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Psych TopicsOld age psychiatry — Alzheimer disease

Psych · Old age psychiatry — Alzheimer disease

Alzheimer disease

Also known as Alzheimer's disease · AD dementia · Major NCD due to Alzheimer disease · Dementia of Alzheimer type · Probable Alzheimer disease · Senile dementia of the Alzheimer type

Exam-exhaustive fellowship reference on Alzheimer disease — NIA-AA 2011 probable/possible clinical criteria; continuum from preclinical and MCI-due-to-AD to dementia; careful ATN biomarker research framing; amyloid/tau/cholinergic pathophysiology; assessment with collateral and cognitive screens; AChEI and memantine doses, titration, monitoring and DOMINO-AD; BPSD link with non-drug first line and antipsychotic mortality caution; capacity, care planning, and disposition. FRANZCP-primary, globally tagged.

high20 referencesUpdated 26 July 202617 min readVerification in progress

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FRANZCPMRCPsychABPNMD-DNBNEET-SS

Red flags

  • Acute fluctuating confusion on known Alzheimer disease — treat as delirium until proven otherwise; search infection, pain, constipation, retention, drugs, metabolic causes
  • Bradycardia, syncope, or significant conduction disease before or during cholinesterase inhibitors — ECG review, hold drug, seek medical advice
  • Severe aggression or psychosis with risk of harm — safety and medical exclusion first; antipsychotics only time-limited last line with explicit mortality counselling
  • Rapidly progressive course over weeks — widen differential (CJD, autoimmune, space-occupying, toxic-metabolic); do not assume typical AD
  • Unsafe driving, wandering, fire risk, or financial exploitation — capacity and risk management, not a cognitive score alone
  • Young-onset or strong family history — specialist pathway; do not routine-test genes without counselling
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Your progress

Saved on this device.

Practise this topic10 MCQs with explanations

Target exams

FRANZCPMRCPsychABPNMD-DNBNEET-SS

Red flags

  • Acute fluctuating confusion on known Alzheimer disease — treat as delirium until proven otherwise; search infection, pain, constipation, retention, drugs, metabolic causes
  • Bradycardia, syncope, or significant conduction disease before or during cholinesterase inhibitors — ECG review, hold drug, seek medical advice
  • Severe aggression or psychosis with risk of harm — safety and medical exclusion first; antipsychotics only time-limited last line with explicit mortality counselling
  • Rapidly progressive course over weeks — widen differential (CJD, autoimmune, space-occupying, toxic-metabolic); do not assume typical AD
  • Unsafe driving, wandering, fire risk, or financial exploitation — capacity and risk management, not a cognitive score alone
  • Young-onset or strong family history — specialist pathway; do not routine-test genes without counselling
The one-line answer

Alzheimer disease is an insidious amnestic dementia you diagnose clinically — McKhann's four boxes, not a biomarker report — sitting on a continuum that runs preclinical, then MCI due to AD, then dementia. Exclude delirium at every acute change, build care around the person and the carer, prescribe a named enhancer at a named dose with a named review date, and keep antipsychotics last, short and counselled.[1][2][4][13][16]

Meet the patient

A 74-year-old retired schoolteacher is brought in by her son. For two years she has asked the same three questions on every phone call. She still cooks, but the gas has been left on twice, and last month she paid the same electricity bill four times.[1]

Her MMSE is 27 out of 30, and on that number alone she has twice been reassured that this is normal ageing. Nobody has asked the son what she used to be able to do, and nobody has run a screen that taxes executive and visuospatial function.[8][9]

Two exam questions are now live. Is 27 out of 30 reassuring? And what exactly goes in the letter — and what do you start? Everything below answers both at consultant depth.[1][8][9]

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References20ShowHide
  1. [1]McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of dementia due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease Alzheimers Dement, 2011.PMID 21514250
  2. [2]Albert MS, DeKosky ST, Dickson D, et al. The diagnosis of mild cognitive impairment due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease Alzheimers Dement, 2011.PMID 21514249
  3. [3]Sperling RA, Aisen PS, Beckett LA, et al. Toward defining the preclinical stages of Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease Alzheimers Dement, 2011.PMID 21514248
  4. [4]Jack CR Jr, Bennett DA, Blennow K, et al. NIA-AA Research Framework: Toward a biological definition of Alzheimer's disease Alzheimers Dement, 2018.PMID 29653606
  5. [5]Jack CR Jr, Andrews JS, Beach TG, et al. Revised criteria for diagnosis and staging of Alzheimer's disease: Alzheimer's Association Workgroup Alzheimers Dement, 2024.PMID 38934362
  6. [6]Dubois B, Feldman HH, Jacova C, et al. Research criteria for the diagnosis of Alzheimer's disease: revising the NINCDS-ADRDA criteria Lancet Neurol, 2007.PMID 17616482
  7. [7]Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission Lancet, 2020.PMID 32738937
  8. [8]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.PMID 1202204
  9. [9]Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment J Am Geriatr Soc, 2005.PMID 15817019
  10. [10]Cummings JL, Mega M, Gray K, et al. The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia Neurology, 1994.PMID 7991117
  11. [11]Reisberg B, Doody R, Stöffler A, et al. Memantine in moderate-to-severe Alzheimer's disease N Engl J Med, 2003.PMID 12672860
  12. [12]Tariot PN, Farlow MR, Grossberg GT, et al. Memantine treatment in patients with moderate to severe Alzheimer disease already receiving donepezil: a randomized controlled trial JAMA, 2004.PMID 14734594
  13. [13]Howard R, McShane R, Lindesay J, et al. Donepezil and memantine for moderate-to-severe Alzheimer's disease N Engl J Med, 2012.PMID 22397651
  14. [14]Birks JS, Harvey RJ Donepezil for dementia due to Alzheimer's disease Cochrane Database Syst Rev, 2018.PMID 29923184
  15. [15]McShane R, Westby MJ, Roberts E, et al. Memantine for dementia Cochrane Database Syst Rev, 2019.PMID 30891742
  16. [16]Kales HC, Gitlin LN, Lyketsos CG Assessment and management of behavioral and psychological symptoms of dementia BMJ, 2015.PMID 25731881
  17. [17]Schneider LS, Dagerman KS, Insel P Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials JAMA, 2005.PMID 16234500
  18. [18]Schneider LS, Tariot PN, Dagerman KS, et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer's disease N Engl J Med, 2006.PMID 17035647
  19. [19]Appelbaum PS, Grisso T Assessing patients' capacities to consent to treatment N Engl J Med, 1988.PMID 3200278
  20. [20]Rabins PV, Blacker D, Rovner BW, et al. American Psychiatric Association practice guideline for the treatment of patients with Alzheimer's disease and other dementias. Second edition Am J Psychiatry, 2007.PMID 18340692

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