In this issue of CONTINUUM, Guest Editor Claudia Kawas, MD, has assembled an expert faculty to help us provide a rational, informed, and contemporary approach to the clinical diagnosis, management, and counseling of our patients with dementia.
In probably no other disorder within neurology are the concepts of disease onset, pathogenesis, and diagnosis evolving more rapidly than in the dementias—albeit without a concomitant significant advancement in preventive or treatment options—yet. In this issue of CONTINUUM, Guest Editor Claudia Kawas, MD, has assembled an expert faculty to elucidate the current state of the art in the dementias and to help us provide a rational, informed, and contemporary approach to the clinical diagnosis, management, and counseling of our patients with these disorders.
This issue begins with a discussion by Drs Reisa Sperling and Keith Johnson on the CSF and imaging biomarkers for Alzheimer disease. Whether these biomarkers are ready, near-ready, or not-ready for prime time (daily clinical practice), these authors inform us about both the potential usefulness and the current pitfalls of these new and evolving tests. Next, Dr Lon Schneider discusses the pharmacologic treatment of Alzheimer disease; within this extremely practical review (including specifics of dosing and listing of common side effects) is a frank and realistic analysis of the limitations of our current therapies. In the next article, Drs John Ringman and Giovanni Coppola inform us nongeneticists about the genetic aspects of Alzheimer disease, including the rare gene mutations that cause autosomal dominant forms of the disease; the common variations (polymorphisms) of the apolipoprotein E gene that have a differential effect on Alzheimer disease susceptibility; and the role of these genetic studies—or lack thereof—in clinical practice. Dr Kristine Yaffee and Tina Hoang then review the evidence that certain cardiovascular, dietary, and lifestyle factors might represent modifiable risk factors for the development of dementia. Next, Drs Anna Burke, Geri Hall, and Pierre Tariot tackle the neuropsychiatric (behavioral) aspects of dementia, providing practical advice in regard to both nonpharmacologic strategies and pharmacologic interventions (recognizing the US Food and Drug Administration warning on both typical and atypical antipsychotics) of these distressing—for both patients and their caregivers—symptoms.
In his review, Dr Douglas Galasko provides us with an expert’s practical approach to the history, examination, and diagnostic assessment of the patient presenting with dementia, which we can emulate in our practices. Dr Oscar Lopez then discusses mild cognitive impairment (MCI), including the history and continuing evolution of this diagnostic concept, underscoring its clinical heterogeneity and the importance of recognizing the potential role of coexisting illnesses in the manifestation of the clinical syndrome. Next, Drs Philip Gorelick and David Nyenhuis provide a state-of-the-art discussion and review of vascular cognitive impairment, from the evolution of the nomenclature to the diagnostic, management, and preventive strategies for this important cause or contributor to cognitive impairment. Next, Drs Tiffany Chow and Ammar Alobaidy present a comprehensive yet extremely accessible review of frontotemporal degeneration and its behavioral and primary progressive aphasia variants, including an approach to the clinical recognition and diagnosis of these syndromes, an exposition of the nomenclature and clinical distinctions between the aphasia variants, and an explanation of the rapidly evolving knowledge regarding the underlying proteinopathies and genetic aspects of these syndromes. Their review is grounded by a discussion of clinical management and support for affected patients and their families. Finally, Drs Szófia Bullain and María Corrada discuss dementia in the oldest old and the unique diagnostic and etiopathologic features of dementia in this fastest-growing segment of the population.
In this issue’s Ethical Perspectives section, Drs B. Joy Snider and Virginia Buckles analyze the ethical issues involved in a theoretical case of a cognitively normal patient requesting amyloid imaging because of her concern for Alzheimer disease. In the Practice Issues section, Dr Jack Tsao provides a practical analysis of the issues to consider in regard to Alzheimer disease genetic counseling, testing, and disclosure, and Drs John Hart, Kyle Womack, Laura Powers, and Marc Nuwer thoroughly review the coding aspects relevant to dementia.
Like all CONTINUUM issues, there are ample opportunities for CME. Reading the material, answering the Multiple-Choice Questions that were crafted by Drs Joanne Lynne and Douglas Gelb, and reviewing the explanatory discussions will assess and enhance your knowledge of the material, and you will be able to earn up to 10 AMA PRA Category 1 CME Credits™. An alternative opportunity also now allows you to obtain up to 12 AMA PRA Category 1 CME Credits specifically approved by the American Board of Psychiatry and Neurology (ABPN) for self-assessment by simply completing and submitting the Self-Assessment Pretest before reading the material and completing the postreading Multiple-Choice Questions. The Patient Management Problem, written by Dr Aimee Pierce, follows the case of a 64-year-old man from his earliest cognitive symptoms to severe dementia. By following his case and answering multiple-choice questions corresponding to important diagnostic, prognostic, therapeutic, and counseling decision points along his course (reinforcing many of the issues addressed in the previous articles) you will have the opportunity to earn up to 2 AMA PRA Category 1 CME Credits.
I thank Dr Kawas and her expert team of authors who have created a CONTINUUMissue providing us with such clear and up-to-date information that we can use at the bedside to inform our individual approaches to the diagnosis, management, and counseling of our patients—and their families—affected by dementia.
—Steven L. Lewis, MD, FAAN