Anna Chodos, MD, MPH - Getting Ahead of Cognitive Decline—Applying Patient-Centered Strategies to Assess and Reduce Dementia Risk in Primary Care: An AI-Guided Case Simulation Activity

Jerome is a 50-year-old accountant, and he's coming into his primary care physician's office because he scheduled an appointment to discuss his brain health and learn about his risk of developing Alzheimer's disease later in life.

Jerome's concerns stem from the fact that his father was recently diagnosed with Alzheimer's disease at age 70, and he underwent APOE testing as part of the workup.

The test revealed that his dad is an APOE4 homozygote.

After learning about his father, Jerome ordered an APOE genotype test for himself, and the test result was that he was a heterozygote.

After getting his APOE test result back, he decided to schedule an appointment with his PCP to discuss his own risk for dementia.

His medical history is hypertension, hyperlipidemia, insomnia, and osteoarthritis in his knee.

His regular medications include lisinopril and zolpidem.

In his current clinical presentation, he has slightly elevated blood pressure at 145 over 90 compared to his last visit, and this is the highest it's been since he started lisinopril three years ago.

You can see his lipid panel here, which shows an elevated total cholesterol of 255 and an LDL of 190.

He has a sedentary job, has limited exercise, and reports poor sleep most nights.

His BMI is 32.

Again, we know his ApoE risk factor profile.

And he drinks one to two beers every night after work.

So let's start with a challenge question.

You're gonna evaluate Jerome's dementia risk profile.

What will you do first? Administer the CADE risk assessment? Order a structural MRI? Administer a MINICOG, MOCA, or MMSE? Administer the ANU-ADRI or BDSI risk assessment? I'm not sure.

The answer is to administer a mini-cog MOCA or MMSE.

This is out of the gate so that we know whether or not he actually has cognitive symptoms now at the present time.

So let's now spend a few minutes talking about modifiable risk factors, the different risk assessments and tools, and what our next steps would be for Jerome's visit.

Currently, there are 14 modifiable risk factors that we know account for 45% of dementias worldwide.

You can see here that the risk factors are grouped according to the stage of life in which we know that they contribute to lifelong risk for dementia, including early life, midlife, and later life.

And you'll see that there are some additional risk factors that are commonly known to affect dementia risk that are not included in this 45% number.

But those are diet, sleep, stress, and also non-modifiable risk factors, which we've already learned about in the context of Jerome's risk, such as genetics, age, and sex.

So this brings us to what we can assess in clinical practice, and furthermore, what those assessments might look like.

Many of these risk factors are included in the information we collect regularly and are in the electronic health record, such as blood pressure, blood tests, BMI, hearing and vision impairment, traumatic brain injury history, diabetes, and depression.