Prediction and Early Detection of Alzheimer's Dementia: Professional Disclosure Practices and Ethical Attitudes

Visual Functions Are Associated with Biomarker Changes in Alzheimer's Disease

Background

While various biomarkers of Alzheimer's disease (AD) have been associated with general cognitive function, their association to visual-perceptive function across the AD spectrum warrant more attention due to its significant impact on quality of life. Thus, this study explores how AD biomarkers are associated with decline in this cognitive domain.

Objective

To explore associations between various fluid and imaging biomarkers and visual-based cognitive assessments in participants across the AD spectrum.

Methods

Data from participants (N = 1,460) in the Alzheimer's Disease Neuroimaging Initiative were analyzed, including fluid and imaging biomarkers. Along with the Mini-Mental State Examination (MMSE), three specific visual-based cognitive tests were investigated: Trail Making Test (TMT) A and TMT B, and the Boston Naming Test (BNT). Locally estimated scatterplot smoothing curves and Pearson correlation coefficients were used to examine associations.

Results

MMSE showed the strongest correlations with most biomarkers, followed by TMT-B. The p-tau181/Aβ1-42 ratio, along with the volume of the hippocampus and entorhinal cortex, had the strongest associations among the biomarkers.

Conclusions

Several biomarkers are associated with visual processing across the disease spectrum, emphasizing their potential in assessing disease severity and contributing to progression models of visual function and cognition.

Impact of sharing Alzheimer's disease biomarkers with individuals without dementia: A systematic review and meta-analysis of empirical data

INTRODUCTION

We conducted a systematic literature review and meta-analysis of empirical evidence on expected and experienced implications of sharing Alzheimer's disease (AD) biomarker results with individuals without dementia.

METHODS

PubMed, Embase, APA PsycInfo, and Web of Science Core Collection were searched according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results from included studies were synthesized, and quantitative data on psychosocial impact were meta-analyzed using a random-effects model.

RESULTS

We included 35 publications. Most personal stakeholders expressed interest in biomarker assessment. Learning negative biomarker results led to relief and sometimes frustration, while positive biomarkers induced anxiety but also clarity. Meta-analysis of five studies including 2012 participants (elevated amyloid = 1324 [66%], asymptomatic = 1855 [92%]) showed short-term psychological impact was not significant (random-effect estimate = 0.10, standard error = 0.23, P = 0.65). Most professional stakeholders valued biomarker testing, although attitudes and practices varied considerably.

DISCUSSION

Interest in AD biomarker testing was high and sharing their results did not cause psychological harm.

HIGHLIGHTS

Most personal stakeholders expressed interest in Alzheimer's disease biomarker assessment. Personal motivations included gaining insight, improving lifestyle, or preparing for the future. There was no short-term psychological impact of sharing biomarker status, implying it can be safe. Most professional stakeholders valued biomarker testing, believing the benefits outweigh the risk. Harmonized guidelines on biomarker testing and sharing results are required.

Burnout among neurologists caring for patients with cognitive disorders in Spain

BACKGROUND

Physician burnout has a negative impact on both physicians and patients. Limited information is available on professional burnout of neurologists. The aim of this study was to assess the presence of burnout among neurologists caring for patients with cognitive disorders and to identify associated factors.

METHODS

An online, cross-sectional study was conducted in collaboration with the Spanish Society of Neurology. Neurologists involved in the care of patients with cognitive disorders answered a survey composed of demographic characteristics, professional background, clinical practice setting, and behavioral factors. Burnout was assessed using a single-item measure from the Physician Work Life Study. A multivariate logistic regression analysis was conducted to determine the association between neurologists' characteristics and burnout.

RESULTS

A total of 188 neurologists answered the survey. The mean age (standard deviation-SD) was 40.6 (11.3) years and 52.7% were male. The majority of participants were general neurologists (60.6%) who attending a median of 20 patients with cognitive disorders (interquartile range 10.0-30.0) weekly. Thirty-nine participants (20.7%) reported burnout. Participants with burnout had greater experiences of regret associated with past clinical decisions than their counterparts (mean Regret Intensity Scale scores of 2.3 and 1.9, respectively; p = 0.003). Burnout was associated with non-academic practice (OR = 3.02 [95% CI 1.18, 7.73], p = 0.021) and care-related regret (OR = 2.53 [95% CI 1.13, 5.64], p = 0.023) in the multivariate analysis after adjustment for confounders.

CONCLUSIONS

Professional burnout was a common phenomenon among neurologists managing cognitive disorders. Identifying physician burnout and its associated factors may be critical for implementing preventive intervention strategies.

Ethical issues when using digital biomarkers and artificial intelligence for the early detection of dementia

Dementia poses a growing challenge for health services but remains stigmatized and under-recognized. Digital technologies to aid the earlier detection of dementia are approaching market. These include traditional cognitive screening tools presented on mobile devices, smartphone native applications, passive data collection from wearable, in-home and in-car sensors, as well as machine learning techniques applied to clinic and imaging data. It has been suggested that earlier detection and diagnosis may help patients plan for their future, achieve a better quality of life, and access clinical trials and possible future disease modifying treatments. In this review, we explore whether digital tools for the early detection of dementia can or should be deployed, by assessing them against the principles of ethical screening programs. We conclude that while the importance of dementia as a health problem is unquestionable, significant challenges remain. There is no available treatment which improves the prognosis of diagnosed disease. Progression from early-stage disease to dementia is neither given nor currently predictable. Available technologies are generally not both minimally invasive and highly accurate. Digital deployment risks exacerbating health inequalities due to biased training data and inequity in digital access. Finally, the acceptability of early dementia detection is not established, and resources would be needed to ensure follow-up and support for those flagged by any new system. We conclude that early dementia detection deployed at scale via digital technologies does not meet standards for a screening program and we offer recommendations for moving toward an ethical mode of implementation. This article is categorized under:Application Areas > Health CareCommercial, Legal, and Ethical Issues > Ethical ConsiderationsTechnologies > Artificial Intelligence.

Attitudes and Viewpoints Toward Prevention Trials in Alzheimer’s Disease

Abstract: Alzheimer’s disease (AD) prevention studies use biomarkers to determine risk in asymptomatic study participants. This involves multifaceted implications. Determinants regarding participation in these trials are therefore of particular relevance. We used semistructured individual interviews to interview uninvolved persons ( n = 10), relatives of Alzheimer’s patients ( n = 10), and patients with mild cognitive impairment ( n = 5) and analyzed the interviews using qualitative content analysis according to Mayring. We discovered various factors to be positive motivations for participation; the most significant inhibiting factor was concern about negative psychological effects. These motivations and concerns should be specifically addressed in the study design of AD prevention trials. The fears and concerns expressed highlight the importance of a good methodological and ethical framework to increase participant acceptance.

Ethical Aspects of Prodromal Synucleinopathy Prognostic Counseling

Alpha-synucleinopathies can be identified in their prodromal phase, raising several ethical issues. In this review, we first provide definitions of prodromal α-synucleinopathies and discuss the importance of distinguishing between prodromes and risk factors. Next, we discuss the implications of a diagnosis of prodromal α-synucleinopathy and considerations regarding prognostic counseling in both clinical and research settings. We review available data on patient preferences regarding disclosure as well as providers' perspectives. We examine the pros and cons of disclosing a diagnosis of prodromal α-synucleinopathy, taking into consideration the differences between clinical and research settings. Asking about willingness to know in clinical and research settings and the shared decision-making process applied to prognostic counseling is discussed. Concerning research settings, ethical aspects regarding clinical trials are addressed. Availability of direct-to-consumer technologies will likely lead to novel contexts requiring prognostic counseling, and future neuroprotective or neuromodulating treatments may require further considerations on the timing, role, and importance of prognostic counseling. Recommendations on how to address ethical gaps should be a priority for patients, medical professional societies, and research workgroups. Ethical issues must be considered as an integral part of the overall clinical and research approach to prodromal synucleinopathies.

Understanding the subjective experiences of memory concern and MCI diagnosis: A scoping review

INTRODUCTION

Many older people experience memory concerns; a minority receive a diagnosis of Mild Cognitive Impairment (MCI) or Subjective Cognitive decline (SCD). There are concerns that medicalisation of MCI and memory concern may fail to acknowledge subjective experiences.

AIM

We explore the meaning individuals give to their memory concerns, with or without a diagnosis of MCI and SCD.

METHOD

We scoped literature exploring subjective experiences of memory concern, with or without a diagnosis of MCI or SCD. We searched CINAHL, PsycINFO and MEDLINE in March 2020, and updated in Sept 2021.We used (Arksey & O'Malley, 2005) framework to guide our scoping review method and thematic analysis to analyse our findings.

RESULTS

We screened 12,033 search results reviewing the full texts of 92 papers. We included 24 papers, including a total of 453 participants, the majority of whom were female, from White ethnic majority populations (or from studies where ethnicity was not identified) with high levels of education. In 15 out of 24 studies, 272 participants were diagnosed with MCI. We identified two themes; Making a diagnosis personal and Remembering not to forget. We found that subjective experiences include normative comparison with others of the same age and responses including fear, relief, and acceptance, but culminating in uncertainty.

CONCLUSION

Drawing upon sociology, we highlight the subjective experiences of living with memory concerns, SCD and an MCI diagnosis. We identify a gap between the intended purpose of diagnostic labels to bring understanding and certainty and the lived experiences of those ascribed them.

Attitudes of Neurologists Toward the Use of Biomarkers in the Diagnosis of Early Alzheimer's Disease

BACKGROUND

Alzheimer's disease (AD) biomarkers reflect key elements of pathophysiology and improve the diagnostic process. However, their use in routine clinical practice is still limited.

OBJECTIVE

We aimed to assess neurologists' barriers and enablers to early AD diagnosis using core AD biomarkers.

METHODS

We conducted an online study in collaboration with the Spanish Society of Neurology. Neurologists answered a survey exploring their attitudes towards AD diagnosis using biomarkers in mild cognitive impairment (MCI) or mild AD dementia. Multivariate logistic regression analyses were conducted to determine the association between neurologists' characteristics and diagnostic attitudes.

RESULTS

We included 188 neurologists with a mean age (SD) of 40.6 (11.3) years, 52.7% male. Most participants had access to AD biomarkers, mainly in cerebrospinal fluid (CSF) (89.9%,#x0025;, n = 169). The majority of participants (95.2%,#x0025;, n = 179) considered CSF biomarkers useful for an etiological diagnosis in MCI. However, 85.6% of respondents (n = 161) used them in less than 60% of their MCI patients in routine clinical practice. Facilitating patients and their families to plan for the future was the most frequent enabler for the use of biomarkers. Short consultation time and practicalities associated with the programming of a lumbar puncture were the most common barriers. A younger neurologist age (p = 0.010) and a higher number of patients managed weekly (p = 0.036) were positively associated with the use of biomarkers.

CONCLUSION

Most neurologists had a favorable attitude to the use of biomarkers, especially in MCI patients. Improvements in resources and consultation time may increase their use in routine clinical practice.

Knowledge of risk and protective factors for dementia in older German adults A population-based survey on risk and protective factors for dementia and internet-based brain health interventions

Background

Evidence on potentially modifiable risk factors for dementia is accumulating rapidly, including e.g. physical inactivity, hypertension, or diabetes. It is unclear to what extent these risk factors are known among the general population in Germany. We investigated knowledge on risk and protective factors for dementia and openness to eHealth interventions for brain health in the older general population in Germany.

Methods

A population-based telephone survey among randomly selected community-dwelling adults aged ≥ 60 years was conducted. We assessed sociodemographic factors, knowledge on risk and protective factors for dementia, openness towards eHealth and psychosocial outcomes (health literacy, resilience). Factors associated with interest in information on brain health and openness towards eHealth interventions were assessed using multivariable logistic regression.

Results

Of n = 500 respondents (mean age: 74.8 years, % female: 62.8), 67.9% believed that dementia risk is modifiable. Participants mostly endorsed physical and cognitive activity as protective factors and social isolation as a risk factor. Knowledge on cardiovascular risk factors was low to moderate. 38.0% were interested in information on dementia risk reduction. Better knowledge of risk factors for dementia and higher age were linked to interest in information on brain health. Being widowed and higher levels of health literacy were associated with lower interest in information. Openness to eHealth interventions was moderate (46.2%). Younger age, better knowledge of risk and protective factors were linked to openness towards eHealth tools, as was knowing someone with dementia and interest in information on brain health.

Conclusion

Belief in preventability of dementia was higher in our sample than previously reported. However, knowledge on cardiovascular risk factors for disease was insufficient and more information and intervention approaches targeted at older adults are needed. Interest in information on dementia risk reduction and eHealth approaches was moderate, and further studies are warranted to assess needs and concerns of older adults regarding dementia prevention.

Moral motivation regarding dementia risk testing among affected persons in Germany and Israel

Recent advances in biomarkers may soon make it possible to identify persons at high risk for late-onset Alzheimer's disease at a presymptomatic (preclinical) stage. Popular demand for testing is increasing despite the lack of cure and effective prevention options and despite uncertainties regarding the predictive value of biomarker tests. This underscores the relevance of the ethical, cultural and social implications of predictive testing and the need to advance the bioethical debate beyond considerations of clinical consequences. Our qualitative study included three groups of affected persons: People with mild neurocognitive disorder, their relatives and family caregivers of people with dementia. We explored their moral motivations regarding predictive, biomarker-based testing and preclinical diagnostics. We interviewed affected individuals in Germany and Israel (N=88; 44 participants in each country). Transcripts of 12 focus groups and 12 semistructured interviews were content analysed with a focus on the moral motivations of affected persons in their justification of why they accept or reject predictive testing and early diagnosis. We grouped the underlying aspects of moral motivation into four ethical categories: beneficence as a form of personal utility focusing on well-being, the ties of responsibility linking families and their individual members, the importance of self-determination by later life planning and notions of a good life. In general, cultural parallels among these motives were very obvious. Cultural variation occurred mainly in openness to suicide, scepticism about test validity and emphasis on personal autonomy. The study underscores the importance of counselling for life-planning issues and of informing test candidates about problems with test validity and about the ambiguity of test results.

Der Wert des Privaten für Menschen mit Demenz

Der Begriff der Privatheit markiert eine erstaunliche Leerstelle in der Diskussion um die Pflege von Menschen mit Demenz (MmD). Der sonst intensiv geführte pflegeethische Diskurs über Fragen der Privatheit scheint hier nahezu vollständig zu verstummen, so als verlören MmD im Verlauf ihrer Erkrankung jedes nachvollziehbare Interesse an einer Privatsphäre und verfügten über keinerlei privaten Bereich mehr, den man bei ihrer pflegerischen Versorgung beachten oder schützen müsste. Eine solche Vorstellung widerspricht allerdings nicht nur verbreiteten moralischen Intuitionen, sondern auch den Auffassungen und Bedürfnissen der Betroffenen selbst. Vor diesem Hintergrund gehen wir der Frage nach, inwieweit sich die Bedeutung von Privatheit für MmD ethisch verständlich und plausibel machen lässt. Zu diesem Zweck werden zunächst die Herkunft und die verschiedenen Bedeutungsdimensionen des Privatheitsbegriffs selbst umrissen, um anschließend seine Schwierigkeiten und Grenzen im Kontext demenzieller Erkrankungen aufzuzeigen. Wie sich dabei herausstellt, kann insbesondere der ausgeprägte Autonomiebezug vorherrschender liberaler Privatheitskonzepte ein erhebliches Hindernis für eine angemessene Konzeptualisierung der Bedeutung der Privatheit für MmD darstellen. Aus diesem Grund loten wir im Anschluss unterschiedliche Möglichkeiten aus, wie sich der „Wert des Privaten“ im Kontext demenzieller Erkrankungen auch losgelöst vom Recht auf individuelle Selbstbestimmung konzeptualisieren ließe. Während autonomiebasierte Konzepte von Privatheit in frühen Stadien noch tragen mögen, wird mit Blick auf den weiteren Krankheitsverlauf daher auch der Relevanz von erkennbaren persönlichen Präferenzen sowie objektiven Bedingungen von Würde und Wohlergehen nachgegangen. Auf diesem Weg lässt sich differenziert aufzeigen, inwiefern Privatheit auch für MmD von Bedeutung sein und im pflegerischen Umgang mit ihnen angemessen berücksichtigt werden kann.

Moving beyond disclosure: Stages of care in preclinical Alzheimer's disease biomarker testing

Alzheimer's disease (AD) begins with an asymptomatic "preclinical" phase, in which abnormal biomarkers indicate risk for developing cognitive impairment. Biomarker information is increasingly being disclosed in research settings, and is moving toward clinical settings with the development of cheaper and non-invasive testing. Limited research has focused on the safety and psychological effects of disclosing biomarker results to cognitively unimpaired adults. However, less is known about how to ensure equitable access and robust counseling for decision-making before testing, and how to effectively provide long-term follow-up and risk management after testing. Using the framework of Huntington's disease, which is based on extensive experience with disclosing and managing risk for a progressive neurodegenerative condition, this article proposes a conceptual model of pre-disclosure, disclosure, and post-disclosure phases for AD biomarker testing. Addressing research questions in each phase will facilitate the transition of biomarker testing into clinical practice.

The Experts' Advice: Prevention and Responsibility in German Media and Scientific Discourses on Dementia

In the absence of effective pharmacological therapy options, the focus of dementia and Alzheimer's research has shifted from treatment and care to risk prediction, early detection, and prevention. Public health communication and media coverage regarding dementia emphasize the individual responsibility for dementia risk management. Focusing on the social and moral implications of the new understanding and public representation of dementia, we present an analysis of medical science, nursing science, and media discourses in Germany between 2014 and 2019. We show which notions of dementia and prevention characterize the medical and nursing science debates regarding dementia and how scientific knowledge is transferred into media discourses on dementia. We further discuss how dementia risk communication interacts with contemporary social and health policies and in what ways current dementia discourses are associated with a (self-)responsibilization of cognitive aging.

European Academy of Neurology/European Alzheimer's Disease Consortium position statement on diagnostic disclosure, biomarker counseling, and management of patients with mild cognitive impairment

BACKGROUND AND PURPOSE

Careful counseling through the diagnostic process and adequate postdiagnostic support in patients with mild cognitive impairment (MCI) is important. Previous studies have indicated heterogeneity in practice and the need for guidance for clinicians.

METHODS

A joint European Academy of Neurology/European Alzheimer's Disease Consortium panel of dementia specialists was appointed. Through online meetings and emails, positions were developed regarding disclosing a syndrome diagnosis of MCI, pre- and postbiomarker sampling counseling, and postdiagnostic support.

RESULTS

Prior to diagnostic evaluation, motives and wishes of the patient should be sought. Diagnostic disclosure should be carried out by a dementia specialist taking the ethical principles of "the right to know" versus "the wish not to know" into account. Disclosure should be accompanied by written information and a follow-up plan. It should be made clear that MCI is not dementia. Prebiomarker counseling should always be carried out if biomarker sampling is considered and postbiomarker counseling if sampling is carried out. A dementia specialist knowledgeable about biomarkers should inform about pros and cons, including alternatives, to enable an autonomous and informed decision. Postbiomarker counseling will depend in part on the results of biomarkers. Follow-up should be considered for all patients with MCI and include brain-healthy advice and possibly treatment for specific underlying causes. Advice on advance directives may be relevant.

CONCLUSIONS

Guidance to clinicians on various aspects of the diagnostic process in patients with MCI is presented here as position statements. Further studies are needed to enable more evidence-based and standardized recommendations in the future.

Barriers and facilitators to the adoption of electronic clinical decision support systems: a qualitative interview study with UK general practitioners

Background

Well-established electronic data capture in UK general practice means that algorithms, developed on patient data, can be used for automated clinical decision support systems (CDSSs). These can predict patient risk, help with prescribing safety, improve diagnosis and prompt clinicians to record extra data. However, there is persistent evidence of low uptake of CDSSs in the clinic. We interviewed UK General Practitioners (GPs) to understand what features of CDSSs, and the contexts of their use, facilitate or present barriers to their use.

Methods

We interviewed 11 practicing GPs in London and South England using a semi-structured interview schedule and discussed a hypothetical CDSS that could detect early signs of dementia. We applied thematic analysis to the anonymised interview transcripts.

Results

We identified three overarching themes: trust in individual CDSSs; usability of individual CDSSs; and usability of CDSSs in the broader practice context, to which nine subthemes contributed. Trust was affected by CDSS provenance, perceived threat to autonomy and clear management guidance. Usability was influenced by sensitivity to the patient context, CDSS flexibility, ease of control, and non-intrusiveness. CDSSs were more likely to be used by GPs if they did not contribute to alert proliferation and subsequent fatigue, or if GPs were provided with training in their use.

Conclusions

Building on these findings we make a number of recommendations for CDSS developers to consider when bringing a new CDSS into GP patient records systems. These include co-producing CDSS with GPs to improve fit within clinic workflow and wider practice systems, ensuring a high level of accuracy and a clear clinical pathway, and providing CDSS training for practice staff. These recommendations may reduce the proliferation of unhelpful alerts that can result in important decision-support being ignored.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01557-z.

Ethical and Social Implications of Using Predictive Modeling for Alzheimer's Disease Prevention: A Systematic Literature Review

BACKGROUND

The therapeutic paradigm in Alzheimer's disease (AD) is shifting from symptoms management toward prevention goals. Secondary prevention requires the identification of individuals without clinical symptoms, yet "at-risk" of developing AD dementia in the future, and thus, the use of predictive modeling.

OBJECTIVE

The objective of this study was to review the ethical concerns and social implications generated by this new approach.

METHODS

We conducted a systematic literature review in Medline, Embase, PsycInfo, and Scopus, and complemented it with a gray literature search between March and July 2018. Then we analyzed data qualitatively using a thematic analysis technique.

RESULTS

We identified thirty-one ethical issues and social concerns corresponding to eight ethical principles: (i) respect for autonomy, (ii) beneficence, (iii) non-maleficence, (iv) equality, justice, and diversity, (v) identity and stigma, (vi) privacy, (vii) accountability, transparency, and professionalism, and (viii) uncertainty avoidance. Much of the literature sees the discovery of disease-modifying treatment as a necessary and sufficient condition to justify AD risk assessment, overlooking future challenges in providing equitable access to it, establishing long-term treatment outcomes and social consequences of this approach, e.g., medicalization. The ethical/social issues associated specifically with predictive models, such as the adequate predictive power and reliability, infrastructural requirements, data privacy, potential for personalized medicine in AD, and limiting access to future AD treatment based on risk stratification, were covered scarcely.

CONCLUSION

The ethical discussion needs to advance to reflect recent scientific developments and guide clinical practice now and in the future, so that necessary safeguards are implemented for large-scale AD secondary prevention.

Attitudes towards prediction and early diagnosis of late-onset dementia: a comparison of tested persons and family caregivers

Background: The focus on early detection of dementia and Mild Cognitive Impairment (MCI) diagnosis has entered the clinics' daily routine. However, there exist epistemic uncertainty and moral concerns whether early detection and prediction of dementia is clinically meaningful for the people affected, primarily due to the lack of effective treatment options.Methods: In this study, we adopted qualitative research methods. Twelve face-to-face interviews with tested persons with MCI and early dementia and five focus groups with family caregivers were conducted in Germany in order to explore and analyze their understanding and assessments of early detection and prediction of dementia in memory clinics.Results: Our study revealed that there was much uncertainty among the participants diagnosed with MCI especially when compared to the participants with an early dementia diagnosis. Their uncertainty concerned the meaning of a 'MCI' diagnosis as well as the validity of specific biomarker test results. Moreover, we identified different lines of moral issues for and against the tests among the participants. They include a) inter-familiar conflicts of interest in the initial phase of memory problems, b) the hope for (future) therapy and prevention, c) the desire for easier access to experts in memory clinics, d) advance planning, e) stigmatization, as well as, f) suicide as an option to avoid the future loss of self-determination.Conclusions: Current clinical and communication strategies only partly address the perspectives and needs of the affected. A standardized and ethically reflected procedure of the information provided by professionals before testing and afterwards, during disclosure, seems necessary. Further, longitudinal studies are needed to improve our knowledge about the experiences tested persons and family caregivers have with different levels of stigma.

Biomarker-Based Risk Prediction of Alzheimer’s Disease Dementia in Mild Cognitive Impairment: Psychosocial, Ethical, and Legal Aspects

Background: Today, a growing number of individuals with mild cognitive impairment (MCI) wish to assess their risk of developing Alzheimer’s disease (AD) dementia. The expectations as well as the effects on quality of life (QoL) in MCI patients and their close others through biomarker-based dementia risk estimation are not well studied. Objective: The PreDADQoL project aims at providing empirical data on effects of such prediction on QoL and at developing an ethical and legal framework of biomarker-based dementia risk estimation in MCI. Methods: In the empirical study, 100 MCI-patients and their close others will be recruited from two sites (Germany and Spain). They receive standardized counselling on cerebrospinal fluid (CSF) biomarker-based prediction of AD dementia and a risk disclosure based on their AD biomarker status. A mixed methods approach will be applied to assess outcomes. Results: The pilot-study yielded a specification of the research topics and newly developed questionnaires for the main assessment. Within this binational quantitative and qualitative study, data on attitudes and expectations toward AD risk prediction, QoL, risk communication, coping strategies, mental health, lifestyle changes, and healthcare resource utilization will be obtained. Together with the normative part of the project, an empirically informed ethical and legal framework for biomarker-based dementia risk estimation will be developed. Conclusion: The empirical research of the PreDADQoL study together with the ethical and legal considerations and implications will help to improve the process of counselling and risk disclosure and thereby positively affect QoL and health of MCI-patients and their close others in the context of biomarker-based dementia risk estimation.

Ethical Implications of Alzheimer's Disease Prediction in Asymptomatic Individuals through Artificial Intelligence

Biomarker-based predictive tests for subjectively asymptomatic Alzheimer’s disease (AD) are utilized in research today. Novel applications of artificial intelligence (AI) promise to predict the onset of AD several years in advance without determining biomarker thresholds. Until now, little attention has been paid to the new ethical challenges that AI brings to the early diagnosis in asymptomatic individuals, beyond contributing to research purposes, when we still lack adequate treatment. The aim of this paper is to explore the ethical arguments put forward for AI aided AD prediction in subjectively asymptomatic individuals and their ethical implications. The ethical assessment is based on a systematic literature search. Thematic analysis was conducted inductively of 18 included publications. The ethical framework includes the principles of autonomy, beneficence, non-maleficence, and justice. Reasons for offering predictive tests to asymptomatic individuals are the right to know, a positive balance of the risk-benefit assessment, and the opportunity for future planning. Reasons against are the lack of disease modifying treatment, the accuracy and explicability of AI aided prediction, the right not to know, and threats to social rights. We conclude that there are serious ethical concerns in offering early diagnosis to asymptomatic individuals and the issues raised by the application of AI add to the already known issues. Nevertheless, pre-symptomatic testing should only be offered on request to avoid inflicted harm. We recommend developing training for physicians in communicating AI aided prediction.

Ambivalent anticipation: How people with Alzheimer's disease value diagnosis in current and envisioned future practices

Emergent biomarkers for Alzheimer's disease (AD) are expected to provide earlier and more precise diagnoses. However, even if biomarkers live up to these expectations, it cannot be taken for granted that patients actually would value an earlier and more precise AD diagnosis. Based on an interview study, we aim to give more insight into the value of an AD diagnosis for patients, in existing as well as future practices, by describing how a diagnosis enables or may enable knowing, foreseeing, and acting in relation to one's illness. Our findings show that how people with AD value a diagnosis is not only characterised by great variety, as previous studies have shown, but also by profound ambivalence for the individual. With lack of treatment and poor prognostics as the status quo, this ambivalence and the way people deal with it are particularly linked to the far-from-straightforward capacity of an AD diagnosis to support anticipation of the future. We argue that in otherwise unchanged practices the envisioned future biomarker-based diagnostics are unlikely to reduce the ambivalence about receiving an AD diagnosis and, in particular, the challenges of anticipation that it entails. Rather, biomarker-based innovations may even reinforce some of the main issues involved.

Automated detection of patients with dementia whose symptoms have been identified in primary care but have no formal diagnosis: a retrospective case-control study using electronic primary care records

OBJECTIVES

UK statistics suggest only two-thirds of patients with dementia get a diagnosis recorded in primary care. General practitioners (GPs) report barriers to formally diagnosing dementia, so some patients may be known by GPs to have dementia but may be missing a diagnosis in their patient record. We aimed to produce a method to identify these 'known but unlabelled' patients with dementia using data from primary care patient records.

DESIGN

Retrospective case-control study using routinely collected primary care patient records from Clinical Practice Research Datalink.

SETTING

UK general practice.

PARTICIPANTS

English patients aged >65 years, with a coded diagnosis of dementia recorded in 2000-2012 (cases), matched 1:1 with patients with no diagnosis code for dementia (controls).

INTERVENTIONS

Eight coded and nine keyword concepts indicating symptoms, screening tests, referrals and care for dementia recorded in the 5 years before diagnosis. We trialled machine learning classifiers to discriminate between cases and controls (logistic regression, naïve Bayes, random forest).

PRIMARY AND SECONDARY OUTCOMES

The outcome variable was dementia diagnosis code; the accuracy of classifiers was assessed using area under the receiver operating characteristic curve (AUC); the order of features contributing to discrimination was examined.

RESULTS

93 426 patients were included; the median age was 83 years (64.8% women). Three classifiers achieved high discrimination and performed very similarly. AUCs were 0.87-0.90 with coded variables, rising to 0.90-0.94 with keywords added. Feature prioritisation was different for each classifier; commonly prioritised features were Alzheimer's prescription, dementia annual review, memory loss and dementia keywords.

CONCLUSIONS

It is possible to detect patients with dementia who are known to GPs but unlabelled with a diagnostic code, with a high degree of accuracy in electronic primary care record data. Using keywords from clinic notes and letters improves accuracy compared with coded data alone. This approach could improve identification of dementia cases for record-keeping, service planning and delivery of good quality care.

Use of Cerebrospinal Fluid Biomarkers of Alzheimer's Disease Risk in Mild Cognitive Impairment and Subjective Cognitive Decline in Routine Clinical Care in Germany

BACKGROUND

The National Institute of Aging and Alzheimer's Association's diagnostic recommendations for preclinical Alzheimer's disease (AD) and mild cognitive impairment (MCI) define AD by pathological processes which can be detected by biomarkers. These criteria were established as part of a research framework intended for research purposes but progressively enter the clinical practice.

OBJECTIVE

We investigated the availability, frequency of use, interpretation, and therapeutic implications of biomarkers for the etiologic diagnosis and prognosis in MCI and subjective cognitive decline (SCD) in routine clinical care.

METHODS

We conducted a cross-sectional questionnaire survey among 215 expert dementia centers (hospitals and memory clinics) in Germany.

RESULTS

From the 98 centers (45.6% of contacted centers) included, two-thirds reported use of the cerebrospinal fluid (CSF) biomarkers Aβ42, tau, and phospho-tau in the diagnostic workup of MCI and one third in SCD. CSF biomarker analysis was more often employed by neurological (MCI 84%; SCD 42%) compared to psychiatric institutions (MCI 61%; SCD 33%; p≤0.001). Although dementia experts disagreed on the risk of progression associated with different CSF biomarker constellations, CSF biomarker results guided therapeutic decisions: ∼40% of responders reported to initiate cholinesterase inhibitor therapy in MCI and 18% in SCD (p = 0.006), given that all CSF biomarkers were in the pathological range.

CONCLUSION

Considering the vast heterogeneity among dementia expert centers in use of CSF biomarker analysis, interpretation of results, and therapeutic consequences, a standardization of biomarker-based diagnosis practice in pre-dementia stages is needed.

Practices and opinions about disclosure of the diagnosis of Alzheimer's disease to patients with MCI or dementia: a survey among Belgian medical experts in the field of dementia

Previous surveys revealed that only a minority of clinicians routinely disclosed the diagnosis of Alzheimer's disease (AD) to their patients. Many health professionals fear that the disclosure could be harmful to the patient. Recent advances in the development of biomarkers and new diagnostic criteria allow for an earlier diagnosis of AD at the mild cognitive impairment (MCI) stage. The Belgian Dementia Council, a group of Belgian experts in the field of dementia, performed a survey among its 44 members about their opinions and practices regarding disclosure of the diagnosis of AD, including MCI due to AD, and its consequences. Twenty-six respondents declared that they often or always disclose the diagnosis of AD to patients with dementia and to patients with MCI when AD CSF biomarkers are abnormal. The majority observed that the disclosure of AD is rarely or never harmful to the patients. Their patients and their caregivers rarely or never demonstrated animosity towards the clinicians following disclosure of the diagnosis of AD. These results should reassure clinicians about the safety of AD diagnosis disclosure in most cases whether the patient is at the MCI or the dementia stage.

Addressing ethical challenges of disclosure in dementia prediction: limitations of current guidelines and suggestions to proceed

Background

Biomarker research is gaining increasing attention focusing on the preclinical stages of the disease. Such interest requires special attention for communication and disclosure in clinical contexts. Many countries give dementia a high health policy priority by developing national strategies and by improving guidelines addressing disclosure of a diagnosis; however, risk communication is often neglected.

Main text

This paper aims to identify the challenges of disclosure in the context of dementia prediction and to find out whether existing clinical guidelines sufficiently address the issues of disclosing a dementia diagnosis and of disclosing the risk of developing dementia in asymptomatic and MCI stage. We will examine clinical guidelines and recommendations of three countries (USA, Canada and Germany) regarding predictive testing and diagnostic disclosure in dementia and Mild Cognitive Impairment (MCI) to show their potentials and limits. This will provide a background to address ethical implications of predictive information and to identify ways how to proceed further. We will start by examining the guidelines and recommendations by focusing on what there is already and what is missing regarding the challenges of disclosing dementia prediction and MCI. Then, we will highlight the novel ethical issues generated by the shift to identify preclinical stages of the disease by biomarkers. We will argue for the need to develop guidelines for disclosing a risk status, which requires different considerations then disclosing a diagnosis of dementia. Finally, we will make some suggestions on how to address the gap and challenges raised by referring to German Stakeholder Conference, which presents us a good starting point to the applicability of involving stakeholders.

Conclusions

This paper underlines the need to develop empirically based guidelines that address the ethical and social strategies for risk communication of dementia prediction by genetic as well as non-genetic biomarkers. According to our analysis, the guidelines do not address the new developments sufficiently. International efforts should aim for specific guidelines on counseling, communicating risk and disclosing results. We argue that guidelines on (risk) disclosure should be developed by involving various stakeholders and should be informed by socio-empirical studies involving laypersons’ needs and wishes regarding risk communication.

Genetic testing for Alzheimer's disease: trends, challenges and ethical considerations

PURPOSE OF REVIEW

Advances in personal genomics have made predictive genetic testing increasingly popular. The purpose of this review is to examine and summarize recent literature regarding the ethical concerns and considerations surrounding genetic testing for Alzheimer's disease.

RECENT FINDINGS

Four basic bioethical principles can be applied in the context of genetic testing: autonomy, nonmaleficence, beneficence and justice. The concepts of clinical validity, clinical utility and personal utility are also necessary for the ethical deliberation of genetic testing for Alzheimer's disease. Ethical considerations can differ among three distinct settings present in the literature: research, clinical and direct-to-consumer services. Studies have found that the negative psychosocial impact of genetic test results on the individual is limited, but emphasize the importance of pre/posttesting genetic counselling.

SUMMARY

The literature should ideally inform policy-making around genetic testing. There exists an urgent need for regulation, particularly in the direct-to-consumer (DTC) market, since interest for testing in this context is rapidly growing. Standardized protocols for disclosure should be developed, and there is a need to find ways to meet the growing need for genetic counselling. Importantly, comprehensive, evidence-based regulation requires that research be conducted in different contexts with more diverse participants.

Ethical and social implications of using predictive modeling for Alzheimer's disease prevention: a systematic literature review protocol

INTRODUCTION

The therapeutic paradigm in Alzheimer's disease (AD) has shifted towards secondary prevention, defined as an intervention aiming to prevent or delay disease onset in pre-symptomatic individuals at risk of developing dementia due to AD. The key feature of AD prevention is the need to treat years or even decades before the onset of cognitive, behavioural or functional decline. Prediction of AD risk and evaluation of long-term treatment outcomes in this setting requires predictive modelling and is associated with ethical concerns and social implications. The objective of this review is to identify and elucidate them, as presented in the literature.

METHODS AND ANALYSIS

A systematic literature review was conducted in Medline, Embase, PsycInfo and Scopus, and was complemented with a grey literature search. All searches were conducted between March and July 2018. Two reviewers independently assessed each study for inclusion and disagreements were adjudicated by a third reviewer. Data are now being extracted using an extraction sheet developed within the group of reviewers, based on an initial sample of three manuscripts, but allowing for inclusion of newly identified data items (ethical arguments). Data will be analysed qualitatively using a thematic analysis technique. Potential biases in selection and interpretation of extracted data are mitigated by the fact that reviewers come from a range of different scientific backgrounds and represent different types of stakeholders in this ethical discussion (academia, industry, patient advocacy groups).

ETHICS AND DISSEMINATION

The study does not require ethical approval. The findings of the review will be disseminated in a peer-reviewed journal and presented at conferences. They will also be reported through the Innovative Medicine Initiative project: Real World Outcomes Across the AD Spectrum for Better Care: Multi-modal Data Access Platform (IMI: ROADMAP).

TRIAL REGISTRATION NUMBER

CRD42018092205.