W(h)ither expertise:choosingwisely in brain imaging

Peter J Whitehouse MD-PhDCase Western Reserve University

University of TorontoIntergenerational Schools International

My involvement

• Guideline development- Role of CT/MRI in the evaluation of dementia• Choosing Wisely -standard imaging and uncomplicated headache

• Molecular imaging - Nicotinic receptors• Choosing “Wisely” -early “Alzheimer's” disease diagnosed through

amyloid PET

• Promoting Responsible Innovation as alternative to ELSI• Coauthor of The Myth of Alzheimer's Disease and founder of The

Intergenerational School

Nicotinic receptors imaging and disease

The Society of Nuclear Medicine and Molecular Imaging (but not any clinical society and only in the American process) developed guidelines asserting “Don’t use PET imaging in the evaluation of patients with dementia unless the patient has been assessed by a specialist in this field.” They state “without objective evidence of dementia, the potential benefit of PET is unlikely to justify the cost or radiation risk. Dementia subtypes have overlapping patterns in PET imaging. Clinical evaluation and imaging often provide additive information and should be assessed together to make a reliable diagnosis and to plan care. For β-amyloid PET imaging, it is not currently known what a positive PET result in a cognitively normal person means; this method is not established for an individual prediction.”

Alzheimers Dement. 2013 Jul;9(4):e106-9. doi: 10.1016/j.jalz.2013.06.001.Update on appropriate use criteria for amyloid PET imaging: dementia experts, mild cognitive impairment, and education. Amyloid Imaging Task Force of the Alzheimer’s Association and Society for Nuclear Medicine and Molecular Imaging.Johnson KA1, Minoshima S, Bohnen NI, Donohoe KJ, Foster NL, Herscovitch P, Karlawish JH, Rowe CC, Hedrick S, Pappas V, Carrillo MC, Hartley DM; Amyloid Imaging Task Force of the Alzheimer’s Association and Society for Nuclear Medicine and Molecular Imaging.Author informationAmyloid PET imaging is a novel diagnostic test that can detect in living humans one of the two defining pathologic lesions of Alzheimer disease, amyloid-β deposition in the brain. The Amyloid Imaging Task Force of the Alzheimer's Association and Society for Nuclear Medicine and Molecular Imaging previously published appropriate use criteria for amyloid PET as an important tool for increasing the certainty of a diagnosis of Alzheimer disease in specific patient populations. Here, the task force further clarifies and expands 3 topics discussed in the original paper: first, defining dementia experts and their use of proper documentation to demonstrate the medical necessity of an amyloid PET scan; second, identifying a specific subset of individuals with mild cognitive impairment for whom an amyloid PET scan is appropriate; and finally, developing educational programs to increase awareness of the amyloid PET appropriate use criteria and providing instructions on how this test should be used in the clinical decision-making process.

CME Update – IDEA “study” supported through CED program• Approximately 20000 PET scans (cost in self-pay space 4000 dollars)• 200 Dementia Experts• People with Mild Cognitive Impairment and Dementias of unclear

cause• Outcomes

• Effects of diagnosis and care• Effects of health utilization

So the experts assess whether they themselves used the PET results in any useful way

DISCUSSION As research translates the criteria forpreclinical AD into clinical practice, our language fortalking about AD will likely change. Just as progress incardiovascular disease changed it into a risk-based diagnosisand simplified the many types of dyslipidemiainto simple concepts of “good” and “bad” cholesterol(HDL and LDL, respectively), one or more biomarkersof AD may achieve this status. In the future, we mayspeak not of AD, but “brain amyloidopathy.” And yet,such terms cannot elide an essential fact. They denote adreaded risk: developing dementia.Although medicine and society have successfully integratedan actuarial model to think about how to havehealthy hearts, bones, and glucose, the brain that is atrisk of dementia presents special challenges.

The discovery of preclinical AD may be how we prevent the tsunami of AD dementia, but we must not drown in thechallenges created by our own discovery.

Innovating Alzheimer’s with care Book series Health, Technology & Society – Palgrave Macmillan

Editors: Marianne Boenink, Harro van Lente Ellen Moors

10.15 – 11.00 Peter Whitehouse – Responsible innovation: the past, present, and future of Alzheimer's diagnostics and therapies

•Focus on how to ensure innovation has ‘the rightimpacts’•Oriented towards goal and process of innovation astrajectory with many actors and stakeholders•Aims to make this process more anticipatory,reflexive, deliberative, inclusive and responsive(systems thinking)•Opportunity costs considered•Includes reflection on influence of power and money

Responsible Innovation

Reading Mentor Program

Bioethics: Bridge to a Global Future ?