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Monday, November 12, 2012

Changes in Diagnosing Alzheimer's and Related Dementias


I am heartened by the medical profession stepping up to the plate and attempting to make doctors do a better job of diagnosing neurocognitive diseases. I think that it’s about time.

By Carole Larkin
Alzheimer's Reading Room


Changes in Diagnosing Alzheimer's and Related Dementias
The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) published by the American Psychiatric Association will be released in May 2013.

This is the “rule book” for all doctors making their diagnoses of neurocognitive disorders.
This includes family doctors, internists, geriatricians, neurologists, psychiatrists, and whoever else will diagnose what is currently termed as dementia.

The DSM-5 is substantially changed from what is in existence now with the DSM-IV. This is carefully explained in a wonderful article in the current issue of Aging Well Vol. 5 No. 6 P. 12 written by James Silberski, MS, CMC. For the complete article see: www.agingwellmag.com/archive/110612p12.shtml

He points out results of these changes that both hearten me and dishearten me in relation to families who seek a diagnosis for their loved ones living with dementia.

To summarize some of the changes:
The definition of Delirium has been revised. It includes a disturbance in attention and orientation to the environment developing over a short period of time (hours or a few days) which is an acute change from baseline and fluctuates within the course of a day. It can be distinguished from a previously existing cognitive disease. 
The term “dementia” has been dropped from the book. Instead it is replaced with the terms “major or minor neurocognitive disorder”. The term dementia was felt to be too stigmatizing. 
All physicians must now first establish the presence of a neurocognitive disorder and then determine if the disorder is major or minor.  
The evidence of a decline in cognition is based on the concerns of the individual themselves or from a knowledgeable informant or the clinician and typically involves test performance in the range of one or two standard deviations below the appropriate norms to be a minor disorder (between the third and sixteenth percentiles) and above two standard deviations to be a major disorder (below the third percentile). 
The difference between minor disorder and major disorder involves the determination that the deficits shown are enough to imperil living independently or not being able to live independently. 
After determining whether the neurocognitive disorder is major or minor, the clinician must then determine the type of neurocognitive disorder it is. 

The disorders listed are: Alzheimer’s disease, Vascular disease, Frontotemporal disease, Traumatic Brain injury, Lewy body disease, Parkinson’s disease, HIV infection, Substance abuse, Huntington’s disease, Prion disease or other neurocognitive disorder not classified elsewhere.
Mr. Silberski voices some concerns over implementation of this policy. I agree with him and wish to add some more of my own.

Physicians will have to spend time and effort transitioning to this new system, namely learning the differences between major and minor disorders and the intricacies of diseases other than Alzheimer’s disease and then explain them to patients. Will they do this or just ignore the whole thing?

Billing codes will be based upon neurocognitive tests which deliver answers in the form of standard deviation and neither of the two preferred tests (the MMSE or the Montreal Cognitive test) do that.
Physicians will have to switch to new tests in order to get paid for using them. Will they do that?

Clearly the intent of these changes is to force physicians to do a more thorough diagnosis than is currently being done. Will physicians order the blood work, brain scans and other testing necessary to define the differences between cognitive disorders? It’s expensive to order MRI’s, Pet Scans and Cerebral Spinal Fluid testing and the current trend in medicine is to penalize physicians for ordering “unnecessary” tests.

Will these tests be viewed as unnecessary and driving up healthcare costs?

Physicians now will be in the position of determining if patients are capable of being independent or not and will have to defend that position with documentation of test scores, etc.

In the past, the determination of the ability to be independent could be seen as a subjective decision and was reached in conference with the patient and family members. Will physicians now be willing to “go it alone”?

Older adults and their families are confused now about the meaning of and differences between neurocognitive diseases (or simply between Alzheimer’s and “dementia”).Will more specificity in identifying the diseases cause even more confusion?

Patients will hear that they have either “major” or “minor” diseases. Will hearing that they have a “minor” disease cause them to think it is trivial and ignore treatment of it?

Will they avoid taking steps to address future issues (legal concerns, safety concerns, etc…)? Also will the change agents (the children) be less concerned and not take steps to prepare for what is to come?

Mild Cognitive Impairment (MCI) is not included in this revision. Is this an oversight or by design? If by design, does this not negate the impetus to diagnose early in the diseases?

I am heartened by the medical profession stepping up to the plate and attempting to make doctors do a better job of diagnosing neurocognitive diseases. I think that it’s about time!!!

I am disheartened that in the attempt, that they have made it so time consuming and difficult that they may have defeated their purpose with a number of physicians, particularly internists and family physicians.

Still, it’s a start, and that’s more than we had before.

Carole Larkin MAG,CMC,CAEd,QDCS,EICS,
is a Geriatric Care Manager who specializes in helping families with Alzheimer’s and related dementias. She also trains caregivers in home care companies, assisted livings, memory care communities, and nursing homes in dementia specific techniques for best care of dementia patients. ThirdAge Services LLC, is located in Dallas, TX.

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Original content the Alzheimer's Reading Room