Jan 17, 2010

Doctors and Family Not Good at Detecting Alzheimer's and Dementia

Diagnosing mild-to-moderate dementia cases can be difficult. Indeed, more than half of such cases are not recognized by physicians.......

By Bob DeMarco
Alzheimer's Reading Room

This comes as no surprise to me.

When most people think of dementia and Alzheimer's disease, they think of memory loss. The image in their mind is of someone laying in a bed, unable to recall their loved one's name. This is the end stage and sometimes comes a decade or more after the initial diagnosis.

The inability of physicians and family to recognize mild cognitive impairment indicates that we have a long way to go in raising public awareness about dementia. As most caregivers look back, they can tell you about telltale signs of the disease that they missed. In retrospect.

What is the Difference Between Alzheimer’s and Dementia

To me, early detection of Alzheimer's and dementia is all about recognizing subtle behavioral changes in older people. Tiny little behavioral changes that gnaw at your stomach. The dragging and scrapping of the feet on the ground. The inability to find the bathroom in a relatives home they have been visiting all their lives. Trouble paying bills. Complaining about money. Fear. Angst. Changes in behavior like meanness, hoarding, or worrying about one single thing over and over.

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The typical reaction to these subtle behavior changes is to think and believe the person is getting old. When you talk to your family and friends about these little subtle changes you are likely to hear them say -- she is getting old. Hearing that brings on a sense of relief and allows you to bury your head in the sand. For a while. Until things get worse, much worse.

This is what happened to me. It stayed that way until that little gnawing in my stomach became a stomach ache. Keep in mind, my mother was living on her own and taking care of herself --even driving -- while this was happening.

Finally, I decided to get to the bottom of things. Even after I determined that there was something wrong with my mother -- very wrong -- I still didn't know what it was. I didn't know what to do. So like most people in this situation I relied on my mother's personal care physician of many years. Guess what he said? Three guesses. He said, "she is getting old".

Alzheimer's and dementia are sinister. They are sneaky and tricky -- at first. Alzheimer's causes denial in everyone that gets near it. This denial is not limited to family and friends. The personal care physicians are in denial. Or worse, they think getting old means you don't deserve the same treatment they would give to a younger person. Yes, this is definitely a part of the problem.

Hey your old. You won't be around much longer anyway. So why bother.

It seems to me that when someone goes into a personal care physician and says they are worried about the way their loved one is behaving the personal care physician should say -- hmm, she is getting old, we better get her a memory test from a specialist.

Would it be hard to train the doctors to do this. It seems that it is.

All people deserve the same treatment regardless of age. Now all we need to do is convince the doctors. This won't be easy.

Best Practices Identified for Early Alzheimer’s Detection

Diagnosing mild-to-moderate dementia cases can be difficult. Indeed, more than half of such cases are not recognized by physicians, according to a recent review of the literature at the Medical College of Wisconsin in Milwaukee. In fact, family members and caregivers, in addition to many physicians, often overlook a decline in cognitive function as well.

To improve prompt diagnosis, Diana Kerwin, MD, assistant professor of medicine and geriatrics, offers the following recommendations published in a recent issue of The Journal of Family Practice:
  • Avoid age bias when determining the need for cognitive screening
  • Screen the vulnerable elderly, or individuals 65 years of age and older who are at high risk of death or functional decline, at the initial visit and annually after
  • Test all patients undergoing cognitive screening for depression as well.
According to Dr. Kerwin, because of the low diagnosis rate by physicians, and the lack of awareness by caregivers, physicians should perform cognitive screening on all high risk patients who are suspected of Alzheimer’s disease, regardless of their age.

Physicians should also perform initial and annual screenings on the vulnerable elderly, and screen suspected Alzheimer’s patients for depression in addition to cognitive function in order to improve early detection of the disease.

As the Baby-Boom generation ages, the number of Alzheimer’s disease cases is expected to surge from the already significant amount of five million cases. Increased awareness and diagnosis will provide optimal care for the aging population.

Early detection of cognitive impairment is also extremely important because the impairment may be related to other medical conditions, such as head trauma, Parkinson’s disease, human immunodeficiency virus (HIV), and thyroid disorder.

Additionally, early detection provides medical, behavioral, and social intervention that may delay cognitive and functional decline.

The US Preventive Services Task Force guidelines recommend that physicians evaluate patients for dementia whenever there is a suggestion of cognitive impairment, based on clinical observation, or based on family or patient concern.

Because psychiatric disorders can impersonate dementia, or can be present simultaneously, suspected dementia patients should also be screened for depression. Depressed patients often complain of memory problems more than those with cognitive dysfunction.

Additionally, depressed patients exhibit impaired function more so than dementia patients. Depression usually interferes with concentration; however, dementia patients appear to concentrate normally, but have greater intellectual strain when answering questions.

The following is a list of optimal screening tests and tools to prevent delayed diagnosis of mild-to-moderate dementia patients:
  • The Mini-Mental State Examination (MMSE)
  • The Mini-Cog
  • The Montreal Cognitive Assessment (MoCA)
  • The AD 8 Dementia Screening Interview
  • The 7-Minute Neurocognitive Screen

Test Your Memory for Alzheimer's Disease (5 Best Self Assessment Tests)

The MMSE is the most widely used cognitive screening tool because it is easy to administer, tracks changes easily, is widely accepted, and is available in more than 50 languages; however, it is not sensitive to mild dementia, and is influenced by age, education, and language skills.

The Mini-Gog is easy to administer, is unaffected by education and language skill, and is highly sensitive to mild dementia.

The MoCA is more time consuming than other tools, but is highly sensitive to mild dementia, available in greater than 20 languages, and diagnoses patients who have memory complaints, but normal MMSE scores.

The AD 8 Dementia screening interview identifies the earliest stages of dementia, but is intended for a family member or caregiver. The 7-Minute Neurocognitive Screen is highly sensitive to early stages of dementia.

Family, friends, and caregivers can also watch for early cognitive decline, thereby helping physicians with early Alzheimer’s detection.

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Original content Bob DeMarco, the Alzheimer's Reading Room