Clinical diagnosis and management of Alzheimer's disease

AD is the most common dementing illness, and its prevalence in the United States is expected to almost double over the next 25 years. Further increases in prevalence are expected to continue after that point. Diagnosis is currently based on history and clinical signs and symptoms. Routine workup should include evaluation for vascular dementia, depression, neurosyphilis, vitamin B ₁₂ deficiency, as well as routine screening laboratory tests. Advances in imaging techniques may improve the ability to diagnose AD before it becomes clinically apparent and may allow for monitoring of AD progression. Currently there are no medications that alter the underlying disease process of AD. Disease-modifying strategies are an active area of research and it is hoped that disease-modifying agents will be available in the near future. FDA-approved medications for the treatment of AD include three cholinesterase inhibitors and one NMDA receptor modulator. The cholinesterase inhibitors should be used early and continuously through the illness. These agents do not have significant differences in terms of efficacy. The NMDA receptor modulator is only indicated for moderate to severe AD. All of these agents produce only modest benefits. Behavioral problems associated with dementia should be managed to the fullest extent possible with nonpharmacologic interventions. If nonpharmacologic interventions fail, atypical antipsychotics and SSRIs can be given a trial. Use of atypical antipsychotics carry risks for diabetes, stroke, and death. As AD is a progressive illness, the use of atypical antipsychotics and SSRIs should be periodically reassessed to evaluate their continued usefulness. Appendix 1 provides a list of Web sites that contain additional information about AD.