Advances in Alzheimer s diagnosis; implications for clinical practice. Wiesje M. van der Flier Alzheimer Europe Conference Berlin, 4 October 2017

Transcription

1 Advances in Alzheimer s diagnosis; implications for clinical practice Wiesje M. van der Flier Alzheimer Europe Conference Berlin, 4 October 2017

2 Grand Challenge Alzheimer s disease 47 million worldwide High costs Caregiver burden Grand challenge: Find treatments Arrange care Timely + accurate diagnosis essential to allow choices, arrange care, choose medication, prevent crises later in disease process

3 Improved diagnosis Novel diagnostic tests amongst largest research succes MRI Cerebral atrophy Hippocampal atrophy CSF Amyloid beta + tau PET Amyloid PET Alzheimer pathology in vivo (accurate diagnosis) Alzheimer pathology before dementia (MCI) # MCI in memory clinics

4 Patient journey Memory complaints/ worry General Practitioner refers to memory clinic How to decide which test? Best application of test How to combine different tests? What about the patient? What does test result mean for my patient? How to explain?

5 ABIDE Alzheimer biomarkers in daily practice Goal: translate available knowledge about MRI, CSF, PET diagnostic tests to daily practice Public-private consortium Special focus on MCI Involvement local professionals Involvement patients + caregivers

6 ABIDE: goals Before diagnostic tests Optimal use of tests After diagnostic tests Involve patients Involve professionals

7 PredictND Goal: Develop computer tools for clinical diagnosis of neurodegenerative diseases Public-private consortium Different types of dementia Combine clinical + technical knowledge Involvement Alzheimer Europe

8 1. What does the patient want? Involve patients

9 Shared decision making Doctors and patients / carers work together to decide which care plan best fits with individual wishes and needs, when there is more than 1 reasonable choice. Doctor: expert on disease. Patient: expert on individual disease process and preferences. 4. Decide together 3. Explore preferences 1. Create choice awareness 2. Inform

10 What about dementia diagnosis? Diagnostic tests or not? And if yes how many tests? How should result be communicated? We asked patients/ carers: They felt involved in decision to initiate diagnostic testing, But not in choice of specific tests They wanted more information about results of specific tests And what the results mean for their personal lives (i.e. prognosis)

11 and what does the doctor think? We asked neurologists and geriatricians: Clinicians feel they involve patients in decision making But this refers mostly to providing information (step 2) And not other steps in shared decision making. Large practice variation amongst clinicians Room for improvement; particularly communication about choices and results. Next step: audiotape: what is actually happening in consulting room?

12 2. How to combine all results?

13 Dementia diagnosis: many different tests Challenge as a clinician How to weigh and combine data? When results are conflicting Incomplete Mixed disease

14 Could a computer tool help? Mattila 2012, Antilla 2013, Rhodius- Meester 2016 PredictND tool Tool to aid diagnostic decision making Trained on large data set of patients + controls Visualizes how data of one individual compare to patients or controls

15 PredictND-tool: fingerprint Combines and visualises all data of 1 patient Size of box: xxxx = important for diagnosis = not so important Colour of box: xx = towards 0 (control) xx = towards 1 (Alzheimer)

16 PredictND-tool: fingerprint Combines and visualises all data of 1 patient Size of box: xxxx = important for diagnosis = not so important Computer tool provides overview of data; facilitates diagnostic process. Next step: can we use this approach to distinguish different types of dementia?

17 Individual risk prediction? If not dementia but MCI, than diagnosis becomes prognosis..

18 MRI and CSF in MCI: what do the results mean? Amsterdam Dementia Cohort: 525 MCI MRI: medial temporal lobe atrophy + whole brain atrophy CSF : Amyloid beta + tau Taking into account age, gender, MMSE

19 Patient characteristics Total n=525 MCI stable n=324 MCI progressors n=201 Age 67±8 66±8 69±8 Seks (F) 210(40%) 118(36%) 92(47%) education 5±1 5±1 5±1 MMSE 27±2 27±2 26±3 Follow-up 2.4±1 2.3±2 2.3±1 CSF biomarkers MRI On group level, we know: age ~progression cognition ~progression atrophy ~progression CSF abeta ~progression CSF tau ~progression Abeta 674± ± ±131 Tau 477± ± ±341 Hippocampus volume 6.6±1 6.9±1 6.2±1 But what to tell the next patient who comes into the office? NWBV 1417± ± ±73

20 Patient characteristics Total n=525 MCI stable n=324 MCI progressors n=201 Age 67±8 66±8 69±8 Seks (F) 210(40%) 118(36%) 92(47%) education 5±1 5±1 5±1 MMSE 27±2 27±2 26±3 Follow-up 2.4±1 2.3±2 2.3±1 CSF biomarkers MRI Predictive modelling Abeta 674± ± ±131 Tau 477± ± ±341 Hippocampus volume 6.6±1 6.9±1 6.2±1 But what to tell the next patient who comes into the office? NWBV 1417± ± ±73 HR= Exp( B*X) Exp( B*X)

21 Prognosis Case: - Female 60 year - MMSE=24 Risk 1 year 16% 3 year 58% MRI: moderate atrophy CSF: normal Severe atrophy Mild atrophy No atrophy

22 Prognosis Case: - Female 60 year - MMSE=24 Risk 1 year 16% 3 year 58% MRI: moderate atrophy CSF: normal Risk 1 year 2% 3 year 15% Risk model provides individualized prognosis. Especially useful to reassure if markers normal. Next step: develop tool to support communication Severe atrophy Mild atrophy No atrophy

23 ADappt: to support communication about diagnosis Model ingevoerd in app toepasbaar in dagelijkse praktijk 1) decide together

24 ADappt: to support communication about diagnosis Model ingevoerd in app toepasbaar in dagelijkse praktijk 1) decide together 2) calculate risk

25 ADappt: to support communication about diagnosis Model ingevoerd in app toepasbaar in dagelijkse praktijk 1) decide together 2) calculate risk 3) explain result

26 Conclusion Improved diagnosis among the largest succeses of dementia research But: we need to bridge the gap between science and clinical practice Room for shared decision making: listen to the patient! Whether or not to test and how specific tests? Manage expectations Improve disclosure of results E-tools can help To integrate available data To interpret data for individual patient To support communication with patient Great relevance: Today, because diagnosis helps to initiate + arrange proper care Tomorrow when curative therapy becomes available

27 And all ABIDE and predictnd projectpartners: