Monday, February 6, 2012

Time to revise your Alzheimer brain autopsy template

Time to put the NIA-Reagan criteria for the neuropathologic diagnosis of Alzheimer's behind you and revise your autopsy reports to reflect the consortium report by the National Institute on Aging and Alzheimer's Association (the NIA-AA criteria). Neuropathologist Tom Montine, MD, PhD headed up the effort to revise the 1997 criteria. According to Medscape News, Montine said there were three main points to be made regarding the new criteria:
Dr. Thomas Montine
'"The first is that it's no longer necessary that someone carry a clinical diagnosis of dementia in order to make a pathological diagnosis of [AD]. We have separated those 2 entities because we now understand that there is a preclinical stage of the disease. That's the major philosophical point... The second point is more on the technical side," he said. The guidelines recommend the "ABC" staging protocol for the neuropathologic changes of AD, based on 3 morphologic characteristics of the disease: A is for amyloid, B is for Braak neurofibrillary tangle staging protocol, and C is for the Consortium to Establish a Registry for AD neuritic plaque scoring system. For all cases, regardless of clinical history, the guidelines state that reporting should follow the format of these examples: 'Alzheimer Disease Neuropathologic Changes: A1, B0, C0' or 'Alzheimer Disease Neuropathologic Changes: A3, B3, C3.' The ABC score is then transformed into 1 of 4 levels of AD neuropathologic change: not, low, intermediate, or high." The third point deals with comorbidity. Although AD is the most common cause of dementia and can exist in a "pure" form, it commonly coexists with pathologic changes of other diseases that can also contribute to cognitive impairment, the document notes. The most common comorbidities are Lewy body disease, vascular brain injury, and hippocampal sclerosis, as well as other neuropathologic changes such as argyrophilic grain disease and TDP-43 inclusions. The new recommendations more explicitly define the manner in which these comorbidities are to be evaluated.

Here's the reference you can put at the end of your new reports:
Hyman BT, Phelps CH, Beach TG, et al. National Institute on Aging - Alzheimer's Association guidelines for the neuropathologic assessment of Alzheimer's disease. Alzheimer's & Dementia: The Journal of the Alzheimer's Association. Volume 8: Issue 1. Pages 1-13, January 2012.


3 comments:

Theresa Matthews said...

Does this mean autopsy levels are going to increase to a certain level? Is the primary focus now looking and finding neuropathology changes at the preclinical stages verses confirming the advanced, final dementia diagnosis where there remains great controversy. Will certain geographical areas be targeted? The $5.3 million in federal funding for prion disease research has been zeroed after more than a decade while AD researchers expect a generous $80 million bolus. The most frequent misdiagnosis of CJD is AD. You have allowed me great lattitude to speak about these challenges and implications on your site. Some of the public health concerns surrounding the other neurodegenerative disorders may be more akin to CJD if they are ultimately reclassified as prion diseases. The prion hypothesis seems to have been accepted as fact when some puzzle pieces remain missing. All of this is difficult for that small but engaged group of us who have suffered greatly at the hands of medicine since there was disease transmission to Daisy. Who is absorbing this cost and funding for autopsy in the search for early brain changes after death? Are these revised plans part of the AD roadmap? Is this a good sign that neurology is finally moving to publicly address and answer the questions that have been whispered since the late 60's instead of openly discussed? Are AD roadmappers now representing all the dementias? Will this move everyone forward or doctors forward and patients further behind subject to even more abuse? It would be great if Mayo's Dr. Ron Peterson would consider responding to these questions especially since those of us who have take the time and resources to educate the President paved the pathway for his changing roadmap.

Agent86 said...

Brain,

Is that an English translation of National Institute on Aging Alzheimer's Association guidelines for the neuropathologic assessment of Alzheimer's disease: a practical approach. Acta Neuropathol. 2012 Jan;123(1):1-11?

Or is it still the same esperanto (or whatever)? I know I'm not the sharpest took in the shed, but befuddled doesn't begin to describe my metal status each time I try to read this report. My mom used to tell me that a camel is just a horse put together by a committee. I fear that she may be right. No offense to the committee members, for whom I have the greatest respect, but perhaps a ghost writer might have been worth the money in this case. As yet another aside, the absence of Kurt Jellinger from the otherwise comprehensive author list is interesting.

Thanks, as always, for your timely and informative posts.

A86

Brian E. Moore, MD said...

To Agent86: The paper you refer to I think can be considered a companion article to the one I cited. In fact, the Acta Neuropathologica article is probably a better reference for us neuropathologists since it is written for the neuropathologist as the intended audience.

To Theresa Matthews: I would say that the major research effort now is to look at the pre-clinical and early clinical stage of the various dementias with the aim of reversing or slowing the progression of the neurodegenerative disease. The new neuropathological guidelines will not significantly impact that trend. I don't have the expertise to answer your specific questions; but I invite other readers to weigh in on the issues you raise.