Online clinical tools to support the use of new plasma biomarker diagnostic technology in the assessment of Alzheimer's disease: a narrative review.

Recent advances in new diagnostic technologies for Alzheimer's disease have improved the speed and precision of diagnosis. However, accessing the potential benefits of this technology poses challenges for clinicians, such as deciding whether it is clinically appropriate to order a diagnostic test, which specific test or tests to order and how to interpret test results and communicate these to the patient and their caregiver. Tools to support decision-making could provide additional structure and information to the clinical assessment process. These tools could be accessed online, and such 'e-tools' can provide an interactive interface to support patients and clinicians in the use of new diagnostic technologies for Alzheimer's disease. We performed a narrative review of the literature to synthesize information available on this research topic. Relevant studies that provide an understanding of how these online tools could be used to optimize the clinical utility of diagnostic technology were identified. Based on these, we discuss the ways in which e-tools have been used to assist in the diagnosis of Alzheimer's disease and propose recommendations for future research to aid further development.

Has COVID-19 affected dementia diagnosis rates in England?

BACKGROUND: The COVID-19 pandemic impacted on the provision of care and routine activity of all National Health Service (NHS) services. While General Practitioner referrals to memory services in England have returned to pre-pandemic levels, the estimated dementia diagnosis rate (DDR) fell by 5.4% between March 2020 and February 2023. METHODS: In this paper we explore whether this reduction is accurate or is an artefact of the way the NHS collects data. RESULTS: We explore the processes that may have affected national dementia diagnosis rates during and following the COVID-19 pandemic. CONCLUSIONS: We discuss what action could be taken to improve the DDR in the future.

Advancing Diagnostic Certainty in Alzheimer's Disease: A Synthesis of the Diagnostic Process.

Changes in diagnostic certainty can be evaluated by assessing the impact of a diagnostic test in driving decision making. Diagnostic tests can be appraised using validated measures of accuracy, i.e., sensitivity, specificity, and positive or negative predictive values against a known reference standard. However, other less well formalized factors affect diagnostic certainty. These inputs are under-researched and more difficult to quantify. Clinicians assess the significance of available data in the context of their expertise, pre-diagnostic confidence, and background knowledge of populations and disease. Inherent qualities of the diagnostic test and an individual clinician's interpretation of the meaning of test results will also affect the subsequent level of diagnostic certainty. These factors are only infrequently considered alongside the diagnostic accuracy of a test. In this paper, we present a model of the different processes which can affect diagnostic certainty in Alzheimer's disease (AD). This model builds upon existing understanding and provides further insights into the complexity of diagnostic certainty in AD and how we might improve this.

Acceptability and feasibility of plasma phosphorylated-tau181 in two memory services.

BACKGROUND: Plasma phosphorylated-tau181 (p-tau181) represents a novel blood-based biomarker of Alzheimer's disease pathology. We explored clinicians' experience of the utility of plasma p-tau181 in Camden and Islington Memory Services. METHODS: Patients were identified by their clinician as appropriate for p-tau181. Their p-tau181 result was plotted on a reference range graph provided to clinicians. This was discussed with the patient at diagnostic feedback appointment. RESULTS: Twenty-nine participants' plasma p-tau181 samples were included (mean age 74 SD 8.5, 65% female). Nine clinicians participated in the study. Eighty-six percent of clinicians found the p-tau181 result to be helpful and in 93% of cases it was clearly understandable. The p-tau181 result was useful in making the diagnosis in 44% of cases. CONCLUSIONS: Plasma p-tau181 is a feasible test for use in memory services and acceptable to clinicians. Clinician feedback on utility in dementia diagnoses was mixed. Further work is required to provide education and training in understanding and interpreting ambiguity in biomarker results.

Clinical utility of cerebrospinal fluid biomarkers in the evaluation of cognitive impairment: a systematic review and meta-analysis.

BACKGROUND: The analytical and clinical validity of cerebrospinal (CSF) biomarkers has been extensively researched in dementia. Further work is needed to assess the ability of these biomarkers to improve diagnosis, management and health outcomes in the clinical setting OBJECTIVES: To assess the added value and clinical utility of CSF biomarkers in the diagnostic assessment of cognitively impaired patients under evaluation for Alzheimer's disease (AD). METHODS: Systematic literature searches of Medline, EMBASE, PsycINFO and Web of Science research databases were conducted on 17 December 2022. Data from relevant studies were extracted and independently screened for quality using a tool for bias. Clinical utility was measured by clinicians' changes in diagnosis, diagnostic confidence and patient management (when available), after their examination of patients' CSF biomarkers. Cost-effectiveness was assessed by consideration of additional cost per patient and quality-adjusted life years. RESULTS: Searches identified 17 studies comprising 2090 patient participants and 593 clinicians. The meta-analysis revealed that clinicians' use of CSF biomarkers resulted in a pooled percentage change in diagnosis of 25% (95% CI 14 to 37), an increase in diagnostic confidence of 14% (95% CI 9 to 18) and a pooled proportion of patients whose management changed of 31% (95% CI 12 to 50). CSF biomarkers were deemed cost-effective, particularly in memory services, where pre-test AD prevalence is higher compared with a primary care setting. CONCLUSIONS: CSF biomarkers can be a helpful additional diagnostic tool for clinicians assessing patients with cognitive impairment. In particular, CSF biomarkers consistently improved clinicians' confidence in diagnosing AD and influenced on diagnostic change and patient management. Further research is needed to study the clinical utility of blood-based biomarkers in the clinical setting.

Improving the handover process in a psychiatry liaison setting.

Efficient handover of patient care is integral to clinical safety. Barriers in communication can lead to adverse outcomes. The Integrated Liaison Assessment Team (ILAT) has a daily handover meeting which presents several challenges to the multidisciplinary liaison team (MDT including high patient turnover, differing staff shift-work patterns, presence of visitors/students and lack of a unified approach to structured discussion at times. Areas identified for improvement included optimising efficiency, structure and handover documentation. Lack of teaching and learning opportunities were also identified. The primary aim was to reduce handover time to 30 min. The secondary aims were to improve communication by introducing the Situation-Background-Assessment-Recommendation (SBAR) tool, improve team satisfaction and introduce a teaching programme in the time saved. The Model for Improvement methodology was used with MDT focus groups and questionnaires to explore change ideas. This informed our 'Plan, Do, Study, Act' cycles to design a structured handover. Daily measures looked at handover length and individual team member satisfaction. Weekly measures included semiqualitative questionnaires highlighting areas for improvement. Feedback was gathered from emails and MDT discussions. A structured handover format incorporating SBAR, key task allocation and a shift handover lead was introduced. A regular MDT teaching programme was initiated. Over 4 weeks, 'Good' handover ratings increased from 22% to 65%; 'Poor' ratings decreased from 25% to 8%. Mean handover time decreased from 47 min to 31.25 min; a decrease of 33.5%. Overall, the team viewed SBAR positively as an efficiency-promoting tool. Structured handover has promoted staff competencies, team morale and information sharing practices among ILAT. MDT teaching improved team communication and confidence. Sustaining motivation to keep up interventions and documentation of handover were identified as key areas for sustained improvement.

Practical application of Alzheimer's Disease Neuroimaging Initiative plasma P-tau181 reference data to support diagnosis of Alzheimer's disease.

OBJECTIVES: To assess plasma phosphorylated tau181 (p-tau181) levels in Alzheimer's disease (AD), cognitively impaired non-AD participants (CI non-AD) and Control participants in the Alzheimer's Disease Neuroimaging Initiative (ADNI) dataset that could potentially act as reference data for clinic diagnoses of AD. METHODS: Data from 1558 participants (649 AD participants, 445 CI non-AD participants and 464 controls) were examined, comparing p-tau181 levels between Controls, AD and other dementias, stratified by age. RESULTS: There were significant differences in plasma p-tau181 values between Controls and those with AD at all ages up to 85 years. There were also significant differences between AD and CI non-AD participants up to the age of 85 years. CONCLUSIONS: Plasma P-tau181 may be a useful tool in the diagnosis of AD in those clinical settings where biomarkers have traditionally been less used. P-tau181 may be less useful as an aid to diagnosis in the very oldest-old. Further work is needed to establish the feasibility and utility of this biomarker within dementia diagnosis services not led by Neurologists, such as UK National Health Service Memory Services.