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Early Detection of Memory Problems:
How & Why it Matters
J. Wesson Ashford, M.D., Ph.D.
Clinical Professor (affiliated)
Department of Psychiatry and Behavioral Sciences
Stanford School of Medicine, Palo Alto, Calif.
Senior Research Scientist
Stanford/VA Aging Clinical Research and Alzheimer Centers
VA Palo Alto HCS
Carol Steinberg
President
Alzheimer’s Foundation of America
National Association of Area Agencies on Aging - N4A
July 15, 2014
Alzheimer’s Foundation of America (AFA)
National 501 (c)3 nonprofit organization
Mission: “To improve quality of life for individuals with
Alzheimer’s disease and related dementias, and their families”
Unites 1,700+ member organizations nationwide that provide
hands-on programs/services
Goals include educating public and professionals; promoting
early detection, treatment and social services intervention;
highlighting successful aging; raising the bar on dementia
care
Medical/memory screening advisory boards composed of
prominent experts
J. Wesson Ashford, M.D., Ph.D.--chairman, AFA Memory
Screening Advisory Board; member, AFA Medical and
Scientific Advisory Board
AFA Memory Screening Advisory Board
Chairman: J. Wesson Ashford, M.D., Ph.D.
Peter Bayley, Ph.D.
Soo Borson, M.D.*
Herman Buschke, M.D.**
Howard Fillit, M.D.
Sanford I. Finkel, M.D.
Lori Frank, Ph.D.
Marta Mendiondo, Ph.D.
Frederick A. Schmitt , Ph.D.
*Author, Mini-Cog screening tool
**Author, MIS screening tool
Memory Problems
A number of problems can cause memory
impairment.
Some memory problems can be readily treated,
such as those caused by vitamin deficiency,
depression, or thyroid problems.
Other memory problems might result from causes
that currently are not reversible, such as
Alzheimer's disease.
National Memory Screening Day
National Memory Screening Day (NMSD) is:
a comprehensive awareness-raising and education initiative
that highlights AFA’s national leadership role in promoting
memory screenings and the importance of early detection
an event introduced by AFA in 2003 and held annually each
November during National Alzheimer’s Disease Awareness
Month in collaboration with community sites nationwide
an event that provides free, confidential memory screenings
and information to people with memory concerns or who want
check their memory now and for future comparison
an initiative that mirrors goals of the historic “National Plan to
Address Alzheimer’s Disease”—education, training, early
detection, care-related support services
NMSD—November 18, 2014
Year-Round Screenings
Community Memory Screening and
Awareness-Raising Education:
The Road to Early Detection and Care
(AFA C.A.R.E.S.)
Builds on National Memory Screening Day
Invites community sites to offer screenings year-round (e.g.,
by appointment, set day, monthly schedule)
Funded in part by a grant from the Edward N. and Della L.
Thome Memorial Foundation, Bank of America, N.A., Trustee
Major Goal: Screening
Initiative
Reverse under-diagnosis and mis-diagnosis of memory
problems … speeding process toward timely, correct diagnosis
“State of a person’s memory” is often not discussed in
doctor’s office
Under-utilization of detection of cognitive impairment as part
of Medicare Annual Wellness Exam
For the majority of Alzheimer’s caregivers, mostly or only
cognitive symptoms (41%) or a combination of cognitive and
behavioral symptoms (40%) contributed to the doctor’s visit
that ultimately resulted in the Alzheimer’s diagnosis.*
Behavioral symptoms were less likely to have been the main
reason that prompted the doctor’s visit, with only 12% of
Alzheimer’s caregivers saying that it was mostly or only
behavioral symptoms that contributed to the visit.*
*AFA/Harris Interactive 2012 survey, Alzheimer’s Caregivers: Behavioral vs. Cognitive Challenges
Other Goals: Screening Initiative
Spark a movement of greater awareness of Alzheimer’s
disease, education/training for families/professionals, and
earlier care and support of the diagnosed individual and
support for families—improving quality of life
Educate and empower healthcare professionals to improve
assessments and coordination of care
Serve as jumping off point to engage community
organizations, communities and health care professionals in a
dialogue about memory issues
Alleviate the fears of those individuals who do not have a
problem
Advance brain health and healthy lifestyle choices
Methodology:
Memory Screenings
Provide screenings in community settings:
Free
Confidential (private space)
Face-to-face
Series of questions and tasks
5-10 minutes each (1 hour = 6 screenings)
Proven tools (e.g., MIS, GPCog, Mini-Cog, BAS)
Online template available for administering, scoring
Administered by qualified screener (e.g., doctor,
nurse, psychologist, pharmacist, social worker)
Methodology:
Next Steps
Screening results are not a diagnosis!
Next steps for participants:
Screeners encourage further evaluation by clinicians
Participants receive test scores and explanatory
letter to bring to healthcare professionals
Participants receive educational materials, including
“Memory Bulletin,” and referrals to resources
Methodology:
Screening Sites
Trusted, convenient local venues:
Grassroots Alzheimer’s agency
Area Agency on Aging
Senior center
Adult day center
YMCA/YWCA/JCC
House of worship
Library
Pharmacy
Doctor’s office
Hospital/clinic
Assisted living residence
Long-term care facility
Methodology:
Screeners
Qualified screeners include:
Doctors
Psychologists
Nurse Practitioners
Nurses (LPN, RN)
Social Workers
Pharmacists
Physician’s Assistants
Medical Directors
Methodology:
AFA Responsibilities
Train screeners, via printed materials, conference calls,
Webinars
Provide free toolkit of materials to carry out event, including
screening tests, educational materials (re: memory, brain
health and caregiving), marketing collateral, forms
Post local screening sites on AFA Website
Arrange screeners, if needed
Helps pay for screeners, depending on need, available funds
Handle national publicity
Available to answer questions
Methodology:
Evaluation
Multiple surveys will add to our greater understanding of the
issues surrounding memory loss and diagnosis:
Participants complete voluntary survey (e.g., age, last visit
to physician, previous screening history)
Screeners complete a survey (e.g., normal/abnormal scores,
tools used)
Clinicians complete a survey- AFA asks participants to give
their physician or another healthcare professional at their next
visit a copy of screening score and a survey for the
professional to complete. It also serves to raise doctors’
awareness of Alzheimer’s disease and proper detection.
Screening Sites complete a post-event survey. AFA will send
feedback forms to participating facilities to gauge overall
perception and experience.
2013 NMSD by the Numbers
7,000+ participating sites
Estimated average 40 participants per site
Estimated 250,000 people screened/got educated
Estimated 22% scored below-normal
3 states with most sites—1) California 2) New York
3) Pennsylvania
Supported by 45 national professional organizations
(e.g., N4A, American Academy of Neurology)
Why Get Involved?
To Benefit the Nation
Alzheimer’s disease—21st century healthcare crisis
Most feared and costly disease in U.S.
Incidence to triple to 16 million by mid-century
Baby boomers are reaching 65+... advanced age is
greatest risk factor for Alzheimer’s disease
Growth of young-onset Alzheimer’s disease … under
age 65, people with Down syndrome
50-66% of cases of dementia are undiagnosed
Barriers to diagnosis/treatment: lack of knowledgestigma, denial, ineffective communication
Aligns with “National Plan to Address Alzheimer’s”
Why Get Involved?
To Benefit Your Community
Free, confidential service
Leads people to a proper diagnosis, treatment and
improved quality of life
Fosters aging in place philosophy
Encourages utilization of community resources
Why Get Involved?
To Benefit Your Site
Free service fosters community goodwill
Gain visibility … opens your doors to the community
in friendly way
Gain recognition as a healthcare/dementia care
resource
Gain marketing point of differentiation …
competitive edge
Heighten staff sensitivity re: memory loss
Provide awareness-raising, education/skills training
to employees
Why Get Involved?
To Benefit Individuals
Proper diagnosis can maximize quality of life:
Research: individuals and their families feel relief, not
increased anxiety or depression upon validating concerns
Allays fears of participants with normal scores
Encourages intervention for participants with below-normal
scores
Proactive, comprehensive management of disease
The earlier medications begin, the more effective in slowing
symptom progression
Diagnosed individuals can participate in legal/financial
decision-making, care planning—better well-being
Help sustain autonomy of aging population
Families can obtain support, plan for future, reduce stress
Early Detection of Memory Problems:
Scientific, Implementation Issues
J. Wesson Ashford, M.D., Ph.D.
Clinical Professor (affiliated)
Department of Psychiatry and Behavioral Sciences
Stanford School of Medicine, Palo Alto, Calif.
Senior Research Scientist
Stanford/VA Aging Clinical Research and Alzheimer Centers
VA Palo Alto HCS
Carol Steinberg
President
Alzheimer’s Foundation of America
Alzheimer’s Disease
First described by Alois Alzheimer,
a German neuropathologist, in 1907
Observed in a 51-year-old female
patient with paranoia, memory loss,
disorientation, and hallucinations
Postmortem studies characterized senile
plaques and neurofibrillary tangles (NFTs)
in the cerebral cortex
– Senile plaques: Extracellular
accumulation of insoluble
fragments of beta-amyloid (A1-42)
– NFTs: Intracellular accumulation
of hyperphosphorylated
tau strands
Reprinted with permission from Brumback, RA, Leech RW, J. Ohio State Med Assoc. 1994: 87, 103-111
Estimate Number of New AD Cases
in Thousands
Estimated Number of New AD Cases, in Thousands
1200
959
1000
1000
820
800
600
400
615
377
411
454
491
200
0
1995
2000
2010
2020
2030
2040
2050
100%
90%
80%
60%
AD
MCI
Non-Affected
50%
40%
30%
20%
10%
Age
84
82
80
78
76
74
72
70
68
66
64
62
0%
60
Percentage
70%
Yesavavage et al., 2002
BIOPSYCHOSOCIAL SYSTEMS AFFECTED BY AD
NEUROPLASTIC MECHANISMS AFFECTED AT ALL LEVELS
(Ashford, Mattson, Kumar, 1998; Teter & Ashford, 2002)
SOCIAL SYSTEMS
INSTRUMENTAL ADLs - EARLY
BASIC ADLs – LATE
PSYCHOLOGICAL SYSTEMS
PRIMARY LOSS OF SHORT-TERM MEMORY
– LEARNING PROCESSES – CLASSICAL, OPERANT
LATER LOSS OF LEARNED SKILLS
NEURONAL MEMORY SYSTEMS
CORTICAL GLUTAMATERGIC STORAGE
SUBCORTICAL (acetylcholine, norepinephrine, serotonin)
CELLULAR PLASTIC PROCESSES
– APP metabolism – early, broad cortical distribution
– TAU hyperphosphorylation – focal effect, dementia related
Why Screening Is Important
Cognitive impairment is disruptive to human
well-being and psychosocial function
Cognitive Impairment is potentially a
prodromal condition to dementia and
Alzheimer’s disease (AD)
Dementia is a very costly condition to
individuals and society
With the aging of the population, there will
be a progressive increase in the proportion
of elderly individuals in the world
Screening will lead to better care
Benefits of Early Alzheimer's
Disease Diagnosis: Social
Undiagnosed AD patients face avoidable problems
– Social, financial
Early education of caregivers
– How to handle patient (choices, getting started)
Advance planning while patient is competent
– Will, proxy, power of attorney, advance directives
Reduce family stress and misunderstanding
– Caregiver burden, blame, denial
Promote safety
– Driving, compliance, cooking, etc.
Patient’s and family’s right to know
– Especially about genetic risks
Promote advocacy
- For research and treatment development
Decreases health-care costs
Benefits of Early Alzheimer's
Disease Diagnosis: Medical
Early diagnosis, treatment, and appropriate intervention
may
– Substantially improve overall course of disease
– Lessen disease burden on caregivers/society
Specific treatments now available
– Cholinesterase inhibitors, NMDA receptor antagonist (memantine)
Improve cognition
Improve function (activities of daily living)
Delay conversion from mild cognitive impairment to AD
Slow underlying disease process, "the sooner the better"
Decrease/delay development of behavior problems
Delay nursing home placement, possibly over 20 months
NMDA=N-methyl-D-aspartate
– Possibly delay nursing home placement longer if started earlier
Alzheimer's Disease Is
Underdiagnosed
Early AD is subtle, the diagnosis continues to be missed
– It is easy for family members to avoid the problem and
compensate for the patient
– Physicians tend to miss the initial signs and symptoms
Less than half of AD patients are diagnosed
– Estimates are that 25%–50% of cases remain undiagnosed
– Diagnoses are missed at all levels of severity: mild, moderate,
severe
Undiagnosed AD patients often face avoidable social,
financial, and medical problems
Early diagnosis and appropriate intervention may lessen
disease burden
– Early treatment may substantially improve overall course
No definitive laboratory test for diagnosing AD exists
– Efforts to develop biomarkers, early recognition by brain scan
AFA Experience with NMSD
AFA’s 2010 National Memory Screening Day Results
Age (years)
N
percent
% male
<35
40
0.9
35.0%
35-44
57
1.3
35.1%
45-54
190
4.4
26.8%
55-64
604
13.8
25.3%
65-74
1330
30.5
27.6%
75-84
1524
34.9
30.4%
>85
617
14.1
30.0%
Total
4362
99.9
29.0%
2334 testing sites - data provided by 48 selected sites
Data provided on 4396 individuals. 4,362 could be analyzed
AFA Experience with NMSD
AFA’s 2010 National Memory Screening Day Survey Results
AFA Experience with NMSD
AFA’s 2010 National Memory Screening Day Survey Results
AFA Experience with NMSD
AFA’s 2010 National Memory Screening Day Survey Results
AFA Experience with NMSD
AFA’s 2010 National Memory Screening Day Testing Results
50
% of sites
40
30
20
10
0
GPCOG
Mini-COG
MMSE
MIS
MOCA
KOKMAN
SLUMS
Screening Test
2334 testing sites - data provided by 48 selected sites
Data provided on 4396 individuals. 3,064 could be analyzed
AFA Experience with NMSD
% Participants Failed Screen
AFA’s 2010 National Memory Screening Day Testing Results
0.20
0.15
0.10
0.05
0
0.00
GPCOG
Mini-Cog
MMSE
MIS
MoCA
Kokmen
SLUMS
Screening Test
12% of participants failed a screening test,
a number consistent with large epidemiological studies
AFA Experience with NMSD
AFA’s 2010 National Memory Screening Day Testing Results
Probability of passing screen
1
s no memory concerns
0.9
O memory concerns
0.8
___ Edu: Above High School
- - - Edu: High School
…. Edu: Grade School
0.7
0.6
0.5
<75
75-84
Age (years)
>84
AFA Experience with NMSD
AFA’s 2010 National Memory Screening Day Conclusions
No significant differences in failure rates were found
across the tests (p>.05).
Overall screening failure rate was 11.7% across all 7 tests
Failure rate increased to 13.5% in participants aged 65
and older.
The failure rate in this sample is similar to dementia
prevalence rates reported by epidemiological studies of
the U.S. population. For example, according to the U.S.
Census Bureau, in 2008, 13% of people aged 65 and
older were estimated to have Alzheimer’s disease.
AFA Experience with NMSD
AFA’s 2010 National Memory Screening Day Conclusions
Overall, 75% of 4,396 participants from reporting sites
in 48 states endorsed subjective memory problems
The presence of subjective memory concerns was
associated with a 1.4 fold (40%) increase in failure
rates for persons of similar age and education but no
memory concerns (OR=1.4; 95% CI: 1.07-1.78), pass
rates varying by age and education 56% to 96%.
As expected, failure rates were higher in older (p<.05)
and less educated (p<.05) participants and an age by
education interaction was observed.
Conclusions About Screenings
AFA’s 2010 National Memory Screening Day Results
Survey results support the feasibility of a
national-level screening event and suggest
data are likely comparable to screening data
obtained in clinical settings.
A voluntary screening event may therefore be
a viable way to enhance public health through
identification of potential cognitive impairment
appropriate for subsequent clinical evaluation.
Alzheimer's Disease
Warning Signs
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Recent memory changes affecting daily life
Challenges in problem solving and planning
Difficulty performing familiar tasks
Disorientation to time and/or place
Difficulty understanding visual images and/or spatial
relationships
Problems with spoken and written language (eg, paraphasia,
agraphia)
Misplacing things
Poor judgment
Withdrawal from activities (eg, social, work)
Changes in personality and/or mood
None of these is a reliable indicator of
MCI or early dementia
Challenges With the MiniMental State Examination
Mini-Mental State Exam (MMSE)
– Folstein MF, et al. J Psychiatr Res. 1975;12:189-198.
Several items do not provide adequate information
Adds noise rather than discrimination between
demented and nondemented individuals
Poor range for measuring change
– Large standard error of measurement
Poor power for assessing medication benefit
Inadequate screening tool
Too long
– Better, shorter tests are available
Copyright is being enforced (test is not free)
Ashford JW. Aging Health. 2008;4:399-432.
Relatively Brief Cognitive and
Memory Tests
Name of Test
Author
Abbreviated Mental Test
Hodkinson, 1972
Short Portable Mental Status Questionnaire (SPMSQ)
Pfeiffer, 1975
Clifton Assessment Procedures for the Elderly-Cognitive
Assessment Scale (CAPE-CAS)
Pattie, 1981
Blessed 6-Item
Katzman, 1983
Visual memory, category fluency, temporal orientation
Eslinger, 1985
Short Test of Mental Status
Kokmen, 1987
Delayed Word Recall test (DWR)
Knopman, 1989
Memory Impairment Screen
Buschke, 1999
Three Words–Three Shapes
Weintraub, 2000
General Practitioner Assessment of Cognition (GP-COG)
Brodaty, 2002
6-Item Screener
Callahan, 2002
Ashford JW. Aging Health. 2008;4:399-432.
Relatively Brief Cognitive and
Memory Tests (cont.)
Name of Test
Author
Efficient Office-Based Assessment of Cognition
Karlawish, 2003
Mini-Cog
Borson, 2003
Rapid Dementia Screening Test (RDST)
Kalbe, 2003
Brief Alzheimer Screen (BAS)
Mendiondo, 2003
Short Cognitive Evaluation Battery (SCEB)
Robert, 2003
AB Cognitive Screen)(ABCS)
Molloy, 2005
Quick & Easy (Q&E)
Dash, 2005
Mild Cognitive Impairment Screen (MCIS)
Shankle, 2005
Blessed Memory Test/Category Fluency
Kilada, 2005
10-Item Free Recall With Serial Position Effect Analysis
Tractenberg, 2005
Ashford JW. Aging Health. 2008;4:399-432.
Animals Named in 1 Minute
(mms >19); CERAD Data Set
Anim als nam ed in 1 m in (m m s>19) - CERAD data set
12
percent of total
10
8
6
4
2
0
0
10
20
30
40
num ber of anim als nam ed
Normal Controls, CS = 1, n = 386
Alzheimer patients, CS = 0, n = 380
CERAD=Consortium to Establish a Registry for Alzheimer's Disease
Brief Alzheimer Screen
http://www.medafile.com/bas.htm
Repeat these 3 words: “apple, table, penny”
So you will remember these words, repeat them again
What is today’s date?
– D=1 if within 2 days
Spell the word “WORLD” backwards
– S=1 point for each word in correct order
“Name as many animals as you can in 30 seconds, GO!”
– A=number of animals
“What were the 3 words I asked you to repeat?” (no prompts)
– R=1 point for each word recalled
BAS = 3 x R + 2/3 x A + 5 x D + 2 x S
Mendiondo MS, et al. J Alzheimers Dis. 2003;5:391-398.
Note: J. Wesson Ashford, MD, PhD, is one of the developers of the Brief Alzheimer Screen (BAS)
Percent of Validation Sample
90
80
Mild AD
70
Control
60
50
40
30
20
10
0
3-22
JW Ashford, MD PhD, 2001
23
24
25
BAS Score
26
27-39
Dementia Screening Test
(screening is not diagnosing)
Need better tests to screen patients for memory
disorders
Test needs to be very brief (~2-3-minutes)
Multiple test-forms needed so it can be repeated
Annual screening annually after age 50 years
– Repeated every 3 months for individuals over 65
years or with concerns/risk factors
– Variety of versions allow daily testing as an exercise
Any change over time needs to be detected
MEMTRAX - Memory Test
(to detect AD onset)
New test to screen patients for AD:
– World-Wide Web – based testing,
Determine level of ability / impairment
Test takes 2 – 3 minutes
Test can be repeated often (even daily)
Any change over time can be detected
Free test is at: www.memtrax.com
MemTrax.com
Between 9/2011 and 8/2012, 18,282 individuals
Took the Memtrax test on-line for the first time, scored>60%,
Provided legitimate Ages between 21 and 99 and stated
Their gender, 5,837 males (blue) and 12,445 females (red)
MemTrax.com
85% of participants scored 90% correct or better
13% of participants scored 80% to 88% correct
2% of participants scored less than 80% correct
There was generally poorer performance with increasing age
MemTrax.com
Recognition time provides a better correlation with age
than percent correct and may be more useful for finding
impairments – specific recommendations are available.
MemTrax.com
Available On-Line
www.medafile.com (information)
For further information, contact:
– Wes Ashford: [email protected]
– Curtis Ashford: [email protected]
Contact Information:
To sign up as a screening site,
www.nationalmemoryscreening.org
866-232-8484
To contact Alzheimer’s Foundation of America,
www.alzfdn.org
866-232-8484
Slides on-line: www.medafile.com/AFA-N4A
Comprehensive Screening
Plan
At age 50 years: initial screen, review risks
–
–
–
–
–
Consider dementia family history
Review of systems, vital signs
Brief cognitive evaluation
Complete blood count (CBC), B12, cholesterol
Begin yearly assessments if high risk
At age 55–60 years: follow-up assessments
– Review of systems, vital signs
– Brief cognitive evaluation
– CBC, B12, cholesterol
At age 65 years and older: begin annual
assessments
– Review of systems, vital signs
– Brief cognitive evaluation
– CBC, B12, cholesterol
Dementia Screening Test
Need test to screen patients for Alzheimer’s disease
Test needs to be on multiple platforms
–
–
–
–
–
Doctor’s offices
Best if computerized for rapid, objective assessment
Internet-based testing
CD-ROM distribution
Kiosk administration (eg, drug stores, shopping malls)
Test needs to be very brief (~1-minute)
Multiple test-forms needed so it can be repeated often (quarterly)
Annual screening annually after age 50 years
– Repeated every 3 months for individuals over 65 years or with
concerns/risk factors
– Variety of versions allow daily testing as an exercise
Any change over time needs to be detected
The test should be free
Example of a test that meets these criteria and is available*
*Available at: http://www.medafile.com/. Accessed April 20, 2009.
Note: Site constructed and maintained by J. Wesson Ashford, MD, PhD; slide reflects his opinions and recommendations
Secondary Screen:
(screening is not diagnosing)
More cognitive testing
Complete orientation testing
Test ability to name animals and vegetables in 1
minute
Ask for recall of 10 items after distraction
Test praxis
Draw clock, cube
Talk with a knowledgeable informant
Ask questions about activities of daily living
Ask questions about depression, sleep
*Available at: http://www.medafile.com/bce.htm. Accessed April 20, 2009.
Note: Site constructed and maintained by J. Wesson Ashford, MD, PhD; slide reflects his opinions and recommendations
However, There Are Other Opinions
About a Comprehensive Screening Plan
The United States Preventive Services Task Force (USPSTF)
concluded that the evidence is insufficient to recommend for
or against routine screening for dementia in older adults1
There are no formal recommendations for routine screening
for dementia by the The American Academy of Neurology and
the Canadian Task Force on Preventive Health Care
– They concluded that there is insufficient evidence to recommend
cognitive screening of asymptomatic individuals2,3
The American Medical Association and the American Academy
of Family Physicians recommend that physicians be alert for
cognitive and functional decline in elderly patients for
recognition of dementia in its early stages4,5
1. Screening for Dementia, Topic Page. June 2003. US Preventive Services Task Force. Agency for Healthcare Research and Quality, Rockville,
MD. Available at: http://www.ahrq.gov/clinic/uspstf/uspsdeme.htm. Accessed April 20, 2009.
2. Petersen RC, et al. Neurology. 2001;56:1133-1142.
3. Canadian Task Force on the Periodic Health Examination. Canadian guide to clinical prevention health care. Ottawa: Canada Communication
Group; 1994:902-909.
4. American Medical Association. Practical guide for the Primary Care Physician on the Diagnosis, Management and Treatment of Dementia.
Available at: http://www.amaassn.org/ama/pub/category/4789.html. Accessed April 20, 2009.
5. Santacruz KS, Swagerty D. Early diagnosis of dementia, American Family Physician, 2001. Available at: http://www.aafp.org/afp/monograph/.
Accessed April 20, 2009.
Need to Develop Better
Tools for Early Assessment
Genetic vulnerability testing (trait risk)
Improve awareness of vulnerability factors, ask the “right
questions” of the patient or informant (education, occupation,
head injury)
Early recognition of the “10 warning signs”
– Activities of daily living (ADLs), behavior changes, forgetting
Increase suspicion and use available screening tools (while
new and better tools/tests are developed)
– "6th vital sign" in elderly
Utilize current diagnostic tests that can best identify probable
AD
– Cerebrospinal fluid: tau levels, amyloid levels
– Brain scan, PET scan: DDNP (amyloid-binding agent), Congo-red
derivatives (amyloid plaque label)
More routine use of mild dementia severity assessments
Detect early change over time
– Measure rate, predict progression