Accurate diagnosis of AD or other cognitive problems can help your older patient and his or her family to plan for the future. Early diagnosis offers the best chance to treat the symptoms of the disease, when possible, and to 52
talking with patients about cognitive problems
discuss ways of positively coping with the condition, including discussing care options. A relatively early diagnosis allows patients to make financial plans, prepare advance directives, and express informed consent for research.
Yet data suggest that only a small fraction of people with AD are ever diagnosed.
When patients are only mildly impaired, they can be adept at covering up what is happening to them. However, giving a few straightforward tests, using a medical history, and taking a family history from another family member can often tell you if there are persistent or worsening problems.
It is best to conduct tests or interviews with the patient alone so that family members or companions cannot prompt the patient. Information can also be gleaned from the patient’s behavior on arrival in your office or from telephone interactions with staff. Family members who may contact you in advance or following the visit are also a source of information, but keep in mind patient privacy concerns.
Although assessing an older person’s cognitive function is important, formal testing of mental status tends to provoke anxiety. If you are concerned about a patient’s cognition, it might be best to leave any formal testing of mental status until the latter part of the appointment—either between the history and the physical examination or after the examination—or to refer the patient to a neuropsychologist for more detailed assessment of cognition.
If you administer a cognitive status test, try to present it in the context of concerns the patient has expressed. Providing support and encouragement during the testing can decrease stress.
There are limitations to any mental status test—for example, the test results can reflect level of education, or the results may appear normal early in the disease. The most commonly used screen is the Mini-Mental State Examination. This test can be used to screen patients for cognitive impairment and can be administered in the primary care setting in about 10 minutes. A positive finding suggests the need for referral to a neurologist or neuropsychologist for a more detailed diagnosis.
Cognitive impairment may reflect a variety of conditions, some reversible.
In particular, it is important to review your patient’s medications to check for anticholinergic or other potentially inappropriate medications. However, talking with patients about cognitive problems 53
since patients or caregivers may assume that the cause is Alzheimer’s disease, you may need to explain the need for a careful history, laboratory tests, and physical examination to search for other conditions or issues.
If your patient does have mild to moderate cognitive impairment, you might ask if there is someone who helps when he or she has trouble remembering.
If your patient says yes, you could also ask if it would be a good idea for you to discuss the patient’s treatment plans with the helper and keep his or her name in your notes for future reference. Make these arrangements early, and check that the patient has given you formal authorization to include the helper in the conversation about your patient’s care.
For more information on Alzheimer’s disease, contact: Alzheimer’s Association
225 North Michigan Avenue, Floor 17
Chicago, IL 60601-7633
1-800-272-3900 (toll-free)
www.alz.org
This national voluntary health organization supports Alzheimer’s disease research and care and offers information and support to patients and families. It has local chapters with community information including referrals, support groups, and safety services.
Alzheimer’s Disease Education and Referral (ADEAR) Center P.O. Box 8250
Silver Spring, MD 20907-8250
1-800-438-4380 (toll-free)
www.nia.nih.gov/alzheimers
A service of NIA, ADEAR provides information, publications, referrals, a health information database, and a clinical trials database for the public and for health care professionals.
For updated Alzheimer’s disease diagnostic guidelines: www.nia.nih.gov/alzheimers/resources/diagnosticguidelines.htm Alzheimer’s Foundation of America
322 8th Avenue, 7th Floor
New York, NY 10001
1-866-232-8484 (toll-free)
www.alzfdn.org
The Foundation brings together groups around the country, including assisted living organizations, community services agencies, State agencies, and others, to collaborate on education, resources, and program design and implementation for people with AD, their caregivers, and families.