MANAGED CARE January 1997. ©1997 Stezzi Communications
Like an assembly line grinding to a halt, the Agency for Health Care Policy and Research has manufactured its last set of regular clinical practice guidelines. The government-funded agency's future role in the guidelines-making arena will be to supply the scientific resources to help health plans, professional medical societies and other groups create guidelines of their own.
After creating 19 sets of guidelines on topics ranging from urinary incontinence to smoking cessation, the seven-year-old agency ended its work with guidelines addressing Alzheimer's disease, the most common form of dementia.
Alzheimer's disease-related dementia is a serious problem for an estimated 5 to 10 percent of the U.S. adult population 65 and older. Despite its prevalence, Alzheimer's disease is often misdiagnosed in the early stages or overlooked because memory loss is thought to be a natural result of old age. Dementia problems are disabling and "should not be viewed as an inevitable part of growing older," states the guidelines panel.
In about 20 percent of patients suffering from dementia symptoms, the cause is actually another treatable condition such as depression, alcoholism and even side effects from medications. Very often, depression can be difficult to distinguish from dementia, says T. Franklin Williams, M.D., professor of medicine emeritus, University of Rochester Medical Center, and panel co-chairman.
Diagnosing Alzheimer's disease can be extremely tricky. Making a proper diagnosis involves a multi-step approach that includes testing the patient's mental and functional ability and talking with the patient and family members.
Specific symptoms to look for include: difficulty with language, learning new things and retaining new information; unusual behavior, problems handling complex tasks, and disturbances of reasoning, spatial ability and orientation. Also, family histories of dementia or Down's syndrome are possible risk factors for Alzheimer's disease.
Background investigation
If there's some suspicion that a patient is having dementia, the 18-member guideline panel recommends physicians review the patient's history, conduct a physical exam, gather reports from family members or caregivers and do a brief mental status test and/or functional status assessment. For a diagnosis of dementia, consult the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).
Whenever possible, obtain history from both the patient and family members or close friends. These interviews can provide supplemental information about the likelihood of disease. The physical examination should include a short neurological evaluation.
There are several mental status tests to choose from, but none of them are meant to be diagnostic tools. Functional assessment can be performed with the Functional Activities Questionnaire, which evaluates day-to-day activities such as balancing a checkbook, shopping, playing games and preparing meals.
To order the guidelines, call or write AHCPR for the "Alzheimer's Disease Guidelines": (800) 358-9295 or AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907.