[Skip to Content]
Sign In
Individual Sign In
Create an Account
Institutional Sign In
OpenAthens Shibboleth
Purchase Options:
[Skip to Content Landing]
October 22, 1997

Diagnosis and Treatment of Alzheimer Disease and Related Disorders: Consensus Statement of the American Association for Geriatric Psychiatry, the Alzheimer's Association, and the American Geriatrics Society

JAMA. 1997;278(16):1363-1371. doi:10.1001/jama.1997.03550160083043

Objective.  —A consensus conference on the diagnosis and treatment of Alzheimer disease (AD) and related disorders was organized by the American Association for Geriatric Psychiatry, the Alzheimer's Association, and the American Geriatrics Society on January 4 and 5, 1997. The target audience was primary care physicians, and the following questions were addressed: (1) How prevalent is AD and what are its risk factors? What is its impact on society? (2) What are the different forms of dementia and how can they be recognized? (3) What constitutes safe and effective treatment for AD? What are the indications and contraindications for specific treatments? (4) What management strategies are available to the primary care practitioner? (5) What are the available medical specialty and community resources? (6) What are the important policy issues and how can policymakers improve access to care for dementia patients? (7) What are the most promising questions for future research?

Participants.  —consensus panel members and expert presenters were drawn from psychiatry, neurology, geriatrics, primary care, psychology, nursing, social work, occupational therapy, epidemiology, and public health and policy.

Evidence.  —The expert presenters summarized data from the world scientific literature on the questions posed to the panel.

Consensus Process.  —The panelists listened to the experts' presentations, reviewed their background papers, and then provided responses to the questions based on these materials. The panel chairs prepared the initial drafts of the consensus statement, and these drafts were read by all panelists and edited until consensus was reached.

Conclusions.  —Alzheimer disease is the most common disorder causing cognitive decline in old age and exacts a substantial cost on society. Although the diagnosis of AD is often missed or delayed, it is primarily one of inclusion, not exclusion, and usually can be made using standardized clinical criteria. Most cases can be diagnosed and managed in primary care settings, yet some patients with atypical presentations, severe impairment, or complex comorbidity benefit from specialist referral. Alzheimer disease is progressive and irreversible, but pharmacologic therapies for cognitive impairment and nonpharmacologic and pharmacologic treatments for the behavioral problems associated with dementia can enhance quality of life. Psychotherapeutic intervention with family members is often indicated, as nearly half of all caregivers become depressed. Health care delivery to these patients is fragmented and inadequate, and changes in disease management models are adding stresses to the system. New approaches are needed to ensure patients' access to essential resources, and future research should aim to improve diagnostic and therapeutic effectiveness.

Advisory Panel on Alzheimer's Disease.  Alzheimer's Disease and Related Dementias: Acute and Long-term Care Services . Washington, DC: US Dept of Health and Human Services; 1996. NIH publication. 96-4136.
Evans DA.  Estimated prevalence of Alzheimer's disease in the US .  Milbank Q . 1990;68:267-289.Crossref
American Academy of Neurology.  Practice parameter for diagnosis and evaluation of dementia (summary statement): report of the Quality Standards Subcommittee of the American Academy of Neurology .  Neurology . 1994;44:2203-2206.Crossref
Costa PT Jr, Williams TF, Somerfield M, et al.  Recognition and Initial Assessment of Alzheimer's Disease & Related Dementias . Rockville, Md: US Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; November 1996. AHCPR publication 97-0702.
US Dept of Veterans Affairs, University Health-System Consortium.  Dementia Identification and Assessment: Guidelines for Primary Care Practitioners . Oak Brook, Ill: University Health System Consortium; 1997.
Evans DA, Funkenstein HH, Albert MS, et al.  Prevalence of Alzheimer's disease in a community population of older persons is higher than previously reported .  JAMA . 1989;262:2551-2556.Crossref
Dartigues JF, Gagnon M, Michel P, et al.  The Paquid research program on the epidemiology of dementia: methods and initial results .  Rev Neurol (Paris) . 1991;147:225-230.
Heeren TJ, Lagaay AM, Hijmans W, Rooymans HG.  Prevalence of dementia in the 'oldest old' of a Dutch community .  J Am Geriatr Soc . 1991;35:755-759.
Hendrie HC, Osuntokun BO, Hall KS, et al.  Prevalence of Alzheimer's disease and dementia in two communities: Nigerian Africans and African Americans .  Am J Psychiatry . 1995;152:1485-1492.
Ritchie K, Kildea D.  Is senile dementia 'age related' or 'aging related'? evidence from a metaanalysis of dementia prevalence in the oldest old .  Lancet . 1995;346:931-934.Crossref
Bachman DL, Wolf PA, Linn RT, et al.  Incidence of dementia and probable Alzheimer's disease in a general population: the Framingham Study .  Neurology . 1993;43:515-519.Crossref
Jorm AF.  The Epidemiology of Alzheimer's Disease and Related Disorders . London, England: Chapman & Hall; 1990.
Barrett JJ, Haley WE, Harrell LE, Powers RE.  Knowledge about Alzheimer disease among primary care physicians, psychologists, nurses, and social workers .  Alzheimer Dis Assoc Disord . 1997;11:99-106.Crossref
Hoffman RS.  Diagnostic errors in the evaluation of behavioral disorders .  JAMA . 1982;248:964-967.Crossref
McDaniel LD, Lukovits T, McDaniel KD.  Alzheimer's disease: the problem of incorrect clinical diagnosis .  J Geriatr Psychiatry Neurol . 1993;6:230-234.
Ryan DH.  Misdiagnosis in dementia: comparisons of diagnostic error rate and range of hospital investigation according to medical specialty .  Int J Geriatr Psychiatry . 1994;9:141-147.Crossref
Callahan CM, Hendrie HC, Tierney WM.  Documentation and evaluation of cognitive impairment in elderly primary care patients .  Ann Intern Med . 1995;122:422-429.Crossref
Ross GW, Abbott RD, Petrovich H, et al.  Frequency and characteristics of silent dementia among elderly Japanese-American men: the Honolulu-Asia Aging Study .  JAMA . 1997;277:800-805.Crossref
McCartney JR, Palmateer LM.  Assessment of cognitive deficit in geriatric patients: a study of physician behavior .  J Am Geriatr Soc . 1985;33:467-471.
German PS, Shapiro S, Skinner EA, et al.  Detection and management of mental health problems of older patients by primary care providers .  JAMA . 1987;257:489-493.Crossref
Pinholt EM, Kroenke K, Hanley JF, et al.  Functional assessment of the elderly: a comparison of standard instruments with clinical judgments .  Arch Intern Med . 1987;147:484-488.Crossref
Mant A, Eyland EA, Pond DC, Saunders NA, Chancellor AH.  Recognition of dementia in general practice: comparison of general practitioners' opinions with assessments using the Mini-Mental State Examination and Blessed dementia rating scale .  Fam Pract . 1988;5:184-188.Crossref
Mohs RC, Breitner JCS, Silverman JM, Davis KL.  Alzheimer's disease: a morbid risk among first-degree relatives approximates 50 percent by 90 years of age .  Arch Gen Psychiatry . 1987;44:405-408.Crossref
Breitner JCS, Silverman JM, Mohs RC, Davis KL.  Familial aggregation in Alzheimer's disease: comparison of risk among relatives of early- and late-onset cases, and among male and female relatives in successive generations .  Neurology . 1988;38:307-312.Crossref
Goate A, Chartier-Harlin MC, Mullan M, et al.  Segregation of a missense mutation in the amyloid precursor protein gene with familial Alzheimer's disease .  Nature . 1991;349:704-706.Crossref
Levy-Lahad E, Wasco W, Poorkaj P, et al.  Candidate gene for the chromosome 1 familial Alzheimer's disease locus .  Science . 1995;269:973-977.Crossref
Sherrington R, Rogaev EI, Liang Y, et al.  Cloning of a gene bearing missense mutations in earlyonset familial Alzheimer's disease .  Nature . 1995;375:754-760.Crossref
Corder EH, Saunders AM, Strittmatter WJ, et al.  Gene dose of apolipoprotein E type 4 allele and the risk of Alzheimer's disease in late onset families .  Science . 1993;261:921-923.Crossref
American College of Medical Genetics/American Society of Human Genetics Working Group on APOE and Alzheimer's Disease.  Statement on the use of apolipoprotein E testing for Alzheimer's disease .  JAMA . 1995;274:1627-1629.Crossref
Relkin NR, Tanzi R, Breitner J, et al.  Apolipoprotein E genotyping in Alzheimer's disease: position statement of the National Institute on Aging/ Alzheimer's Association Working Group .  Lancet . 1996;347:1091-1095.
Stephenson J.  Researchers find evidence of a new gene for late-onset Alzheimer disease .  JAMA . 1997;277:775.Crossref
National Institute on Aging.  Progress Report on Alzheimer's Disease 1996 . Bethesda, Md: National Institute on Aging; 1996. NIH publication 96-4137.
Ernst RL, Hay JW.  The U.S. economic and social costs of Alzheimer's disease revisited .  Am J Public Health . 1994;84:1261-1264.Crossref
Schulz R, O'Brien AT, Bookwala J, Fleissner K.  Psychiatric and physical morbidity effects of dementia caregiving: prevalence, correlates, and causes .  Gerontologist . 1995;35:771-791.Crossref
Russell LB, Gold MR, Siegel JE, Daniels N, Weinstein MS.  The role of cost-effectiveness analysis in health and medicine: Panel on Cost-Effectiveness in Health and Medicine .  JAMA . 1996;276:1172-1177.Crossref
American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders . 4th ed. Washington, DC: American Psychiatric Association; 1994.
McKeith LG, Galasko D, Kosaka K, et al.  Consensus guidelines for the clinical and pathologic diagnosis of dementia with Lewy bodies (DLB): report of the consortium on DLB international workshop .  Neurology . 1996;47:1113-1124.Crossref
Mega MS, Cummings JL, Fiorello T, Gornbein J.  The spectrum of behavioral changes in Alzheimer's disease .  Neurology . 1996;46:130-135.Crossref
Stern Y, Alpert M, Brandt J, et al.  Utility of extrapyramidal signs and psychosis as predictors of cognitive and functional decline, nursing home admission and death in Alzheimer's disease: prospective analysis from the Predictors Study .  Neurology . 1994;44:2300-2307.Crossref
Lerner AJ, Hedera P, Koss E, Stuckey J, Friedland RP.  Delirium in Alzheimer disease .  Alzheimer Dis Assoc Disord . 1997;11:16-20.Crossref
Francis J, Kapoor WN.  Prognosis after hospital discharge of older medical patients with delirium .  J Am Geriatr Soc . 1992;40:601-606.
Alexopoulos GS, Meyers BS, Young RC, Mattis S, Kakuma T.  The course of geriatric depression with 'reversible dementia': a controlled study .  Am J Psychiatry . 1993;150:1693-1699.
Rasmusson DX, Brandt J, Steele C, et al.  Accuracy of clinical diagnosis of Alzheimer disease and clinical features of patients with non-Alzheimer neuropathology .  Alzheimer Dis Assoc Disord . 1996;10:180-188.Crossref
Larson EB, Edwards JK, O'Meara E, Nochlin D, Sumi SM.  Neuropathologic diagnostic outcomes from a cohort of outpatients with suspected dementia .  J Gerontol . 1996;51:M313-M318.
Pfeffer RI, Kurosaki TT, Harrah CH Jr, Chance JM, Filos S.  Measurement of functional activities in older adults in the community .  J Gerontol . 1982;37:323-329.Crossref
Teri L, Truax P, Logsdon R, Uomoto J, Zarit S, Vitaliano PP.  Assessment of behavioral problems in dementia: the revised memory and behavior problems checklist .  Psychol Aging . 1992;7:622-631.Crossref
Folstein MF, Folstein SE, McHugh PR. ' Mini-Mental State': a practical method for grading the cognitive state of patients for the clinician .  J Psychiatr Res . 1975;12:189-198.Crossref
Herholz K, Adams R, Kessler J, et al.  Criteria for the diagnosis of Alzheimer's disease with positron emission tomography .  Dementia . 1990;1:156-164.
Kippenhan JS, Barker WW, Pascal S, Nagel J, Duara R.  Evaluation of a neural-network classifier for PET scans of normal and Alzheimer's disease subjects .  J Nucl Med . 1992;33:1459-1467.
Brust JC.  Vascular dementia: still overdiagnosed .  Stroke . 1983;14:298-300.Crossref
Snowdon DA, Greiner LH, Mortimer JA, Riley KP, Greiner PA, Markesbery WR.  Brain infarction and the clinical expression of Alzheimer disease: the Nun Study .  JAMA . 1997;277:813-817.Crossref
Arnold SE, Kumar A.  Reversible dementias .  Med Clin North Am . 1993;77:215-230.
Knapp MJ, Knopman DS, Solomon PR, Pendlebury WW, Davis CS, Gracon SI.  A 30-week randomized controlled trial of high-dose tacrine in patients with Alzheimer's disease: the Tacrine Study Group .  JAMA . 1994;271:985-991.Crossref
Rogers SL, Friedhof LT, Apter JT, et al.  The efficacy and safety of donepezil in patients with Alzheimer's disease: results of a US multicentre, randomized, double-blind, placebo-controlled trial .  Dementia . 1996;7:293-303.
Kaufer DI, Cummings JL, Christine D.  Effect of tacrine on behavioral symptoms in Alzheimer's disease: an open-label study .  J Geriatr Psychiatry Neurol . 1996;9:1-6.
Knopman D, Schneider LS, Davis K, et al.  Long-term tacrine (Cognex) treatment effects on nursing home placement and mortality: the Tacrine Study Group .  Neurology . 1996;47:166-177.Crossref
Schneider LS.  Clinical pharmacology of amino-acridines in Alzheimer's disease .  Neurology . 1993; 43( (suppl 14) ):S64-S79.
Watkins PB, Zimmerman HJ, Knapp MJ, Gracon SI, Lewis KW.  Hepatotoxic effects of tacrine administration in patients with Alzheimer's disease .  JAMA . 1994;271:992-998.Crossref
Cognex (tacrine) [package insert]. Morris Plains, NJ: Warner-Lambert Co; 1996.
Aricept (donepezil) [package insert]. New York, NY: Pfizer Inc; 1997.
Sano M, Ernesto C, Thomas RG, et al.  A controlled trial of selegiline, alpha-tocopherol, or both as treatment for Alzheimer's disease .  N Engl J Med . 1997;336:1216-1222.Crossref
Baines S, Saxby P, Ehlert K.  Reality orientation and reminiscence therapy: a controlled cross-over study of elderly confused people .  Br J Psychiatry . 1987;151:222-231.Crossref
Woods P, Ashley J.  Simulated presence therapy: using selected memories to manage problem behaviors in Alzheimer's disease patients .  Geriatr Nurs . 1995;16:9-14.Crossref
Logsdon RG, Teri L.  The Pleasant Events Schedule-AD: psychometric properties of long and short forms and an investigation of its association to depression and cognition in Alzheimer's disease patients .  Gerontologist . 1997;37:40-45.Crossref
Meyers K, Griggin M.  The Play Project: use of stimulus objects with demented patients .  J Gerontol Nurs . 1990;16:32-37.
Mintzer JE, Lewis L, Pennypaker L, et al.  Behavioral intensive care unit (BICU): a new concept in the management of acute agitated behavior in elderly demented patients .  Gerontologist . 1993;33:801-806.Crossref
Teri L, Uomoto J.  Reducing excess disability in dementia patients: training caregivers to manage patient depression .  Clin Gerontol . 1991;10:49-63.Crossref
Teri L, Logsdon R, Uomoto J, et al.  Treatment of depression in dementia patients: a controlled clinical trial .  J Gerontol B Psychol Sci Soc Sci . 1997;52:159-166.Crossref
Patterson MB, Bolger JP.  Assessment of behavioral symptoms in Alzheimer disease .  Alzheimer Dis Assoc Disord . 1994;8( (suupl 3) ):4-20.
Schneider LS, Pollock VE, Lyness SA.  A meta-analysis of controlled trials of neuroleptic treatment in dementia .  J Am Geriatr Soc . 1990;28:553-563.
Rada RT, Kellner R.  Thiothixene in the treatment of geriatric patients with chronic organic brain syndrome .  J Am Geriatr Soc . 1976;24:105-107.
Madhusoodanan S, Brenner R, Arujo L, et al.  Efficacy of risperidone treatment for psychoses associated with schizophrenia, bipolar disorder, or senile dementia in 11 geriatric patients: a case series .  J Clin Psychiatry . 1995;56:514-518.
Salzman C, Vaccaro B, Lieff J, et al.  Clozapine in older patients with psychosis and behavioral disturbances .  Am J Geriatr Psychiatry . 1995;3:26-33.
Chacko R, Hurley R, Jankovic J.  Clozapine use in diffuse Lewy body disease .  J Neuropsychiatry Clin Neurosci . 1993;5:206-208.
Jeste DV, Eastham JH, Lacro JP, Gierz M, Field MG, Harris MJ.  Management of late-life psychosis .  J Clin Psychiatry . 1996;57( (suppl 3) ):39-45.
Grad R.  Benzodiazepines for insomnia in community-dwelling elderly: a review of benefit and risk .  J Fam Pract . 1995;41:473-481.
Tariot PN, Erb R, Leibovici A, et al.  Carbamazepine treatment of agitation in nursing home patients with dementia: a preliminary study .  J Am Geriatr Soc . 1994;42:1160-1166.
Mellow AM, Solano-Lopez C, Davis S.  Sodium valproate in the treatment of behavioral disturbance in dementia .  J Geriatr Psychiatry Neurol . 1993;6:205-209.
Sultzer DL, Gray KF, Gunay I, et al.  A double-blind comparison of trazodone and haloperidol for treatment of agitation in patients with dementia .  Am J Geriatr Psychiatry . 1997;5:60-69.
Sakauye KM, Camp CJ, Ford PA.  Effects of buspirone on agitation associated with dementia .  Am J Geriatr Psychiatry . 1993;1:894-901.Crossref
Nyth AL, Gottfries CG, Lyby K, et al.  A controlled multicenter clinical study of citalopram and placebo in elderly depressed patients with and without concommitant dementia .  Acta Psychiatr Scand . 1992;86:138-145.Crossref
Overman W Jr, Stoudemire A.  Guidelines for legal and financial counseling of Alzheimer's disease patients and their families .  Am J Psychiatry . 1988;145:1495-1500.
Cohen-Mansfield J, Rabinovich BA, Lipson S, et al.  The decision to execute a durable power of attorney for healthcare and preferences regarding the utilization of life sustaining treatments in nursing home patients .  Arch Intern Med . 1991;151:289-294.Crossref
Mittelman MS, Ferris SH, Shulman E, Steinberg G, Levin B.  A family intervention to delay nursing home placement of patients with Alzheimer's disease: a randomized, controlled trial .  JAMA . 1996;276:1725-1731.Crossref
Gwyther LP, Rabins PV.  Practical approaches for treating behavioral symptoms of people with mild to moderate Alzheimer's disease .  Prim Psychiatry . 1996;3:27-38.
Fitten LJ, Perryman KM, Wilkinson CJ, Little RJ, Burns MM, Pachana N.  Alzheimer and vascular dementias and driving: a prospective road and laboratory study .  JAMA . 1995;273:1360-1365.Crossref