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Dr. Patricia Yarberry Allen is a collaborative physician. Today, which marks the end of World Alzheimer’s Month, she asks neurologist Joseph Safdieh to help her address the concerns of the daughter of a 67-year-old woman whose tests indicate “some kind of dementia.” What, the worried daughter wants to know, are the additional tests her mother should take, and is it important to know what kind of dementia she has?
Dear Dr. Pat:
My mother is only 67, but has begun to exhibit memory loss and some confusion when not in her regular routine. She called me two weeks ago when she could not find her way to my new house (20 minutes away) from her home. She seemed to be unfazed by the fact that she had driven here 4 times before, and thought that it was perfectly normal for me to spend 30 minutes finally locating her, then letting her follow me back to my house. She is thin, has no diseases that we know about, and exercises daily. She did smoke for 40 years, and does have 2 drinks a night. She doesn’t sleep well at all now at night, and frequently naps during the day. She acts like a much older person than her age.
After she got lost, I took her to see her GP, who did blood work and a “mini mental status exam.” She did not do well on this test at all, and became extremely agitated when she could not answer many of the questions. The GP then referred her to a neurologist at the medical center who specializes in Alzheimer’s. The neurologist did a brain scan and other tests and told us that she did not have a brain tumor, Lewy body disease, or fronto-temporal dementia. He agreed with her GP that she has some real cognitive impairment. This specialist told me that my mother should not drive anymore, and that we needed to provide some oversight of her behavior even now. He said that she was very young for this kind of cognitive impairment, which led him to believe that this was Alzheimer’s but he could not be certain that it wasn’t vascular dementia. Is it important that we know what kind of dementia she has? Are there any other tests that should be done? Is there anything that can be done to slow the progress of this dementia?
Dr. Pat Responds:
As difficult as this diagnosis must have been for you to hear, you were fortunate that the GP in charge of your mother’s care did all of the right things to establish a working diagnosis and made it clear that your mother should not be allowed to drive anymore. Accidents by older adults who have cognitive impairment are a serious problem that no family wants to deal with. The extended family that will be in charge of her care has been given an opportunity to create a financial and caregiving plan now so that your mother will be able to live in as much comfort and safety as possible. I have asked our WVFC medical advisory board neurologist, Dr. Joseph Safdieh, to answer some of your questions. I also encourage you to join local community support groups for family members of Alzheimer’s patients and to take time for self-care.
Dr. Safdieh Responds:
I am certainly sorry to hear of your mother’s illness. Cognitive symptoms are quite common as people age. It is important to note that even in normal aging, there can be some slowing down of word recall and memorization. However, it would not be considered normal aging if memory loss or other cognitive symptoms develop that cause an impairment in day-to-day functioning.
Certainly, getting lost in a familiar neighborhood is a worrisome sign. Dementia is a symptom complex, not a specific disease, and is diagnosed based on the development of loss of cognitive functioning in at least two domains (memory plus one other), with resulting functional impairment. Once the diagnosis of dementia is established, it is important that the diagnosing physician rule out what we call “reversible causes.” These reversible causes include vitamin B12 deficiency, thyroid disturbances, depression, brain lesions, and hydrocephalus (increased fluid in the brain). These conditions can easily be excluded with blood tests and an MRI. Once those causes are excluded, the diagnosis of the cause of dementia is made on clinical grounds.
The most common cause of dementia is Alzheimer disease. Lewy body disease is suspected when patients demonstrate significant visual hallucinations and muscle stiffness. Fronto-temporal dementia is suspected when there are significant early personality changes before memory loss develops. Vascular dementia is a complicated one because it can exist alone, but often occurs in conjunction with Alzheimer disease. In fact, it is well established that vascular risk factors, such as high blood pressure and smoking, are risk factors for Vascular as well as Alzheimer dementia.
The FDA recently approved a special kind of “PET scan” that can look for the changes in the brain that occur in Alzheimer disease. However, this test is expensive and not yet readily available or covered by Medicare, since it is not clear that it matters at this time whether someone has Alzheimer versus another brain degenerative disease causing dementia. That said, in the future, there will likely be more widespread adoption of such technologies that can differentiate Alzheimer from other types of dementia. In 2013, this is less critical because at this time, there are no well-established treatments to slow the progression of Alzheimer disease. There are medications that can improve memory, but not slow the disease. The federal government has a significant interest in funding medical research studies in this area, although the recent implementation of a very shortsighted sequestration policy will no doubt slow new discoveries in this field.
Dr. Joseph Safdieh