Jun 29, 2010

Dementia and Depression -- How to get a "Fully Baked" Diagnosis

Why not try and treat what is able to be treated? It may just save your family from unnecessary grief.....
By Carole B. Larkin
Alzheimer's Reading Room

The Alzheimer’s Association, the Alzheimer’s Foundation of America -- and other groups that deal with Alzheimer’s disease and other dementia -- all advocate diagnosis. They are right, of course, but there’s more to it than that.

Real differences abound in diagnoses -- the "half baked" diagnosis and the "full baked" diagnosis. A half baked diagnosis is a doctor who asks a few memory questions and then says,”Yes, you have dementia. Here, take this.” He gives you a prescription for Aricept or one of the other four FDA approved drugs. A full baked diagnosis consists of three parts:

An MRI or similar scan. Two things can be seen on the scan. The first is white spots indicating that a “mini-stroke” (or TIA) has taken place in that area of the brain. The importance of finding mini-strokes is that none of the four FDA approved medicines do any good when someone has had a mini stroke.

If you are prescribed one or more of the drugs approved to treat Alzheimer's and your loved one has Vascular Dementia (dementia coming from mini or regular strokes in the brain) you are just throwing money on a "half baked diagnosis". A better use of your money might be to give your loved one something that they really love and that brings them momentary happiness? (Dark chocolate for me!)

An MRI will also show atrophy of the brain (the brain shrinking). If the brain has shrunk you can see an actual space on the MRI between the brain and the skull bones. I call that the “Air Gap”. After all, dead brain cells are skinnier than live brain cells, so they take up less space in the head. If the front of the brain (behind your forehead) has a bigger air gap than the middle or back part of the brain; then the diagnosis may be in part, Frontotemporal Dementia, which is different from straight Alzheimer’s. A neurologist that deals with Frontotemporal Dementia should be the doctor consulted for medicines appropriate to that disease.

Specific blood work looking for other things that can cause dementia, like thyroid deficiency, B12 deficiency, potassium deficiency, and other types of chemical imbalances showing up in the blood. These things can be correctible, thus ending the dementia.

Finally, a series of verbal and physical tests that not only test memory, but also test executive skills, such as: time/space orientation, attention span, concentration abilities, and expressive language ability among others. These tests take between two and four hours to complete.

Only if all of the above are done, do you get a true diagnosis, at this point in time. I’m sure that more tests will be done in the future to be able to further refine the diagnosis but right now that’s all we have available to most people. The special PET and other imaging scans are usually done for research purposes and are cost prohibitive for most people. Eventually I hope we have them available on a regular basis.

The Link between Depression and Dementia

The link between depression and the dementias is not discussed much -- but it is real.

Research shows a correlation between persons who already have depression and risk for developing Alzheimer’s. We know that depression is a risk factor for Alzheimer's and other dementias. We know that the diseases can be "co-morbid" (two or more disorders simultaneously), using doctor-speak. We already know that many people have depression that is never treated -- even before the cognitive diseases show up.

What I haven’t seen are warnings to the caregivers to be extra vigilant with their loved ones who already have signs of depression when they are diagnosed with Alzheimer’s or a related dementia. A diagnosis of Alzheimer’s or other dementia could, and most likely does exacerbate the already existing depression and could easily result in as depression so deep that the person decides to act (suicide). I personally know of at least one family in the Dallas area that suffered this result. What a tragedy for the family.

What is the harm of trying an antidepressant -- unless it might not mix well with previously existing meds? The caregiver would be able to see if it helped their loved one or not, possibly within a month's time. If the attitude and behavior are not better, the antidepressant gets tapered down and eventually stopped. If the attitude and the behavior get better -- you’ve found the correctable part of the problem and done something positive about it. I have found that antidepressants have made a huge difference in quality of life in some people with cognitive illnesses.

New research seems to point out that the flat effect (decrease in strength of emotion) in Alzheimer’s and other dementia sufferers is what exists rather than depression. In some people I’m sure it’s true. I've seen it. But when people absolutely refuse to get out of bed every morning, cry at the drop of a hat, and talk constantly about wanting to die, there’s every reason to think that there is depression going on, not just a flat effect.

The message to families is to watch their loved ones closely at and after diagnosis of a cognitive disease. If they seem depressed, or even just dull and emotionless, you want to consider taking them to a psychiatrist (geriatric, if possible) to let the professional sort out the diseases.

Why not try and treat what is able to be treated? It may just save your family from unnecessary grief.

Printable version of this article -- http://docs.google.com/View?id=dft6gc32_50g24sc3gj

Carole Larkin MAG, CMC, DCP, EICS is a geriatric care manager who specializes in helping families with Alzheimer’s and related dementias issues. 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 sufferers. ThirdAge Services LLC, is located in Dallas, TX.

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Original content Carole Larkin, the Alzheimer's Reading Room