Guidelines provided for brain amyloid imaging in people with Alzheimer’s

The first criteria for the appropriate use of positron emission tomography (PET) imaging technology to aid in the diagnosis of people with suspected Alzheimer's disease were released Monday by the Society of Nuclear Medicine and Molecular Imaging (SNMMI) and the Alzheimer's Association.

While elevated beta amyloid plaques are one of the defining pathologic features of Alzheimer's, many elderly people with normal cognition also have elevated levels of these plaques, as do people with conditions other than Alzheimer's dementia. Therefore, the potential clinical use of amyloid PET requires careful consideration so that its proper role may be identified, suggests the two groups.

To develop the new criteria, the Alzheimer's Association and SNMMI assembled an Amyloid Imaging Taskforce (AIT) consisting of dementia and imaging experts to review the scientific literature and develop consensus recommendations for the clinical use of the new technology.

The AIT concluded that amyloid imaging could potentially be helpful in the diagnosis of people with cognitive impairment when considered along with other clinical information, and when performed according to standardized protocols by trained staff. In addition, they emphasized that the decision whether or not to order amyloid imaging should be made only after a comprehensive evaluation by a physician experienced in the assessment and diagnosis of cognitive impairment and dementia, and only if the presence or absence of amyloid would increase certainty in the diagnosis and alter the treatment plan.

According to the AIT, appropriate candidates for amyloid PET imaging include:

• Those who complain of persistent or progressive unexplained memory problems or confusion and who demonstrate impairments using standard tests of cognition and memory.
• Individuals meeting tests for possible Alzheimer's, but who are unusual in their clinical presentation.
• Individuals with progressive dementia and atypically early age of onset (before age 65).

Inappropriate candidates for amyloid PET imaging include:

• Those who are age 65 or older and meet standard definitions and tests for Alzheimer's, since a positive PET scan would provide little added value.
• Asymptomatic people or those with a cognitive complaint but no clinical confirmation of impairment.

Amyloid PET imaging is also inappropriate:

• As a means of determining the severity of dementia.
• When requested solely based on a family history of dementia or presence of other risk factors for Alzheimer's, such as the ApoE-e4 gene.
• As a substitute for genetic testing for mutations that cause Alzheimer's.
• For non-medical reasons, such as insurance, legal or employment decisions.

"As amyloid imaging becomes more prevalent in clinical settings, medical professionals must understand how to appropriately utilize the test," said Frederic H. Fahey, D.Sc., SNMMI president, in a statement. "Neurology and dementia experts should order the test only when appropriately indicated, and nuclear medicine and molecular imaging professionals must ensure they have been adequately trained to interpret the results of the scan. Working together, we hope that the information garnered from amyloid PET imaging will aid in diagnosis and play a pivotal role in the development of new treatments for Alzheimer's."

The taskforce acknowledged that the healthcare provider makes the ultimate judgment regarding the care of each patient. The AIT sought to assist this process and identified the following general sequence of events for the use of amyloid PET according to the new criteria:

• Evaluation by a dementia expert to assess the need for diagnostic testing, possibly to include amyloid PET if the AUC are met.
• Referral to a qualified provider of amyloid PET services.
• Performance, interpretation and reporting of the amyloid PET scan according to established standards.
• Incorporation of the PET result into the clinical assessment process.
• Disclosure of the PET result by the clinician to the patient and caregivers, along with discussion of the result and its management consequences.

Although identifying potential benefits, the AIT concluded that amyloid PET results will not constitute and is not equivalent to a clinical diagnosis of Alzheimer's disease dementia. They said that imaging is only one tool among many that clinicians should use judiciously to manage patients, and that amyloid PET imaging does not substitute for a careful history and examination.

The criteria were published online today as an article "in press" by Alzheimer's & Dementia: The Journal of the Alzheimer's Association.

Patricia Sheehan

Patricia Sheehan was Editor in Chief of I Advance Senior Care / Long Term Living from 2010-2013. She is now manager, communications at Nestlé USA.