Assessment

When Should I be Concerned?
When someone’s behavior changes without cause (like irritability) or instrumental Activities of Daily Living (ADLs) like menu planning, cooking, become erratic. Or, when basic ADLs like personal hygiene, dressing appropriately, taking one’s medications correctly fail. Problems in ADLs often appear when family reports that the patient is not changing their clothes, or bathing as frequently as they once did. See the 10 Signs of Alzheimer's at the Alzheimer’s Association web site for more. When these problems are seen in conjunction with short-term memory loss, repeating oneself, impaired judgment, word-finding or fluency problems, and/or episodes of confusion, then evaluation is called for.

Why Try to Discover Dementia Early?
First of all, it may not be dementia. Medical problems (e.g., a UTI), severe depression, or even over-the-counter sleep aides can cause confusion and memory difficulties. If it is dementia, then the earlier it is detected the sooner treatment can start. Remember, many types of dementia can be reversed. We have four FDA approved medications that will not cure (i.e., repair the damage from) dementia, but they have been shown to slow its behavioral and, possibly, its neurological decline. Knowing one has dementia, or its precursor state Mild Cognitive Impairment, can allow time for important legal planning to protect one’s estate. Also, risk factors can be evaluated and reduced like diabetes and smoking. Steps to reduce AD risk like adding the right vitamins, certain types of exercise, eating dark chocolate, and even moderate alcohol drinking can be started early, when they help the most.

What to do?
The first step is to talk to the patient’s primary medical provider (PCP), usually a doctor, nurse practitioner or physician’s assistant. The PCP may do a brief screening using the Mini Mental State Exam (MMSE). The MMSE is not sensitive to Mild Cognitive Impairment or early dementia, so even though a patient does well on this measure, it cannot rule out possible dementia. Doctors are now using the Montreal Cognitive Assessment (MoCA) which is a better screening test, you know it's the one that found President Trump 100% normal. It was validated on less than 100 Canadians, so it has limitations of course. It is better than the MMSE at ruling in possible early neurocognitive disorders, but neither the MMSE or MoCA are very good at ruling out early neurocognitive disorders. In other words it is more likely to miss them when they are present, rather than fail to rule them out when they are not present. Confusing, but that is a basic testing tenet regarding a measures sensitivity vs. its selectivity.

If you are worried, insist on a referral for more comprehensive testing. Call your local Council on Aging (COA), Alzheimer's Services (508-775-5656) or Elder Services (508-394-4630) for advice on a referral for dementia assessment in the Southeastern Mass area.

Do I need a Brain Scan?
The changes inside the neurons associated with Alzheimer's Disease (AD) are so tiny they can only be seen under as election microscope, which requires a sample of brain tissue which most people are unwilling to provide, at least until after they die. So scans are not helpful in diagnosing AD. However, they can pick up signs of stroke disease which can be helpful in diagnosing vascular dementia, or they might in a rare occasion pick up other pathology like a tumor. Your doctor can help you decide if one is warranted.

If you have a brain scan and the report describes reduced brain volume, don't worry. The blood flow to the brain shrinks by about 30% by age 70 so one shouldn't be surprised if "atrophy" or loss of brain volume is determined. Studies continue to look at volumetric size of the hippocampus, a brain structure involved in new learning and forming new memories; however, there is not yet adequate evidence that this is useful to diagnosis. If you would like to participate or learn more you can contact her. Presently, according to Dr. R. Wilson, a neuropsychologist at Rush University's Alzheimer's Disease Center, about a third of people who die without any signs of cognitive impairment have enough neurofibrillary tangles (damaged material in the neurons) and plaques between the neurons to meet current criteria for the disease. So while postmortem analysis can diagnose AD accurately, this effects cognitive changes altering life quality only two-thirds of the time.




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