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Clinical Atlas Prestige · Evidence-first

Psych VivasOld age psychiatry — Alzheimer disease

Psych Vivas · Old age psychiatry — Alzheimer disease

Alzheimer disease — structured clinical viva

Fellowship viva covering McKhann probable AD, ATN research biomarkers caution, donepezil continuation, memantine role, DICE BPSD, antipsychotic mortality, and Appelbaum capacity.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the old-age psychiatry registrar. A 74-year-old man with progressive amnestic cognitive decline over three years now needs help with finances and cooking. MRI (educational report) shows medial temporal atrophy without large cortical infarcts. Family ask whether a 'blood test for Alzheimer' will confirm the diagnosis and whether donepezil should be stopped because he is 'getting worse'. He has new suspiciousness about neighbours. Discuss NIA-AA clinical diagnosis, biomarker framing, AChEI/memantine evidence including DOMINO-AD, BPSD approach, antipsychotic risks, and capacity for financial decisions.

Interpretation

Reveal interpretation

Formulate probable AD dementia (McKhann): insidious progressive amnestic syndrome with IADL interference and no better alternative on available history/imaging pattern. Clinical diagnosis does not require a blood test; emerging blood and CSF/PET biomarkers can increase biological certainty in specialist pathways (ATN: A+T+ as research biological AD) but need counselling, access awareness, and must not replace exclusion of delirium/reversibles. 2024 criteria updates exist — mention awareness without inventing local funding rules.[1][2][3]

Do not automatically stop donepezil because the disease progresses: DOMINO-AD supports cognitive/functional benefit of continuation versus withdrawal in moderate-to-severe AD if tolerated; consider memantine for moderate–severe stages with standard titration and renal caution.[4]

New suspiciousness is BPSD — apply DICE, exclude delirium/medical drivers, non-drug first. Antipsychotics only if severe risk remains: counsel increased mortality risk, time-limit, review.[5][6]

Financial capacity: decision-specific Appelbaum assessment (understand, appreciate, reason, communicate), not automatic incapacity from diagnosis; arrange supports and legal pathways as needed.[7]

Key points

Probable AD is still clinical

McKhann criteria remain the everyday diagnostic spine; biomarkers refine certainty in specialist contexts.

DOMINO-AD

Continuing donepezil can still help when AD becomes moderate–severe — progression alone is not an automatic stop rule.

Antipsychotic mortality

Atypical antipsychotics increase death risk in dementia; last line only after non-drug care.
[1] [4] [6]

References

  1. [1]McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of dementia due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups Alzheimers Dement, 2011.PMID 21514250
  2. [2]Jack CR Jr, Bennett DA, Blennow K, et al. NIA-AA Research Framework: Toward a biological definition of Alzheimer's disease Alzheimers Dement, 2018.PMID 29653606
  3. [3]Jack CR Jr, Andrews JS, Beach TG, et al. Revised criteria for diagnosis and staging of Alzheimer's disease: Alzheimer's Association Workgroup Alzheimers Dement, 2024.PMID 38934362
  4. [4]Howard R, McShane R, Lindesay J, et al. Donepezil and memantine for moderate-to-severe Alzheimer's disease N Engl J Med, 2012.PMID 22397651
  5. [5]Kales HC, Gitlin LN, Lyketsos CG Assessment and management of behavioral and psychological symptoms of dementia BMJ, 2015.PMID 25731881
  6. [6]Schneider LS, Dagerman KS, Insel P Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials JAMA, 2005.PMID 16234500
  7. [7]Appelbaum PS, Grisso T Assessing patients' capacities to consent to treatment N Engl J Med, 1988.PMID 3200278