Timely Detection and Care Planning in Alzheimer Disease
NOVEMBER 06, 2019
Alireza Atri, MD, PhD: OK. This one I’m going to pose to Mary. Mary, what is the value of timely detection, making an accurate diagnosis, and actually creating an appropriate care plan?
Mary A. Norman, MD: As a primary care physician and geriatrician, diagnosing Alzheimer disease and related dementias early is absolutely critical. It really impacts everything else we do for our patients. No. 1 is looking for things that will maximize their cognitive function. Oftentimes, there are many things on a typical medication list for which I take my pen out. We bring all of the bottles in, and we start taking over-the-counter Benadryl, and decongestants, and antihistamines, and unnecessary vitamins away. So that education for the family members and the patients with Alzheimer disease about the impact that these other drugs can have on them.
Early treatment. We do have some medications that will help, and perhaps, change the course of Alzheimer disease. We want to make sure that we educate the patients for that chance to make the right choice for them individually.
Research. That’s where our hope for cure is—in research. My patients typically want to know about research opportunities. Their families want to know about how they can help with research opportunities.
And then I think about care planning and safety, which is just critical. We see, more and more often, that our patients with early Alzheimer disease are really targets for scams. There are safety issues in their home—with leaving the oven on, and with not doing unsafe things. I have to remove ladders. I find that I see a lot of falls in early Alzheimer disease, where they’re trying to climb on the roof like they once could and now they do not have very good judgment. Driving safety, and things like gun safety. So to be able to have that shared decision making with our patients, and family members, and caregivers. How do we optimize health, wellness, and safety?
Alireza Atri, MD, PhD: Wonderful. And so for you, what are some of the triggers for starting an evaluation? And I guess if you think about the who, the patient, who is that patient?
Mary A. Norman, MD: Good question. I think there are quite a few triggers that we have in primary care, and as family members with our loved ones, to recognize that there are some changes from their baseline function. And I think that’s a critical piece. I always tell this story: I always burn the bread when I’m making dinner. It’s the last thing I put in the oven, and I’ve always done that. So when I’m 80 and I burn the bread, that may not be a trigger.
But in my clinical practice, I talk about my detailed engineers. They have come in for the last 10 years with their blood pressure that’s carefully tracked and graphed every day, and now they come in and their blood pressure is off the roof and they no longer are keeping records. I often find someone on thyroid medicines. Well, their TSH [thyroid-stimulating hormone] will be out of whack. They’ll have a change in personality. They come in more depressed. They’re stopping doing activities that they normally enjoy. Sometimes we’ll see family members come in with a concern, and also patients come in. If I ask, “How do you think your memory is? How is your cognition?” Often that will be the trigger where they’ll say, “Things really have slowed down.” And that’s probably one of the biggest questions. When we do our annual wellness visits each year, I ask for goals. I ask what their goals are for the day, for the year, and typically there is some question about cognition in there and wanting to either maintain or worry that maybe there have been changes.
Alireza Atri, MD, PhD: Great. It sounds like concerns or changes that are prompted by the patient themselves, a loved one, or what you see that may be changing in the clinical status, may be a prompt.
Marc, what concerns come to you as a geriatric psychiatrist? What psychiatric symptoms tend to be triggers for you to think that there may be a neurocognitive behavioral disorder that’s driving these symptoms?
Marc E. Agronin, MD: A lot of the changes that Mary mentioned involve not only cognition, but also mood and behavior. And so, without question, we often see hand-in-hand with the cognitive changes in dementia, changes in a person’s ability to regulate their mood. And so, we see increases in rates of depression, increases in anxiety, often in uncharacteristic ways. So even though someone may have had depression and anxiety in the past, we just see now that it seems more resistant, or more difficult for them to manage. It doesn’t always respond as readily to treatment. The person is not always as participatory in treatment. And those may be warning signs that we’re really dealing with an underlying cognitive problem.
I would say there are 2 other areas that are very common that we deal with: One being behavioral changes in terms of agitation. People are more irritable, more reactive than they were before. And this is concerning because those aren’t always typical manifestations of depression and anxiety. Especially when it seems to represent a personality change, we really need to see what’s going on.
The other thing is apathy. Apathy is actually one of the most common neurovegetative symptoms that we see associated with every form of dementia. And so, when we see someone who just is not as motivated—Mary mentioned the example of someone who previously was really good about regulating their blood pressure or their medications, who now suddenly is not doing it, where there’s a lack of motivation, which is different than changes in mood—that’s concerning. And that really warrants a more comprehensive evaluation, looking both at potential cognitive changes in addition to any medical changes and other psychiatric manifestations.
Transcript edited for clarity.