The Small Guide to Alzheimer's Disease - Gary Small

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American Academy of Neurology (www.aan.com). This professional organization advances the art and science of neurology, thereby promoting the best possible care for patients with neurological disorders.

       • American Association for Geriatric Psychiatry (www.aagponline.org). A professional organization that is dedicated to enhancing the mental health and well-being of older adults through education and research.

       • American Geriatrics Society (www.americangeriatrics.org). A professional association that provides assistance in identifying local geriatric physician referrals.

       • American Psychiatric Association (www.psychiatry.org). A medical specialty society that works to ensure that mental disorders are accurately diagnosed and receive effective treatments.

      Another important referral source is your local university medical center department of psychiatry, neurology, or medicine, particularly geriatric medicine. Doctors affiliated with reputable academic medical centers are generally accomplished individuals with excellent credentials and experience. Local or national branches of professional societies like the American Psychiatric Association as well as national advocacy groups like the Alzheimer’s Association can also be useful referral sources. Members of these groups usually agree to professional and ethical standards set by the organizations, and they often provide continuing education to their members.

      When patients and their families come to me for help with cognitive issues, I take a systematic approach. I try to assess the clinical issues at hand, but I also need to gain the patient’s trust if we are to move forward together with a treatment plan. Educating people at the outset about what to expect is an important first step to building that trust—with both patients and their families. Unless the patient has very mild memory complaints, family members usually accompany them to the first visit.

      Following introductions, I explain what I hope to accomplish with them at the initial appointment. I also ask patients and their family members about their expectations so I can better understand what they want to accomplish. I describe the type of information that I need to obtain in order to understand the patient’s particular cognitive problems and plan a treatment strategy.

       • Obtain a history of the symptoms from patients, caregivers, and family members. This includes the date of onset of problems, other medical conditions, and any medications being taken.

       • Perform a neurological and general physical examination as well as a mental status exam using standardized rating scales, such as the Mini Mental State Examination (MMSE) or the Montréal Cognitive Assessment (MoCA) test.

       • Determine the patient’s functional abilities and level of independence.

       • Draw blood for laboratory testing to assess whether medical illnesses are present.

       • Perform a brain scan, such as a magnetic resonance imaging (MRI), a computed tomography (CT), or possibly a position emission tomography (PET) study.

      Although I first meet with everyone together, I let them know that I will spend time alone with each of them during the appointment. Explaining this at the beginning of the visit helps minimize any anxious or paranoid feelings that patients or family members may experience when I request to speak with individuals alone. It also makes it easier to perform cognitive testing on the patient without caregivers cueing the patient and biasing the assessment. Further, those individual meetings allow family members to speak more freely about their concerns when the patient is out of earshot.

      Visiting the doctor can be quite an anxiety-provoking experience. This is especially true when people are concerned that the diagnosis may be one that will have a negative prognosis, such as Alzheimer’s disease. That anxiety can distract patients and family members to the point that they often forget important questions they wanted to ask during the appointment.

      It’s a good idea, therefore, to write out your questions in advance of the appointment with the doctor so you are sure to cover all the points that you wish to address. It’s also helpful to bring in a summary of the patient’s medical history. In order for doctors to summarize the patient’s problems, they generally follow a systematic approach. Knowing this system that doctors use to organize their notes (see box) can help you prepare for their needs.

       • Chief complaint. Main symptom(s) of concern to the patient/family

       • History of present illness. An account of the timeline and nature of the current illness

       • Past history. A summary of previous relevant illnesses, both general medical issues and neuropsychiatric conditions

       • Educational and social history. A review of accomplishments and challenges

       • Risk factors and protective factors. Smoking, alcohol, head trauma history; exercise, diet, psychological stressors; and other relevant lifestyle habits

       • Review of systems. A check of different body organs and systems (eyes, lower-body function [i.e., gait], lungs, heart, etc.)

       • Pertinent medical history and medications. These details sometimes shed light on physical conditions that can impair cognition

       • Physical, neurological, and mental exam results, previous test and scan results. The doctor’s summary of the findings from the evaluation procedures and medical record

       • Impression. The diagnostic impressions listed by the doctor

       • Treatment plan. The doctor’s itemized plan, including need for more testing, medication interventions, and nonpharmacological strategies

      It’s important to bring a list of all the patient’s current medications to the appointment with the doctor. Over the years, patients tend to change doctors or have multiple practitioners caring for them, so taking an inventory of all the medicines can not only be revealing; it can also lead to improved cognitive abilities and overall better care. If the medication regimen is disorganized or complicated, I encourage families to bring the actual medication bottles to the appointment so I can review them systematically with the family. This is very important because so many medications can trigger cognitive symptoms, and sorting out what might be causing side effects or drug interactions can have an important impact on the patient’s outcome.

      Usually patients with cognitive complaints are older, and as we age we are more likely to take multiple medications. Approximately 10 percent of patients presenting with suspected dementia are experiencing a medication side effect that is contributing to the cognitive decline. Several medicines used to treat psychiatric illnesses, sedating drugs, or narcotic agents can disrupt cognition as well. Histamine H2 receptor antagonists (e.g., famotidine or Pepcid, cimetidine or Tagamet) for stomach problems, cardiac medications such as digoxin and beta-blockers, corticosteroids, nonsteroidal anti-inflammatory agents

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