Overview of Methodologic Issues for Pharmacologic Trials in Mild, Moderate, and Severe Alzheimer's Disease

Abstract

To address the issue of mild, moderate, and severe Alzheimer's disease (AD), it is necessary to initially establish some agreement on terminology. In recent decades, these terms have frequently been defined using screening instrument scores with measures such as the Mini-Menal State Examination (MMSE). There are many problems with this approach, perhaps the most salient of which is that it has contributed to the total and tragic neglect of patients with severe AD. An alternative approach to the classification of AD severity is staging. This approach has advanced to the point where moderately severe and severe AD can be described in detail. Procedures for describing this previously neglected latter portion of AD have recently been extensively validated. Staging is also uniquely useful at the other end of the severity spectrum, in differentiating early aging brain/behavior changes, incipient AD, and mild AD. Temporally, with staging procedures, it is possible to track the course of AD approximately three times more accurately than with the MMSE. The net result of the advances in AD delineation is that issues such as prophylaxis, modification of course, treatment of behavioral distrubances, loss of ambulation, progressive rigidity, and the development of contractures in AD patients can now be addressed in a scientifically meaningful way that will hopefully bestow much benefit in AD patients and those who care for them.

MMSE Cross-Domain Variability Predicts Cognitive Decline in Centenarians

“…The GDS is a 7-step rating scale made up of detailed clinical descriptions of seven major clinically distinguishable cognitive stages, ranging from no cognitive impairment to very severe cognitive impairment. Content validity of the GDS was demonstrated by Overall, Scott, Rhodes, and Lesser [19], and inter-rater and retest reliability has been demonstrated regularly at over 0.9 [20].…”

Subjective Memory Complaints: Presence, Severity and Future Outcome in Normal Older Subjects

“…Subjects were classified as: stable -'nondeclining' if at all followup visits they met the criteria for GDS 1 or 2 indicating normal cognition, and 'declining' if they met criteria for GDS 6 3 [22,23] on at least the final 2 examinations. Finally, the 'unstable' outcome group included subjects who were assessed with a GDS = 3 (i.e.…”

Functional Ability Correlates with Cognitive Impairment in Parkinson’s Disease and Alzheimer’s Disease

“…The Global Deterioration Scale (GDS) is a global staging system which measures cognitive and functional ability and is sensitive to both normal aging and AD. GDS also has shown positive correlation between global dysfunction and cognitive impairment in AD [5,6] .…”