Good point - which is why I believe the approval will be based on sleep, with ERP/EEG taken as suporting biomarker evidence.
As I stated last week, there is also a need for inexpensive early stage diagnostics so that is why the Aussies will be researching ERP/EEG intensively for roll out into the general population once 2-73 is approved.
The National Health and Medical Research Council (NHMRC) Partnership Centre for Dealing with Cognitive and Related Functional Decline in Older People was established in 2013 with funding support from the NHMRC, HammondCare, Alzheimer’s Australia, Brightwater Care Group and Helping Hand Aged Care. One of the activities of the Partnership Centre was to develop Australian clinical practice guidelines for dementia. The guidelines were adapted from existing guidelines5 using ADAPTE methodology6 to reflect the Australian context and the latest evidence. A multidisciplinary guideline committee, which included consumers, was appointed to refine the scope of the guidelines and form recommendations based on systematic reviews of the evidence.
The purpose of the guidelines is to provide recommendations for an agreed standard of practice for the diagnosis and management of people with dementia in Australia. The guidelines address care of people with dementia in community, residential care and hospital settings and are relevant to medical practitioners, nurses, aged care workers and allied health professionals. They are also useful for researchers, educators, policy makers and decision makers.
Main recommendations The guidelines provide 109 recommendations, categorised as evidence-based recommendations (formulated after a systematic review of the evidence), consensus-based recommendations (formed where a systematic review has failed to identify sufficient studies to inform a recommendation) and practice points (based on expert opinion). Key recommendations prioritised by the committee for implementation are presented in the Box.
Initial screening and assessment
The purpose of initial screening is to identify people who may benefit from more intense assessment—it has the dual purpose of identifying potential need and also minimising the potential drain on resources caused by unnecessary intense assessment processes. Screening is different from case-finding as it refers to action to determine the presence of likely or possible disease in a person without problems or symptoms pointing to the possibility of dementia (Bridges-Webb & Wolk 2003:31). An assessment of dementia not only aims to determine the condition causing the symptoms (whether to rule out dementia, or determine which disease is causing dementia), but also to assess the needs of the person with dementia and their family and carers.
Barriers to early diagnosis include a lack of routine screening for dementia and a lack of access to specialty consultative services (Shores et al. 2004). However, many experts are reluctant to advocate a population-based screening program, arguing that there is currently insufficient evidence to justify the resources that would be required to implement routine screening for dementia of people who do not display symptoms using existing standardised assessment tools (Bridges-Webb & Wolk 2003:31). Further arguments against the implementation of a screening program are that there does not currently exist a screening test that can reliably detect dementia in a cost-effective manner before patients develop noticeable symptoms, and secondly that, even if such a test did exist, there is no treatment available that can cure dementia if applied in the pre-symptomatic phase (refer to Box 2.1 for characteristics of an effective population-based screening program).
Thus, initial screening and assessment for dementia is generally initiated when a patient or his/her family expresses concern about symptoms, or when the clinician notices changes or signs which may be associated with a dementing illness in the course of their contact with the patient (Bridges-Webb & Wolk 2003:31). This requires that clinicians, in particular general practitioners (GPs), are aware of signs and symptoms that may be associated with dementia and are open to identifying and discussing these with patients and their families if and when they become apparent.
Assessment and screening instruments
A variety of assessment tools exist which may be helpful in screening for, diagnosing and/or monitoring dementia. In the context of dementia, assessment tools are employed for two basic purposes:
1. to screen people for the likely presence/absence of cognitive impairment which may be indicative of dementia
2. for in-depth assessment for the purposes of formal diagnosis, care planning, and monitoring of disease progression or treatment efficacy.
As dementia is a syndrome with several characteristic features (not all of which may be present in any one case), most assessment instruments include separate components, subscales or domains. Few tests are capable of discriminating across all types and levels of dementia. For example, tests that are capable of identifying mild cognitive impairment may not be suitable for differentiating among more advanced stages of dementia and vice versa. Thus, assessment tools are often best used in combination and in the context of other forms of assessment such as clinical interview, informant interview and biological testing (McDowell & Newell 1996:289; Meade & Bowden 2005). A combination of screening tests may be used to increase the rate of diagnosis for those who have dementia, and reduce the likelihood of falsely diagnosing dementia (Flicker et al. 1997, cited in Black et al. 2001), and clinicians are generally encouraged to look for other evidence of symptoms or functional change in everyday life (Meade & Bowden 2005).
Diagnosis cannot be made purely on the basis of screening. People who screen positive for cognitive impairment must undergo further clinical evaluation to confirm or reject a differential diagnosis of dementia (Black et al. 2001). Thus, though GPs may often be the first port of call for people who are worried about their own or a loved one’s cognitive functioning, the final diagnosis of dementia is usually made by a neurologist, geriatrician or psychogeriatrician (Wilkinson et al. 2004, cited in Brodaty et al. 2006). Initial assessment/screening tools must achieve a balance between comprehensiveness and clinical utility. Many standardised tools were initially intended to be a component of a battery of tests in the full assessment and diagnosis of dementia. In applying such items and subscales to initial assessment and screening rather than to diagnosis, a balance must be found between minimising test length and complexity, evaluating total cognitive function and maintaining test accuracy (Boustani et al. 2003). In their entirety, these instruments have more in common with diagnostic protocols (discussed below) than screening instruments.
AI
