Originally written for Thayer - You write - "I'm concerned about my mom. My brothers and sister thinks she has the onset of AD. I'm either in denial or hoping for the best. Anyway what is the intial test she would take to diagnois the disease? How should I approach her on it?"
Recognizing dementia in a family member is sometimes very difficult. When our family member is experiencing various difficulties, we at first attribute it to “just getting older”. Sometimes the difficulties amplify when there are major changes in the person’s life – such as moving to a new location or the death of a spouse – and we blame the change without realizing that a dementia may be the basic cause of the confusion.
In Alzheimers, memory problems are usually the first problem to be noticed. The specific problem is putting new memories into storage, while existing memories from earlier times are not affected. The reason is that brain damage is greatest in the hippocampus, a small portion of the brain that controls the memory storage process. In alzheimers, the disease process zeros in on the hippocampus before other parts of the brain are significantly affected. The kind of problems seen when a person cannot make new memory includes losing the car in a parking lot frequently, asking a question over and over (because they cannot remember the answer you give them), repeating conversations (cannot remember that they already told you before). All of us forget things as we get older – but we realize what we forgot when reminded. A person with Alzheimers never puts the information into memory and will not remember the event when reminded (prompted).
There are some other types of dementia that do not affect memory formation in the early stages the way Alzheimers does. One dementia has prominent problems of personality change while the memory is not affected. So you should not judge by memory alone. Other dementia problems include; trouble with reasoning, making decisions dealing with more abstract concepts like math ( paying bills, keeping the checkbook, understanding bills and bank statements), reliance on cash, carrying large amounts of cash instead of using checks. Later, losing the concept of time. getting lost while driving (visual-spatial function needed for processing/remembering location) understanding procedures for activities of living ( meal planning, making out shopping lists, shopping from the list, making multi-course meals, cooking with basic ingredients – may warm up prepackaged food instead) keeping the house clean and in good repair
To see lists of problems that a person with dementia experiences, use the search box at the upper left to look for posts titled "FAQ". There are three posts dealing with the problems seen in dementia.
FAQ4 - The Ten Warning Signs of Alzheimer's The 10 warning signs published by the Alzheimers Association is the most widely quoted list, however, it is difficult to correlate specific problems to the general categories in the list.
The following two lists contain some specific behaviors and difficulties that people with dementia commonly have with activities of daily living. Take a look and see if there are difficulties that your family member is having. FAQ7 - Behavior Changes in Alzheimer's Three Stages FAQ22 - The 7 Levels of Dementia
If you think your family member has several difficulties and you suspect dementia - List the different problems with a brief description of the problems (and when each problem first occured. The doctor will be interested in the length of time over which the problems developed.) Get the list to the doctor before an appointment. This is important, because family doctors are notorious for brushing off vague complaints of depression or memory weakness. You need to provide instances of other thought deficits that support the possibility of dementia. Also, it is difficult to list these problems in front of your family member, and doing so will provoke a reaction and impair the relationship you have with the person. Most doctors will be discrete about reading the list. Keep it to less than one page and keep it very factual to make sure it gets read. Deliver this list/write up to the doctor’s office and instruct the staff to place it in the patient’s chart where it will be read at the beginning of the next appointment.
Then you have to get the person to the doctor’s office - this may be easier said than done. People with classic Alzheimers are totally unaware that they have any memory deficit (lack of self awareness). They know that life is more difficult than it should be, but they blame all these difficulties on others. The person with Alzheimers is unwilling to recognize that they have a problem and will actively fight against going to the doctor about a problem that they KNOW that they do not have.
Families usually use a behind the scenes approach to get the person to the doctor. They accompany the person to a regular appointment, play up any physical ailment to get the person to make an appointment, or call the doctors office and have the office call the person with some reason why they should come in (a follow up appointment, haven’t been in for a while, need a med review, etc)
You must accompany the person and go into the exam room with the person. Use any excuse (you have a minor question to ask the doctor, etc). Too often the person will go into the appointment alone and then come out and announce that the doctor said everything is fine! – then what do you do? Also, the doctor is not allowed to talk to you unless the patient is present, or has written authorization to discuss the person’s condition. While waiting for the appointment, help the person fill out paperwork. If you do not have a POA (Power of attorney for health)get a copy of a medical information release form from the receptionist– put it at the bottom of the paperwork, and try to get the patient to sign it without making a big deal about what it is. Less than honest? – perhaps- but at this stage you must fib, make up stories, anything to get the person the help they need.
Most family doctors will not diagnose dementia – they will refer to a neurologist for a proper diagnosis. The resistant family member will usually respect the authority of the doctor and follow through with the doctor’s instructions. Skillful doctors will downplay the problem and gently explain that there is something that needs to be followed up. Subtle is better to avoid provoking a negative response.
The family doctor is usually the entry point for getting a diagnosis. The doctor will order a number of lab tests to find out if there are physical conditions contributing to the situation. The neurologist will want to have these lab results when making the consultation. The doctor may not know what specialist to use for the evaluation. You can call your local alzheimers Association to find out who the dementia specialists are in your area. While any neurologist can make a basic diagnosis, a dementia specialist is better for follow-up care and diagnosis of more unusual types of dementia.
At the office of the Neurologist, it is helpful to sit in the corner where your family member cannot see you (behind the person). The doctor is likely to ask questions like "do you do the cooking for your family?" and look to you for an indication of whether your family member is answering the question accurately. (People with alzheimers often claim to do things that they stopped doing long ago.)
The neurologist will want to know what meds the person is on, so bring a list of all meds the person is on and when taken (Or just bring all the med bottles in a big Zip-lock bag) including regularly taken OTC meds and herbal suppliments. (many meds can contribute to the level of confusion.)
The very basic screening test the the MMSE (mini mental state examination) It is a thirty question that tests memory and other basic thought process. The doctor will usually run other blood tests to rule out vitamin deficiencies, metabolic imbalances, or other illness. Follow up with an MRI brain scan is common. The MRI will look for the subtle signs of Alzheimers and rule out other possible brain adnormalities (signs of stroke, tumors, etc.)
One other thing that must be mentioned, people with Alzheimers lack initiative. You can not rely on the person to follow through, to make appointments, to remember and go to appointments. You must step in and make sure that these things happen.
IT MAY NOT BE DEMENTIA YET. You should also be aware that there are people that have problems only with their memory. These people are said to have Mild Cognitive Impairment. They have memory difficulties only, and not the other cognitive difficulties such as judgement and ability to pay bills, for instance. These people can function independently and with out danger to themselves if they use notes, lists, etc to compensate for their reduced memory capacity. The doctor will monitor these people and usually prescribe aricept to enhance memory and slow the memory loss. Many but not all of these people convert over to dementia over a period of years. The conversion rate is about 15% per year.
Norbert
--------------------------------------------------- A writeup that describes the diagnostic process:
--- Steps to Diagnosis --- (from the Alz Organization)
Finding the right doctor
The first step in following up on symptoms is finding a doctor you feel comfortable with. Alzheimer’s Association clients report they are most likely to be satisfied seeing someone who is well informed about Alzheimer’s disease. Your local Alzheimer’s Association can help you find the right doctor. There is no single type of doctor who specializes in diagnosing and treating memory loss or Alzheimer’s disease. Many people contact their regular primary care physician or internist about their concerns. Primary care doctors often oversee the diagnostic process and provide treatment themselves. In some cases, the primary care doctor may refer a patient to one of the following specialists: • A neurologist, who specializes in diseases of the brain and nervous system • A psychiatrist, who specializes in disorders that affect mood or the way the mind works • A psychologist with advanced training in testing memory, concentration, problem solving, language and other mental functions
Steps to diagnosis
There is no single test that proves a person has Alzheimer’s. The medical workup is designed to evaluate overall health and identify any conditions that could affect how well the mind works. Experts estimate a skilled physician can diagnose Alzheimer’s with more than 90 percent accuracy. Doctors can almost always determine that a person has dementia, but it may sometimes be difficult to pin down the exact cause. Understanding the problem Be prepared for the doctor to ask: • What kind of symptoms have you noticed? • When did they begin? • How often do they happen? • Have they gotten worse?
Reviewing medical history
The doctor will interview the person being examined or family members to gather information about current and past illnesses. The doctor will also obtain a history of medical conditions affecting other family members, especially whether they may have had Alzheimer’s disease or a related disorder.
Evaluating mood and mental function Mental status testing gives the doctor a general idea of whether a person: • Is aware of having symptoms or feels nothing is wrong • Knows the date, time and where he or she is • Can remember a short list of words, follow instructions and do simple calculations About the mini-mental state exam (MMSE) The mini-mental state examination (MMSE) is one of the tests most commonly used to assess mental function. In the MMSE, a health professional asks a patient a series of questions designed to test a range of everyday mental skills.
Examples of questions include: • Remember and repeat a few minutes later the names of three common objects (for instance, horse, flower, penny) • State the year, season, day of the week and date • Count backward from 100 by 7s or spell “world” backwards • Name two familiar objects present in the office as the examiner points to them • Identify the location of the examiner’s office (state, city, street address, floor) • Repeat a common phrase or saying after the examiner • Copy a picture of two interlocking shapes • Follow a three-part instruction, such as: take a piece of paper in your right hand, fold it in half, and place it on the floor The maximum MMSE score is 30 points. A score of 20 - 24 suggests mild dementia, 13 - 20 suggests moderate dementia, and less than 12 indicates severe dementia. On average, the MMSE score of a person with Alzheimer’s declines about 2 - 4 points each year.
About the mini-cog
Another popular mental status test is the “mini-cog,” which involves two tasks: (1) remembering and a few minutes later repeating the names of three common objects, and (2) drawing a face of a clock showing all 12 numbers in the right places and a time specified by the examiner. In addition to assessing mental status, the doctor will evaluate a person’s sense of well-being to detect depression or other mood disorders that can cause memory problems, loss of interest in life, and other symptoms that can overlap with dementia.
Physical exam and diagnostic tests
The physician will • Ask about diet, nutrition and use of alcohol. • Review all medications. It is helpful to bring a list or the containers of all medicines currently being taken, including over-the-counter drugs and supplements. • Check blood pressure, temperature and pulse. • Listen to the heart and lungs. • Collect samples of blood and urine. Information from these tests can help identify other disorders that may cause memory loss, confused thinking, trouble focusing attention, or other symptoms similar to dementia. Such disorders include: • Anemia, malnutrition or certain vitamin deficiencies • Excess use of alcohol • Medication side effects • Certain infections • Diabetes • Kidney or liver disease • Thyroid abnormalities • Problems with the heart, lung or blood vessels
Neurological exam The neurological examination is an important part of the physical. Its goal is to assess the function of the brain and nervous system to identify symptoms of brain disorders other than Alzheimer’s.
During the neurological exam, the physician may test: • Reflexes • Coordination and balance • Muscle tone and strength • Eye movement • Speech • Sensation
Brain imaging
New imaging technologies have revolutionized our understanding of the structure and function of the living brain. • Structural imaging provides information about the shape, position or volume of brain tissue. Structural techniques include magnetic resonance imaging (MRI) and computed tomography (CT). • Functional imaging reveals how well cells in various brain regions are working by showing how actively the cells use sugar or oxygen. Functional techniques include positron emission tomography (PET) and functional MRI (fMRI). Currently, a standard medical workup for Alzheimer’s disease often includes structural imaging with MRI or, less frequently, CT. These images are used primarily to detect tumors, evidence of small or large strokes, damage from severe head trauma or a buildup of fluid.
(my note - while most diagnostic workups include an MRI examination, I have read medical articles that state that in an older patient, with a classical presentation, and other common causes are ruled out, that an MRI is not necessary. As the article above states, the MRI cannot diagnose Alzheimers. It's primary purpose is to rule out other causes of brain injury and look for shrinkage consistant with Alzheimers. Very early in Alzheimers, there is not enough shrinkage to really be seen in a way that has diagnostic significance.)
Promising areas for brain imaging research
Researchers are studying whether the use of MRI and other imaging methods may be expanded to play a more direct role in diagnosing Alzheimer’s. Many studies have shown that the brains of people with Alzheimer’s shrink significantly as the disease progresses. Research has also shown that shrinkage in specific brain regions may be an early sign of Alzheimer’s. However, scientists have not yet agreed upon standardized values that would establish the significance of a specific amount of shrinkage for any individual person at a single point in time. Research with PET and other functional imaging methods also suggests that those with Alzheimer’s typically have reduced brain cell activity in certain regions. However, as with the shrinkage detected by structural imaging, there is not yet enough information to translate these general patterns of reduced activity into diagnostic information about individuals. At this time, PET is used primarily in research studies in hopes of gaining further knowledge about its potential for wider use in diagnosing Alzheimer’s and monitoring progression and response to treatment. Today, Medicare will cover a PET scan for Alzheimer’s only to help distinguish the disease from frontotemporal dementia, a rare related disorder that may cause dramatic loss of function in the front and side regions of the brain. Another promising area of functional imaging research focuses on developing tracer compounds that will attach to key abnormal brain deposits implicated in Alzheimer’s. For example, preliminary data suggests that one such tracer, called Pittsburgh compound B, may attach to beta-amyloid and “light up” in a PET scan.
[This Message was Edited on 08/27/2008]
