The Small Guide to Alzheimer's Disease - Gary Small

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and I could try to do a casual assessment without Harry even knowing it.

      Steve opened the front door and seemed relieved to see us. We went into the den where Harry was watching football.

      “The Smalls are here, Dad. You remember them, right?”

      Harry looked at us with a total lack of recognition. “Right. How ya doing?”

      “Fine. Good to see you.” I sat down on the couch and asked, “Who’s winning?”

      “Winning?”

      “The football game?”

      “Oh.”

      I suspected that Harry didn’t know who was playing, let alone who was winning.

      We sat and chatted during the game. I could see that Harry was having trouble following the conversation, but like so many other patients in the early stages of cognitive impairment, Harry was still pretty good at faking it. He nodded, cheered, and laughed when everyone else was doing it, but I could see he didn’t really get the jokes or engage in the conversation.

      After the game, we moved to the dining room for dinner, and I sat next to Steve’s dad.

      “So, Harry, how long are you staying for this trip?”

      “Don’t know, but it’s great having the kids home again.”

      As we ate our salads, I noted that Harry was having trouble staying oriented and tracking the conversation.

      When dinner was served, Harry turned to Steve and said, “Remember when I caught you dressed up in your sister’s clothes? You should have seen your face!”

      “I was five, Dad.”

      Harry reached over, grabbed an asparagus spear off my plate, and took a bite. “This is so good.”

      The more time I spent with Harry, the more convinced I became that he was suffering from a significant cognitive impairment. He could still recall details from years ago, but his memory for recent events was definitely off. In fact, Harry’s short-term memory was so bad that it was hard to believe he still lived on his own. Although his symptoms pointed to Alzheimer’s dementia, I didn’t have enough information to confirm that diagnosis.

      I was also concerned about Harry’s deteriorating social skills. Eating food off my plate and embarrassing Steve with inappropriate comments suggested a problem in his frontal lobe—the part of the brain that controls judgment and social graces. This kind of behavior can indicate the early stages of frontotemporal dementia, which can often be mistaken for Alzheimer’s but has a different brain effect and responds differently to medicines. At the end of the evening, I was convinced that we needed to get Harry in for a brain scan to help pinpoint his diagnosis and get him started on the right treatment.

      Unfortunately, getting Harry in for a scan was not the only problem. Steve was having a hard time processing the idea that his father was truly declining mentally. Like many of my patients’ family members, Steve was a smart guy who wanted the best for his father, but he hadn’t really expected to hear how serious Harry’s cognitive decline had become. He was upset, and I can certainly understand that. When my own mother began to forget things and repeat herself over and over, intellectually I knew what was happening, but emotionally I wanted to ignore it. The fact is that denial is a common emotional stage that most people experience when coming to terms with the reality that a loved one may be losing their mental abilities.

      For many people, overcoming such denial—one way or another—is the first step to getting help. Unfortunately, when patients and their families finally decide they do want help, many are uncertain where to find it. They may not be sure whether a psychiatrist, neurologist, geriatrician, or some other specialist is the best person for them, so they end up seeing numerous specialists and obtaining several unnecessary and repeated evaluations, scans, blood tests, and lumbar punctures. Many times a second opinion is helpful, but too often patients end up with too many conflicting opinions, and rather than focusing on a clear path forward, they can become unsure of who to trust and what to do.

      I believe that the best thing to do first is to discuss any memory concerns with a doctor you trust, who is often your primary care physician (PCP). It may be an internist, family practitioner, or any doctor you know and have faith in. Many different specialists and generalists know how to diagnose and treat Alzheimer’s disease and related conditions. However, in some circumstances, specific types of specialists are better equipped to deal with the problems at hand.

      Because of the shortage of neurologists and geriatric psychiatrists, many primary care doctors have developed expertise in diagnosing and treating dementia. Then again, certain clinical situations are best addressed by particular specialists.

       • Primary care physicians. For typical cases that do not present in unusual ways, internists and family practitioners who have an interest in cognitive problems are able to effectively diagnose and treat patients with dementia.

       • Geriatric psychiatrists. These specialists are well equipped to care for patients who have symptoms of depression, anxiety, personality change, or psychosis that often develop along with their cognitive symptoms. Geriatric psychiatrists can also be helpful if psychological conflicts emerge among family members.

       • Neurologists. Any patient experiencing a cognitive decline along with a neurological condition such as Parkinson’s disease or Huntington’s disease might wish to seek a consultation from a neurologist.

       • Geriatricians. Patients with multiple medical problems or gait instability, as well as those aged 80 years or older, may benefit from seeing a geriatric internist.

      In addition to determining the kind of specialist who might be suitable, it’s helpful to come up with a list of the most important qualities you are seeking in a doctor. These may include age, background, clinical style, and other professional qualities. Keep in mind that even if you find a doctor who meets your qualifications, the two of you may not click when you meet in person. That personal connection is important since you will likely have lots of questions for your doctor and you will want to feel comfortable while communicating. Always ask yourself whether this doctor is the kind of person you could trust and who will take your questions seriously. Keep in mind that many doctor/patient relationships strengthen over time as mutual trust builds. However, if your doctor turns out to be unpredictable and inconsistent, it will be hard to develop trust.

      One of the best ways to find a doctor is to ask for referrals from people you already trust. If you are not comfortable with your own personal physician but you happen to know someone in the medical field, that person could be an excellent referral source. Friends and relatives who have dealt with patients with cognitive problems themselves can be good referral sources as well. Chances are they went through their own vetting process to find their doctor, and they may be able to enlighten you about who’s out there and who might be a good fit for you.

      The websites of the following organizations include links that can guide you to doctors in your area:

       • Alzheimer’s Association (www.alz.com). This national organization provides information on services, programs, publications, and local chapters.

       • Alzheimer’s Foundation of America (www.alzfdn.org). A nonprofit foundation supporting strategies that help lighten the burden and improve

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