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Vital Brain Aging Clinical Path Overview

  • Educate

  • Assess

  • The Methods

  • Diagnosis

  • Treatment













Assessment Results

Regardless of the results of the memory assessment (normal or abnormal), it is important to follow the guidelines that promote ongoing cognitive vitality for your patients.

Normal Assessment Result

If the patient does not show objective evidence of memory or cognitive impairment, and that is clinically consistent with the physician's impression, then:

  1. Reassure the patient and educate them about risk factors they should manage, and share the brochure "Risk Factors for Memory Loss." Please request this free brochure by email at or by calling at 949-764-6288.
  2. Advise the patient to use the risk factor identification tool for Alzheimer's disease and related disorders (ADRD) at the Vital Brain Aging website (www.ocbrain.org). This will make them aware of their risks, as well as how best to manage them, according to evidence-based medicine.
  3. Schedule the patient for re-assessment in 12 months to assure that they remain cognitively healthy.

Abnormal Assessment Result

If the patient shows objective evidence of memory or other cognitive impairment, then the cause of the problem should be diagnosed and treated by using one of the following two options:

Order ADRD Diagnostic Work-Up
Following the National Institute of Neurological and Communicative Diseases and Stroke/Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) diagnostic guideline for ADRD will generate an accurate diagnosis in more then 90% of cases.

For diagnostic guideline, please review:

  • ADRD Diagnostic Work-Up
  • Other Diagnostic Work-Up

Refer to an ADRD Specialist
Vital Brain Aging maintains a list of specialists who can accept referrals as needed. To obtain the list, please contact the program at:

Education and Screening Coordinator

Phone: 949-764-4579

Delivering AD Diagnosis

In recognition of the growing importance of Alzheimer's disease, the National Alzheimer's Association held four regional town hall meetings with more than 800 participants, including 300 people living with the disease. The outcome of the meetings, summarized as The 2008 Report: Voices of Alzheimer's Disease, identified diagnostic challenges and dissatisfying interactions with the medical community as key challenges to address.

Several specific insights were voiced by the meeting participants and published by the Alzheimer's Association as Principles for a Dignified Diagnosis Principles for a Dignified Diagnosis. These insights from families and patients with Alzheimer's disease provide suggestions on how to improve the diagnostic challenges and process that both patients and physicians face. These insights include:

  • Talk to me (a patient) directly, the person with dementia.
  • Tell the truth.
  • Test early.
  • Take my concerns seriously, regardless of my age.
  • Deliver the news in plain but sensitive language.
  • Coordinate with other care providers.
  • Explain the purpose of different tests and what you hope to learn.
  • Give me tools for living with this disease.
  • Work with me on a plan for healthy living.
  • Recognize that I am an individual and the way I experience this disease is unique.
  • Alzheimer's is a journey, not a destination. As a healthcare professional who touches patients' lives, you might be interested in reading the short document Principles for a Dignified Diagnosis.

ADRD Diagnostic Work-up


Routine ADRD diagnostic tests include:

A. Blood tests to exclude potentially contributing causes of cognitive impairment, including:
  • Chemistry panel: hyponatremia, hypocalcemia, hypercalcemia, hypokalemia, renal dysfunction, hepatic dysfunction, hyperglycemia, hypoglycemia, protein wasting.
  • CBC with differential: anemia, leukopenia, leukemia, thrombocytosis, thrombocytopenia, megaloblastosis, lymphocytopenia, lymphocytosis, monocytosis, acute infection.
  • Fasting lipid panel: low HDL (<45), high LDL (>100).
  • Vitamin D-1,25(OH)2, B12, folate: vitamin deficiencies.
  • Homocysteine: omocysteinemia (>14).

B. Urinalysis: proteinuria, glucosuria, ketonuria, hematuria, bacteruria.

C. Non-contrast MRI with volumetric assessment of hippocampus (CT if MRI not possible).
Radiologic interpretations consistent with a diagnosis of:

Alzheimer's Disease:

  • Relatively greater atrophy in the hippocampus, medial temporal or temporal lobe.
  • Amount of ischemic vascular disease does not explain any observed atrophy.
  • Absence of hydrocephalus, masses, or hemorrhages.
  • Subtle amounts of atrophy may be missed. Therefore, a negative CT or MRI report (e.g., normal, age-related changes, mild generalized atrophy) does not exclude Alzheimer's disease if there is objective cognitive impairment.

Cerebrovascular Etiology:

  • Extensive ischemic white matter disease.
  • Well-placed lacunar infarcts or hemorrhages in the hippocampus or thalamus.
  • Large infarct of the anterior, middle or posterior cerebral artery.
  • Medium to large cerebral hemorrhages, or residua thereof.

Traumatic Brain Injury:

  • Focal or asymmetric patterns of atrophy, especially in inferior frontal or anterior temporal lobes.
  • Small, petechial hemorrhages, especially in the white matter.
  • Diffuse axonal injury, seen as focal areas of white matter demyelination, and blood residua.

Normal Pressure Hydrocephalus:

  • Ventriculomegaly greater than the degree of cortical atrophy.
  • Periventricular white matter increases in signal intensity (transependymal edema).
  • Ballooning of the 3rd ventricle.
  • Thinning of the corpus callosum.


If the routine ADRD diagnostic tests do not identify the etiology, then there are two possibilities:

  1. The objectively established cognitive impairment is a false positive result and the patient does not have a progressive cognitive impairment.
  2. The routine ADRD diagnostic tests were not sensitive enough (a false negative result), and more specialized ADRD diagnostic testing is needed.

There are five approaches to differentiating between these two possibilities.

  1. Repeat the same cognitive test now. Look for variability in performance to identify whether the previous result was a false positive or false negative.
  2. Repeat cognitive testing with the same tests in 4 to 6 months to look for change. This will establish whether there is a progressive cause of cognitive impairment or not.
  3. Refer to a neuropsychologist for a more comprehensive battery of tests (if not already done) that can help better determine if there is evidence of a progressive cognitive impairment and can help differentiate AD from non-AD causes.
  4. Refer to an ADRD specialist.
  5. Perform more specialized diagnostic testing, which can differentiate AD from non-AD causes.

Other Diagnostic Work-Up Considerations

Tests that can be used to further confirm cognitive impairment not due to Alzheimer's disease (AD) depend upon the patient's underlying medical conditions and risks for possible:

Iatrogenic Causes
Causes Action
Radiation therapy, chemotherapy, anticonvulsants, anticholinergics, antipsychotics, and chronic abuse or dependence upon benzodiazepines, tranquilizers, anxiolytics or sedatives. Withdrawal, reduction or substitution of the potentially offending medication.

Organ and Systemic Disorders
Disorders Action
Neurotoxins:
Lead, mercury, carbon monoxide, organophosphate insecticides, toluene, industrial solvents.
Refer to rheumatology or immunology.
Immunologic:
Systemic lupus, temporal arteritis, cerebral arteritis.
Serum protein- and immuno-electrophoresis, specialized studies for cerebral vasculitis and immunodeficiency syndromes.
Refer to rheumatology or immunology.
Severe Pain Syndromes: MR of the spine or other affected body part, EMG/NCV studies. Refer to pain specialty.
Metabolic Syndrome:
The US National Cholesterol Education Program Adult Treatment Panel III (2001) requires at least three of the following:

Central Obesity:
Waist circumference:
>= 102 cm or 40 inches (male),
>= 88 cm or 36 inches (female) or
body mass index > 30 kg/m2.

Fasting Lipid Panel:
Triglycerides >= 150 mg/dl (>= 1.7 mmol/L).
HDL-C < 40 mg/dL (male), < 50 mg/dL (female).
Blood Pressure >= 130/85 mm Hg.

Fasting plasma glucose >= 6.1 mmol/L (110 mg/dl).
Refer to endocrinology, internal medicine, diabetology.
Diabetes or Pre-diabetes: Fasting glucose, HgbA1c. Refer to diabetology, endocrinology.
Thyroid Disorders: Hypothyroidism, hyperthyroidism. ???
Cerebrovascular disease:
Small and large strokes, subdural, subarachnoid, cerebral, and intraventricular hemorrhages.

Orthostatic blood pressures, carotid/transcranial Doppler, MR angiography, sedimentation rate, PT/PTT, coagulopathy studies.
Refer to stroke neurology.
Cerebrovascular disease:
(Coronary artery disease, Arrhythmia, Valvular Disease, Congestive Heart Disease, Cardiomyopathy): CRP, ECG, Cardiac Doppler, Holter monitor and other appropriate cardiac studies.
Refer to cardiology.
Sleep Disorders (Sleep Apnea, Myoclonus, REM Behavior Disorder, Restless Legs) Refer to sleep specialist.
Pulmonary Disease (COPD, restrictive lung disease, other hypoxic disorders) Refer to internal medicine or pulmonology.
Kidney Disease: GFR, urinalysis Refer to nephrology.
Liver Disease: Liver enzymes, hepatic encephalopathy ???

Disorders Affecting The Central Nervous System
Causes Action
Depression, Anxiety, Obsessive Compulsive Disorder: appropriate history or standardized scale evaluation. Refer to psychiatry.
Other Psychiatric Disorders. Refer to psychiatry.
Parkinson's Disease:
Movement disorder followed by executive dysfunction, visual-spatial deficits and memory loss at least several years later.
Refer to neurology or epileptology.
Lewy Body Disease:
Marked fluctuation in level of confusion, loss of balance, difficulty walking, REM behavior disorder, visual hallucinations, visual problems, executive dysfunction, aprexia.
Refer to neurology or epileptology.
Frontal Temporal Lobe Disease:
Usually age of onset is 50-60 years old. Primarily affects frontal and temporal lobes. Loss of language, apraxia, personality changes, disinhibition or other behavioral abnormalities, and flat or inappropriate affect are early features.
Refer to neurology or epileptology.
Traumatic Brain Injury:
Can be progressive if multiple head injuries or very severe single head injury with loss of consciousness.
Epilepsy: EEG studies.
Refer to neurology or epileptology.
Epilepsy:
EEG studies.
Refer to neurology or epileptology.
CNS Infection (HIV, Cryptococcus, cysticercosis, neurosyphyllis) Refer to infectious diseases.
CNS Demyelination (Multiple Sclerosis, Kufs disease, Adrenoleukodystrophy, Metachromatic leukodystrophy, other storage diseases) Refer to neurology.

Delivering AD Diagnosis

In recognition of the changing landscape of Alzheimer's disease, the Alzheimer's Association held four regional town hall meetings with more than 800 participants, including 300 people living with the disease. The outcome of the meetings, summarized as The 2008 Report: Voices of Alzheimer's Disease, identified diagnostic challenges and dissatisfying interactions with the medical community as key challenges to address.

Several specific insights were voiced by the meeting participants and published by the Alzheimer's Association as Principles for a Dignified Diagnosis. These insights from families and patients with Alzheimer's disease provide suggestions on how to improve communication between physicians and patients facing a diagnosis. These insights include:

  • Talk to me (the patient) directly.
  • Tell the truth.
  • Test early.
  • Take my concerns seriously, regardless of my age.
  • Deliver the news in plain but sensitive language.
  • Coordinate with other care providers.
  • Explain the purpose of different tests and what you hope to learn.
  • Give me tools for living with this disease.
  • Work with me on a plan for healthy living.
  • Recognize that I am an individual and the way I experience this disease is unique.
  • Alzheimer's is a journey, not a destination.

As a healthcare professional who touches patient's lives, you might be interested in reading the short document Principles for a Dignified Diagnosis.