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.

 

Diagnosing AD

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.

2022 Alzheimer’s disease facts and figures. Alzheimer’s Association. 2022;18.

 

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.

Alzheimer's disease diagnostic guidelines. National Institute on Aging.

 

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

  Petersen RC, Lopez O, Armstrong MJ, et al. Practice guideline update summary: Mild cognitive impairment. Neurology. 2018;90(3):126–135.

   

• Lancet Commission: Dementia prevention, intervention, and care: 2020 report

  Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet. 2020;396(10248):413–446.

   

• Alzheimer’s Association: Management of AD for professionals

  Management. Alzheimer’s Association.

   

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.

 

Basic steps for patients with early AD

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).

Emerging therapies that target amyloid in the brain could potentially help early AD patients. Amyloid-targeting drugs that are either FDA-approved or in development include lecanemab (Leqembi) from Eisai and Biogen, gantenerumab from Genentech and Roche, aducanumab (Aduhelm) from Biogen, and donanemab from Eli Lilly.

However, according to Dr. Kassem, aducanumab has been controversial in coming to market.

“There are mixed results on whether it is clinically improving patients, although it does appear to be effective in reducing amyloid beta proteins in the brain,” Dr. Kassem said. “Use of this medication is only offered to a small subset of patients due to risk versus benefits.”

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.

Langa KM, Levine DA. The diagnosis and management of mild cognitive impairment: A clinical review. JAMA. 2014;312(23):2551–2561.

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.