In a sweeping new position statement, the American Association for
Geriatric Psychiatry (AAGP) has affirmed that "there now exists a
minimal set of care principles for patients with [Alzheimer's disease] and
Consequently, AAGP says, "the detection and treatment of Alzheimer's
must now be considered part of the typical care practices for any physician
and other licensed clinicians who interact with patients with this
The new position statement, developed by a task force convened by AAGP last
year, was published in the July American Journal of Geriatric
Psychiatry. The chair of the task force, Constantine Lyketsos, M.D., a
professor of psychiatry at John Hopkins University School of Medicine, is the
lead author of the position statement.
The position statement is not a practice guideline, stressed Christopher
Colenda, M.D., M.P.H., AAGP president and dean of the Texas A&M Health
Sciences Center College of Medicine. Rather, the aim of the statement, Colenda
told Psychiatric News, is to "assert where the organization and
its experts stand" with respect to specific points of treatment for
Alzheimer's patients and to outline how experts in geriatric psychiatry can"
be supportive of clinicians in the field by giving them advice on how
to approach the care of these patients, which they are now seeing in everyday
Colenda is a co-author of the AAGP position statement, which he said is
targeted to nongeriatric specialists.
In developing the statement, AAGP recognized that existing scientific
evidence, coupled with clinical experience and common sense, provided
sufficient information to create the principles of care.
The care model consists of a series of therapeutic interventions, including
both pharmacologic and nonpharmacologic, that address the following clinical
In addition, the statement addresses clinical care for Alzheimer's patients
across a range of clinical settings such as primary care, specialist care, and
long-term care, including assisted-living environments.
Colenda noted, however, that the principles do not address diagnosis and
initial assessment of patients with Alzheimer's. Other practice guidelines are
available that cover screening and diagnostic workups, he said.
AAGP, he added, is participating in the review and updating of APA's
Practice Guideline for the Treatment of Patients With Alzheimer's Disease and
Other Dementias of Late Life. That guideline, first published in 1997, was the
subject of a Guideline Watch published in April 2006, and a revised guideline
is targeted for publication during the first half of 2007.
It is important to note, Colenda said, that the principles of care focus
solely on dementia associated with Alzheimer's, and are not necessarily
applicable to patients with other types of dementia.
The AAGP's position statement includes five sections (see
box). The first section
discusses current understanding of the pathophysiology of Alzheimer's and the
primarily pharmacologic interventions aimed at changing the progressive
pathophysiological trajectory that defines the disease. Symptomatic therapies
are covered in the second section, including cholinesterase inhibitor therapy
to slow cognitive decline.
The third section addresses neuropsychiatric symptoms that affect over 90
percent of patients with Alzheimer's, including agitation, aggression,
delusions, and hallucinations. A discussion of supportive care for patients
follows, addressing safety issues and modifications to daily routine and
structure that have been found to be beneficial.
In the final section, the provision of supportive care to family and
caregivers is discussed, including the critical need to educate caregivers on
realistic assessments and prognosis for Alzheimer's patients. Assisting
caregivers in accessing resources and long-range planning is also covered.
"The care of patients with Alzheimer's dementia presents a number of
challenges," Colenda explained. "First and foremost, people are
not being diagnosed early enough. If we could have a real sensitivity within
the primary care setting to doing a cognitive assessment in all folks over the
age of 65, we could perhaps identify those who have mild cognitive impairment
While some patients with MCI never progress to a dementia-related illness,
Colenda added, many do. If screening was done regularly, patients with MCI
could be monitored more closely, and perhaps treatment could be started
"Of course, we don't yet know if treatment early in the course of MCI
can change outcomes," Colenda conceded. "However, the potential is
there." Good cardiovascular health can reduce risk of developing
progressive vascular dementia, and it is reasonable to hypothesize, he said,
that intervening earlier in the trajectory of progressive cases of MCI could
As research begins to define the pathophysiological basis of Alzheimer's
and other dementias more clearly, Colenda noted, "we can design
compounds that will directly address that pathophysiology, and we may be able
to have significant treatments that preserve cognitive health and reduce the
disability associated with dementia."
"Position Statement of the American Association for Geriatric
Psychiatry Regarding Principles of Care for Patients With Dementia Resulting
From Alzheimer Disease" is posted at<www.ajgponline.org>.▪