mental Health and Clinical Research at the Miami Jewish Health Systems, conveyed that excitement to his audience. With the aging of the Boomer population, many clinicians are seeing an explosion of AD cases. By the year 2050, it is estimated that 16 million Americans will be affected. Beginning with Dr Alzheimer’s first case, “a peculiar disease of the cerebral cortex” and continuing to the present, the only way to verify a diagnosis has been with an autopsy of the brain. Early diagnosis is inefficient and may take years to establish-all while the disease progresses.

The first diagnostic criteria for AD were developed jointly by the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer’s Disease and Related Disorders Association (NINCDS-ADRDA) in 1984. In addition to the 4 criteria, the NINCDS-ADRDA specified that 8 cognitive domains had to be affected.

The National Institute on Aging and the Alzheimer Association has now released new guidelines. The difference in the new guidelines is that they propose 3 clinical stages:

• Phase 1: a newly defined stage of preclinical AD
• Phase 2: mild cognitive impairment due to AD
• Phase 3: probable dementia due to AD

The preclinical stage is the time to arrest disease progression, but first it needs to be identified. By Phase 3 there is clear cognitive decline that impairs functional ability in all areas of everyday life.

“Neuropsychological testing is the gold standard to identify the pattern and degree of impairment,” said Dr Agronin, but the new era of biomarkers can provide a means for early detection and intervention. Current evidence shows that measurable biomarker changes in the brain already exist in Phase 1-years before symptoms are detected by the affected individual or by his or her physicians.

Findings indicate that starting medications early and continuing at optimum dose can significantly lower rates of cognitive decline. Dr Agronin suggested that patient assessment include clinical history and interview, neuropsychological testing, and structural imaging with CT or MRI, as well as a check of amyloidb and Tau protein levels in cerebrospinal levels. He cautioned that due diligence is needed as symptoms of other disorders can muddy the diagnostic waters; the following need to be ruled out before a diagnosis of AD can be established:

• Meningiomas
• Alcohol abuse
• Medication-induced cognitive changes
• Bipolar variant with impulse discontrol
• Inattention due to adult ADHD

Although much research is still needed, cautious optimism is warranted. Dr Agronin stressed the need for study participants and urged clinicians to enroll their patients in ongoing studies (ongoing studies can be found at www.ClinicalTrials.gov.)