DETECT— Navigating a New Era in Alzheimer’s Disease: Integrating Disease-Modifying Therapies into Clinical Practice
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A 72-year-old man presents for a follow up visit in primary care and complains of decline in memory over the past year. He keeps forgetting things and has to write down more reminders than he used to. Collateral information corroborates that he remains essentially independent in his activities of daily living. A Mini-Cog exam is performed at the visit, showing a score of 3/5 with 0/2 for clock and 2/3 for recall. Also, a MoCA screen shows a score of 24/30 with deficits in clock draw (-1 off), trails (-1 off) and 1/5 short term recall (-4 off). Physical and neurological examinations are essentially normal. What is his cognitive-functional status? 
Mrs. A is a 79-year-old woman with multiple-domain amnestic MCI and a diagnosis of AD-MCI. She had confirmed elevated cerebral amyloid plaques (A+) documented 2 years ago as part of a Medicare real-world study. Her last brain MRI from that study demonstrated three cerebral microhemorrhages. Her current MoCA is 19 and APOE ε4 genotype is unknown. In evaluating her potential eligibility for treatment with a disease-modifying therapy, which of the following would you consider?
A 68-year-old woman started an anti-amyloid monoclonal antibody 1 month ago for mild dementia associated with Alzheimer’s disease. She presents today with mild headache, confusion, and dizziness. Magnetic resonance imaging (MRI) confirms moderate amyloid-related imaging abnormalities-edema (ARIA-E). What should you do for this patient? 
Ms. L, a 74-year old woman with a family history of dementia, is referred to your clinic by her PCP after reporting increasing forgetfulness over the past year. She scores 25/30 on the MMSE, and neuropsychological testing confirms mild cognitive impairment (MCI). Her daily functioning is intact, and labs and MRI rule out other causes. Her brain MRI shows mild regional atrophy and mild white matter changes; and there are no hemorrhages, infarcts, masses, lesions or substantial other abnormalities. The patient and family are interested in treatment options, and you want to determine if she qualifies for a disease-modifying (DMT). Which of the following steps is most appropriate to confirm eligibility for DMTs and streamline access to therapy 
Mr. J, a 70-year-old man with confirmed MCI due to Alzheimer’s disease (positive amyloid PET) visits your clinic to discuss next steps and potential therapy with anti-amyloid antibodies. His baseline MRI is unremarkable, and his APOE- ε4 status is ε3/ ε4 (heterozygous ε4 positive). He and his daughter are eager to understand the risks, monitoring requirements, and what benefits to realistically expect from treatment. Which of the following would you communicate to Mr. J and his daughter?
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