Physician survey on Alzheimer Disease care

[IT514]

http://www.medscape.com/features/sl...disease-report?src=wnl_edit_tpal&uac=199533FY

Nothing earth shattering here, just an opinion survey. Interesting nonetheless and I'm curious to hear thoughts/reactions from those see AD and other dementias routinely.

---

Members don't see this ad.

 

[WisNeuro]

I'll say the mildly concerning things are the 78% recommending brain fitness programs despite any evidence that they do anything besides cost money, 12% recommending a very expensive amyloid PET scan despite it not being ready for routine clinical care with as of yet poor predictive accuracy.

More concerning are the numbers suggesting that the MMSE and MoCA are used for diagnostic purposes, for which they are very poorly suited for, and that most are starting out MCI type patients with an acetylcholinesterase inhibitor, which the data suggests is useless for anything besides relieving constipation.

But, all in all, not too surprising, seems to take a while for clinical data to actually start impacting clinical care in certain fields, and the management of AD is no exception. Medicine is full of "I do this because this is what I was taught" rather than "I do this, because this is what the best data available suggests I should do."

 

[deleted343839]

I hope the question about standardized scales was interpreted broadly to mean both screening/detection and diagnosis. They are two different things but I can see how they might have been equated in the context of this survey. Not that the MMSE is a great case finding tool, either. And about the same proportion said they'd use the MMSE to assess disease progression, so yeah... makes it hard to reach a generous interpretation.

 

[WisNeuro]

I hope the question about standardized scales was interpreted broadly to mean both screening/detection and diagnosis. They are two different things but I can see how they might have been equated in the context of this survey. Not that the MMSE is a great case finding tool, either. And about the same proportion said they'd use the MMSE to assess disease progression, so yeah... makes it hard to reach a generous interpretation.

I hope so, too. But, in my experience, it is far too often used as a diagnostic tool in conjunction with a 15 minute interview with the patient in a primary care setting. Far too many older adults with psychiatric disorders misdiagnosed because of one isolated MoCA/MMSE below cutoff. Can lead to devastating iatrogenic effects in a portion of individuals. Being told you have Alzheimer's (when you really don't) apparently deepens their depression. Who knew?

 

[IT514]

More concerning are the numbers suggesting that the MMSE and MoCA are used for diagnostic purposes, for which they are very poorly suited for, and that most are starting out MCI type patients with an acetylcholinesterase inhibitor, which the data suggests is useless for anything besides relieving constipation.

Yeah I was surprised by the MCI-ach inhibitor number. I would have expected more variability there. I was also surprised that opinions on ach inhibitor discontinuation in late stage AD were that low with the exception of geriatricians at 98% (I laughed out loud when I saw that graph). One could surmise that geriatricians have a relatively better handle on meds, and this is what I have experienced in practice.

And as for the MMSE and MoCA, the question is a bit of a set-up and perhaps poorly phrased, but I would have liked to have seen the CDR or other functional status measures a bit higher. Cant tell you how many MODERATE stage dementia patients I have seen with 28/30 on the MMSE. And as noted above, the risk for a "false positive" (particularly w/ the MoCA and SLUMS in my experience) is there as well.

 

[WisNeuro]

Cant tell you how many MODERATE stage dementia patients I have seen with 28/30 on the MMSE.

Or how many anxious/depressed patients with normal cognition on full evaluation who once scored a 22 on the MMSE/MoCA and were labeled as having dementia.

 

[deleted343839]

Can lead to devastating iatrogenic effects in a portion of individuals. Being told you have Alzheimer's (when you really don't) apparently deepens their depression. Who knew?

That's a really good point. For all the talk about diagnosing dementia too late in its course we too often sidestep the issue of false positives. I'm glad the field has shown restraint in recommending against routine cognitive screening because I'm afraid a lot of people's lives would be worse for it.

 

[IT514]

http://www.ncbi.nlm.nih.gov/pubmed/26741499

This article is related to FTD, but fits with the current discussion. Just came across it yesterday.