What's best for your patients with early Alzheimer disease?
Key Takeaways
The growing prevalence of Alzheimer disease (AD) calls attention to the need for clinicians to be knowledgeable in caring for patients at the early stages of the disease.
There are currently no curative treatments for any stage of AD, including early AD; available treatments can only aim to reduce symptoms.
Lifestyle and social changes are important, as are ongoing cognitive status checks.
As the high prevalence of Alzheimer disease (AD) could affect clinical care in all specialties, it is important for all clinicians to be aware of how to care for patients with AD, especially in the early stages of the disease.
While there are no curative treatments for any stage of AD, clinicians should be aware of the many treatments used to address its symptoms.
Recommending lifestyle and social changes, along with cognitive status checks, may be helpful to patients in the early stages of AD.
The latest guidelines
A 2022 report from the Alzheimer’s Association, projected that the number of people aged 65 and older with AD dementia will reach 12.7 million by 2050.[]
Before starting care for patients with early AD, it is important to confirm the diagnosis. However, according to MDLinx advisor Mohammad Kassem, MD, MBA, a neurologist practicing in Ohio, the most current formal AD diagnosis and management guidelines are from 2011.[]
Due to the lack of updated guidelines, a reasonable approach may be to use the recommendations in the following three documents from highly regarded sources:
American Academy of Neurology: Practice guideline update summary: Mild cognitive impairment[]
Lancet Commission: Dementia prevention, intervention, and care: 2020 report[]
Alzheimer’s Association: Management of AD for professionals[]
Once the differentials are ruled out and the diagnosis has been confirmed, clinical care can proceed, keeping in mind the many potential comorbidities in older patients.
Initiating care
The three documents make very similar recommendations for initiating care for patients with early AD and/or mild cognitive impairment (MCI), including:
Assess for MCI with validated tools
Evaluate patients with MCI for modifiable risk factors
Perform lab tests for potentially reversible causes
Discuss diagnosis, prognosis, and the lack of effective pharmacologic options
Recommend lifestyle changes
Recommend cognitive training
Consider prescribing medications to treat non-cognitive symptoms
Consider prescribing medications to treat cognitive symptoms
If possible, evaluate current medications that may contribute to impaired cognition, discontinuing them as appropriate
It is acceptable to choose not to offer cholinesterase inhibitors, but if offering, discuss lack of evidence
Discuss biomarker and genetic testing research with patients and their families
Continue to monitor overall basic health parameters
Schedule regular checkups to assess cognitive status
Refer patients to specialists as needed
Consider recommending participation in clinical trials
Lifestyle changes
As per the three documents cited above, lifestyle changes that are important in early AD patients include:
Exercise training—While studies showing the effect on AD have not identified strong results, it still makes sense to initiate this.
Hearing aids—Prescribe them when appropriate, because improved hearing can help cognition.
Smoking cessation—Recommend this along with avoidance of smoking uptake.
Pollution—Reduce exposure to air pollution and second-hand tobacco smoke.
Alcohol—Limit (or preferably, eliminate) its use.
Reduce obesity.
Medication
Cholinesterase inhibitors are indicated for early, mild AD, but are only modestly helpful in improving cognition and activities of daily living. They do not stop or reverse the course of cognitive decline, and have side effects, as well as cost issues, that should be considered.
"In general, for mild to moderate dementia we use cholinesterase inhibitors such as donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne). "
— Mohammad Kassem, MD, MBA
Emerging therapies that target amyloid in the brain could potentially help early AD patients. As of February 2023, Amyloid-targeting drugs that are either FDA-approved or in development include AZ-801 (valiltramiprosate) from Alzheon, aducanumab (Aduhelm) from Biogen, donanemab from Eli Lilly, gantenerumab from Genentech and Roche, and lecanemab (Leqembi) from Eisai and Biogen.
Also, depression, anxiety, and agitation are common in early AD, and treatment with antidepressants and anxiolytics is standard practice. While many alternative treatments are under investigation for AD, there is inconsistent evidence for any recommendations.
Address social needs
A clinical review published in JAMA on the diagnosis and management of MCI discussed addressing patients’ social needs, which should involve their families and caregivers.[] The authors recommended the following steps:
Encourage social interactions.
Discuss a living will, power of attorney, financial issues, and long-term care plans.
Investigate community resources for patients with early AD.
Have a conversation about safe driving.
Review home safety, including kitchen safety, firearms, poisons, and potential fall risks.
Taking these steps in the early stages of AD may not help slow a patient’s cognitive decline, but they can be helpful to the patient’s emotional well-being and quality of life.
Regular medical evaluation of patients’ cognitive function may be useful in determining further treatment plans.
What this means for you
While there are no curative treatments for any stage of AD, the management approaches discussed above are worth trying, even if their effectiveness in slowing cognitive decline is uncertain. Clinicians should schedule a follow-up every 6 months to assess a patient’s changes in cognitive function, and to evaluate their evolving needs.