Researchers Develop Guidelines for Evaluating Cognitive and Behavioral Syndromes in Adults

CHICAGO—An Alzheimer’s Association workgroup has developed 20 recommendations for the clinical evaluation of patients with cognitive or behavioral complaints. All middle-aged or older individuals who report or whose care partner or clinician reports cognitive, behavioral, or functional changes should undergo a timely evaluation, the guidelines advise. A care partner almost always should be involved the evaluation, according to the guidelines.

The recommendations cover the recognition and evaluation of symptoms, selection of brain imaging and other tests, and communication with and support of affected individuals and their caregivers.

Alireza Atri, MD, PhD

Alireza Atri, MD, PhD, cochair of the workgroup, presented the recommendations at AAIC 2018. The authors plan to finalize and publish the guidelines in 2018.

“Until now, we have not had highly specific and multispecialty US national guidelines that can inform the diagnostic process across all care settings and that provide standards meant to improve patient autonomy, care, and outcomes,” said Dr. Atri, Director of the Banner Sun Health Research Institute in Sun City, Arizona, and Lecturer in Neurology at the Center for Brain/Mind Medicine at Brigham and Women’s Hospital and Harvard Medical School in Boston.

Cognitive Behavioral Syndromes

The clinical practice guidelines recognize a broad category of cognitive behavioral syndromes marked by memory and thinking symptoms as well as changes in sleep, anxiety, personality, and relationships.

The Alzheimer’s Association in 2017 convened a Diagnostic Evaluation Clinical Practice Guideline workgroup to develop evidence-based guidelines. The group includes experts in medical, neuropsychologic, and nursing specialties. The members conducted a systematic review of the literature and made recommendations using a modified Delphi consensus process. They graded the recommendations as “A” (must be done; will improve outcomes in almost all cases), “B” (should be done), and “C” (may be done).

The recommendations emphasize obtaining a history from not only the patient, but also from someone who knows the patient well to establish the presence and characteristics of any substantial changes and to categorize the cognitive behavioral syndrome.

Other recommendations for evaluating patients with cognitive behavioral syndromes include the following:

• For patients with atypical or rapidly progressive cognitive behavioral symptoms, the clinician should expedite an evaluation and strongly consider referral to a specialist. (Level A)
• The evaluation process should use tiers of assessments and tests based on a patient’s presentation, risk factors, and profile. (Level A)
• The clinician should involve an informant to obtain reliable information about changes in cognition, activities of daily living, mood and other neuropsychiatric symptoms, and sensory and motor function. Use of structured instruments for assessing these domains is helpful. (Level A)
• Clinicians should use validated tools to assess cognition. (Level A)
• When office-based cognitive assessment is not sufficiently informative (eg, when interpretation of results is uncertain due to a complex clinical profile or confounding demographic characteristics), neuropsychologic evaluation is recommended. (Level A)
• The clinician should obtain MRI as a first-tier approach to aid in establishing etiology. If MRI is not available or is contraindicated, CT should be obtained. (Level B)
• If etiology remains uncertain after interpretation of structural imaging, a dementia specialist can obtain molecular imaging with FDG-PET to improve diagnostic accuracy. (Level B)
• In cases with continued diagnostic uncertainty, a dementia specialist can obtain CSF according to appropriate use criteria for analysis of aβ42 amyloid and tau/p-tau profiles to evaluate for Alzheimer’s disease pathology. (Level C)
• If diagnostic uncertainty remains after obtaining structural imaging and FDG-PET, and CSF aβ and tau/p-tau profiles are unavailable or uninterpretable, the dementia specialist can obtain an amyloid PET scan according to the appropriate use criteria. (Level C)
• In a patient with an established cognitive behavioral syndrome and a likely autosomal dominant family history, the dementia specialist should consider whether genetic testing is warranted. A genetic counselor should be involved throughout the process. (Level A)