This issue of Continuum is devoted to the diagnosis, management, and counseling of our patients with dementia. To accomplish this goal, I am very thankful to Dr John C. Morris for accepting my invitation to be the guest editor of the issue and for enlisting such renowned expert colleagues to provide us with the most up-to-date information and recommendations on these common disorders whose pathophysiologic mechanisms, diagnostic markers, and potential therapeutic strategies are increasingly being elucidated.
The issue begins with the article by Dr Eric M. McDade, who describes the most recent information about the clinical diagnosis (including imaging and fluid biomarkers) and management of Alzheimer disease (AD), with emphasis on the role of addressing comorbidities in these patients. Next, Drs Angelina J. Polsinelli and Liana G. Apostolova describe the diagnostic features of the atypical AD variants, including early-onset AD, posterior cortical atrophy, logopenic variant primary progressive aphasia, dysexecutive variant AD, behavioral variant AD, and corticobasal syndrome, highlighting the importance of early diagnosis to provide the appropriate counseling and services to these patients.
In the next article, Dr Bradley F. Boeve details the current diagnostic criteria, genetic and pathologic aspects, clinical features, and management options for behavioral variant frontotemporal dementia. Drs Jennifer G. Goldman and Samantha K. Holden then review the clinical diagnosis and management of the cognitive syndromes associated with movement disorders, including Parkinson disease, atypical parkinsonian syndromes, choreiform disorders, ataxic syndromes, dystonia, and emerging information about essential tremor. Drs Ellen Chang Wong and Helena Chang Chui next review the pathophysiology of vascular cognitive impairment and dementia, including the main categories of subcortical ischemic vascular dementia, poststroke dementia, multi-infarct dementia, and mixed dementia as well as cerebral amyloid angiopathy, highlighting the importance of preventive strategies in mitigating disease impact.
The next articles in the issue address the clinical investigation of patients with dementia. First, Dr Sandra Weintraub provides a detailed review of the role of neuropsychological assessment in dementia diagnosis, including principles of evaluation, the instruments used in these assessments, and how such assessments inform our clinical diagnosis of patients with cognitive and behavioral disorders. Next, Drs Cyrus A. Raji and Tammie L. S. Benzinger describe the important and expanding role of neuroimaging in dementia diagnosis, including structural imaging (eg, for both exclusion of structural pathology and assessment of atrophy patterns) and functional imaging, as well as the options available and those on the horizon for molecular imaging for evidence of pathologic markers of dementia. Dr Suzanne E. Schindler next provides an up-to-date summary of the current role of fluid biomarkers in dementia diagnosis, particularly the indications for, and considerations underlying, the use of CSF and blood-based tests that can assess for the amyloid- and tau-based pathologic markers of AD.
Dr Julie A. Schneider then summarizes the neuropathology of dementia disorders, including AD, Lewy body dementias, frontotemporal dementia, vascular dementia, and limbic-predominant age-related transactive response DNA-binding protein 43 (TDP-43) encephalopathy (LATE), and their underlying proteinopathies, while underscoring the common and important finding of mixed pathologies contributing to many patients’ clinical manifestations of dementing illness. Dr Suman Jayadev then reviews the genetics of AD, including the evolving knowledge of genetic risk in familial and sporadic forms of both early-onset and late-onset AD, emphasizing the important role of expert genetic counseling when such testing is being considered in clinical practice.
Drs Joyce (Joy) E. Balls-Berry and Ganesh M. Babulal next discuss the causes and consequences of health disparities in AD diagnosis and management, highlighting the role of factors such as social determinants of health, discrimination and oppression, and access to care.
Dr Cynthia M. Carlsson discusses the management of dementia, including nonpharmacologic and pharmacologic therapies (along with the current and controversial role of anti-amyloid agents, whose indications and insurance coverage considerations evolved during the production of this issue) and the role of the clinician in helping to make patients aware of community-based support to address the many needs of this population.
In the final review article of the issue, Dr Gregory S. Day discusses the timely recognition, clinical features, diagnostic evaluation, and management of the rapidly progressive dementias, providing an organized and practical approach to ensure that important and treatable conditions are not missed in the pursuit of a specific diagnosis.
In the Medicolegal Issues article, Dr Joseph S. Kass and Ms Rachel V. Rose use the example of amyloid-targeting therapy for AD to discuss the medicolegal and ethical dimensions of a physician’s reluctance to prescribe a medication, particularly when that medication is not yet considered the standard of care for the patient’s condition.
After reading the issue and taking the Postreading Self-Assessment and CME Test written by Drs Douglas J. Gelb and Nuri Jacoby and edited by Dr Joseph E. Safdieh, associate editor of Continuum and associate editor of self-assessment and CME, readers may earn up to 20 AMA PRA Category 1 CreditsTM toward self-assessment CME or, for Canadian participants, a maximum of 20 hours toward the Self-Assessment Program (Section 3) of the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada. Additional credit can be obtained by listening to Continuum Audio interviews associated with this and other Continuum issues, available to all subscribers, and completing tests on the Continuum Audio web platform or mobile app. Continuum Audio is also accredited by the Royal College of Physicians and Surgeons of Canada.
This issue also features Continuum issues read aloud. Different from Continuum Audio, these are recordings read verbatim from the print articles by Dr Michael Kentris, a neurologist at the Clinical Neuroscience Institute in Dayton, Ohio. The audio files are available to all Continuum subscribers in the AAN’s Online Learning Center at continpub.com/CME. I encourage you to listen and submit the survey with your feedback.
I would like to offer my deepest thanks to Dr Morris for his truly remarkable devotion to this issue, from his extensive content outline to the recruitment of world-class experts and his rapid and thoughtful attention to the many and evolving details as they occurred throughout the development process. The result is an issue that provides us with the most up-to-date information to inform our diagnosis, management, and counseling of patients and families dealing with dementia.
I am very thankful to Dr John C. Morris…for enlisting such renowned expert colleagues to provide us with the most up-to-date information and recommendations on these common disorders whose pathophysiologic mechanisms, diagnostic markers, and potential therapeutic strategies are increasingly being elucidated.
STEVEN L. LEWIS, MD, FAAN