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Reaching through the fog: A rising tide of Alzheimer's disease

Primary care physicians will help treat a growing number of Alzheimer's patients as the nation's elderly population surges. But younger patients also are susceptible.

By Christine S. Moyer — Posted Dec. 20, 2010

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By the time that Alzheimer's dementia develops, tangles of tau proteins have twisted through the brain, starving cells of needed nutrients. The cerebral cortex is shriveled. The hippocampus has shrunk substantially. Ventricles expand with fluid, filling the empty space.

Atrophy continues until the ability to perform even basic functions, such as speaking, swallowing and walking, are lost.

If physicians diagnose the condition before dementia sets in, medication can delay the progression of symptoms. But many patients with the disease go untreated or receive medication too late.

Part of the problem is inefficient dementia screening tools, Alzheimer's specialists say. Another factor is that primary care physicians, who see a majority of dementia patients, have limited time to identify and diagnose Alzheimer's.

"The brain is a complicated organ, and when the brain fails, it's not fair to expect anyone to assess the problem in seven or 15 minutes," said Pierre Tariot, MD, director of the Banner Alzheimer's Institute's Memory Disorders Center in Phoenix.

The sheer numbers

Challenges for primary care physicians and other doctors are expected to mount as the nation's elderly population more than doubles during the next 40 years. In 2050, there will be an estimated 88.5 million Americans 65 and older, up from the approximately 40.2 million today, according to the latest U.S. Census Bureau data.

An estimated 5.3 million Americans have Alzheimer's disease, including 200,000 people younger than 65, according to the Alzheimer's Assn. By 2050, as many as 13.5 million could have the disease, which is the leading cause of dementia.

With the surge of seniors will come more cases of the disease, the Alzheimer's Assn. said. Advancing age is the greatest risk factor for developing the neurologic condition.

Complicating matters, most patients with Alzheimer's also have chronic problems such as diabetes and hypertension. Managing these health issues is difficult in Alzheimer's patients, because they often have trouble following their doctor's medication instructions and nutrition recommendations.

The burden of caring for Alzheimer's patients will continue to fall largely on primary care physicians, because there is an inadequate supply of specialists to meet the nation's need, experts say.

"It looks to be a tidal wave that's coming," Dr. Tariot said. "Physicians are not adequately prepared to diagnose, support and treat these people."

Some physicians already are noticing an increase in Alzheimer's patients. In the past few years, they say they have diagnosed the disease more frequently in younger people.

Arizona neurologist Marwan Sabbagh, MD, said there is a growing public awareness that severe memory problems are not a natural part of aging. Because of this understanding, younger patients are bringing concerns of cognitive decline to their doctors' attention. The increase in early-onset Alzheimer's will pose a problem for primary care physicians, he said.

"Dementia management is time-consuming," said Dr. Sabbagh, research medical director and director of clinical research at Banner Sun Health Research Institute in Sun City, Ariz. "You have to address patients' medical needs, behavioral issues, and family and caregiver stress. [Primary care doctors] have to do all of that in 15 to 20 minutes. It's a lot to take on."

Previous research has shown that dementia often is underdiagnosed in primary care. A 2000 Archives of Internal Medicine study found that primary care physicians did not recognize dementia in two-thirds of patients in a Honolulu outpatient practice between August and September 1998. When dementia was mild -- and thus most responsive to treatment -- 91% of the cases were overlooked.

Looking for guidance, many physicians attended an Oct. 1 session on dementia and Alzheimer's disease at the American Academy of Family Physicians' annual scientific assembly in Denver. The session was so popular that doctors packed the room, and the overflow crowd filled another space.

Jill Grimes, MD, a family physician in Austin, Texas, who led the session, urged physicians to be vigilant about identifying early symptoms of Alzheimer's in their patients. Early identification and treatment is considered key to delaying progression of the disease.

But when doctors diagnose a patient with Alzheimer's, she cautioned, the challenge of caring for the individual has just begun.

Diagnosing Alzheimer's

To identify the disease in its early stages, physicians have to look beyond the patient's primary medical problem for other underlying health issues during office visits, said internist and geriatrician Gisele Wolf-Klein, MD, director of geriatric education at North Shore-Long Island Jewish Health System in New York.

She encourages doctors to observe the way patients are dressed during office visits. Signs of cognitive impairment include wearing clothes that are inappropriate for the season or appearing dirty and unkempt, said Dr. Wolf-Klein, professor of clinical medicine at Albert Einstein College of Medicine in New York.

When doctors suspect cognitive problems, they should ask patients if they have concerns about memory and, if so, what specifically is worrying them, said Ron Petersen, MD, PhD, chair of the Alzheimer's Assn.'s medical and scientific advisory council.

He also encourages doctors to ask family members or caregivers if they have noticed a change in the patient's memory. Family members' accounts of what is happening often are more reliable than information from the patient, dementia experts say.

The American Academy of Neurology recommends physicians screen patients for dementia if cognitive impairment is suspected. The academy recommends that doctors consider using the Mini Mental Status Exam and the Memory Impairment Screen. The U.S. Preventive Services Task Force, however, said there is insufficient evidence to recommend for or against routine screening for dementia in older adults.

Medical experts are updating diagnostic guidelines for Alzheimer's disease for the first time in 25 years, in light of new advancements in the pathology and progression of the disease. The proposed guidelines call for removing age restrictions for the onset of the disease and expanding symptoms beyond memory impairment. They also will update criteria to distinguish Alzheimer's dementia from other forms of cognitive impairment.

For some doctors, the challenge is not identifying Alzheimer's, but rather delivering the diagnosis to patients and their families.

"You're giving, essentially, a fatal diagnosis," said Jeffrey Cummings, MD, director of the Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas.

Five drugs are licensed by the Food and Drug Administration to treat Alzheimer's. In some patients, the medication temporarily improves symptoms and delays the decline of the disease, Dr. Cummings said. But none of the drugs modifies the disease process.

Dr. Cummings tries to remain positive when giving an Alzheimer's diagnosis. He tells patients, "Your testing indicates a loss of brain cells in the memory areas of the brain, and we call this process Alzheimer's disease. We have therapies for Alzheimer's disease that you and I will be talking about. We also have clinical trials that are developing new therapies."

He encourages physicians to include the patient's caregiver in the conversation because he or she will be responsible for purchasing the medication, administering it and monitoring side effects. Caregivers "are facing the challenge of a lifetime," he said.

Alzheimer's caregivers average 47 hours of care a week, according to a 2006 study by the MetLife Mature Market Institute, a research organization for issues of aging and longevity. More than 32% said their health worsened because of their responsibilities.

Dr. Cummings regularly meets with caregivers of his Alzheimer's patients and monitors their health. Lexington, Ky., family physician John Richard, MD, urges caregivers to find time for themselves and to continue pursuing their interests and hobbies.

Caring for Alzheimer's patients

In the disease's early stages, Dr. Wolf-Klein encourages patients to create a long-term plan to address details such as who will be in charge of finances when they no longer can manage them on their own and whether they want to be placed in a nursing home.

As the disease progresses, she said discussing a patient's driving ability is among the most challenging aspects of caring for such patients. Recommending that a patient stop driving often upsets the individual who is losing independence, and it places an additional burden on the family, Dr. Wolf-Klein said.

Physicians' legal responsibility for reporting impaired drivers varies across the country. Six states mandate that health professionals tell their state's Dept. of Motor Vehicles about patients medically unfit to drive, according to the American Medical Association. The states are California, Delaware, Nevada, New Jersey, Oregon and Pennsylvania.

The AMA recommends that physicians report a patient's medical impairments to the DMV when there is clear evidence of a strong threat to patient and public safety and when the doctor's advice to discontinue driving is ignored. The determination of whether a patient is unable to drive should be made by the DMV, the AMA said.

In the near future, Dr. Cummings expects there will be tests to diagnose early cases of Alzheimer's and more powerful medication that could alter the disease process. For now, however, physicians rely largely on cognitive impairment questionnaires and drugs that only temporarily ease patients' symptoms.

It's not what doctors want, he said. But it's all they have.

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ADDITIONAL INFORMATION

Dementia screening tools

The American Academy of Neurology recommends that physicians screen patients for dementia if cognitive impairment is suspected. The academy recommends that physicians consider using the following screening tools:

Mini Mental Status Exam: A short, untimed test that quantifies cognitive function and screens for cognitive loss by testing a person's orientation, attention, calculation, recall, language and motor skills. There are 11 sections in the test, including naming common objects, writing a sentence and copying a design of two intersecting shapes. Patients receive one point for each correct answer.

Memory Impairment Screen: A four-item recall test that assesses memory impairment. Patients are given the names of one item in each of the following categories: animal, city, vegetable and musical instrument. After a short delay, the individuals are asked to recite the four items in any order. If the patient misses an item, the physician cues the individual by telling him or her the category.

Source: "AAN Guideline Summary for Clinicians: Detection, Diagnosis and Management of Dementia," American Academy of Neurology (link)

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Questioning methods of screening

Among the screening tools available to assess a patient's cognitive impairment, some have "weaker evidence" supporting their use, said the American Academy of Neurology. The academy said there is inconclusive or conflicting evidence for the usefulness of the following screening methods, which are regularly used by doctors.

Kokmen Short Test of Mental Status: A five-minute mental status test that examines a patient's orientation, attention, immediate recall, arithmetic, abstraction, construction, information and delayed recall.

7-Minute Screen: Consists of four components that assess a patient's orientation, memory, ability to draw a clock and verbal fluency.

Clock Drawing Test: Patients are asked to either draw a clock from memory, fill in the numbers on a pre-drawn circle or set the hands at a fixed time on a pre-drawn clock.

Time and Change Test: A two-question test that asks patients to tell the time on a clock and to make a dollar out of an assortment of change.

Source: "AAN Guideline Summary for Clinicians: Detection, Diagnosis and Management of Dementia," American Academy of Neurology (link)

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External links

"2010: Alzheimer's Disease Facts and Figures," Alzheimer's Assn., March 9 (link)

"Physician's Guide to Assessing and Counseling Older Drivers," American Medical Association (link)

"The MetLife Study of Alzheimer's Disease: The Caregiving Experience," MetLife Mature Market Institute, August 2006 (link)

U.S. Preventive Services Task Force on screening for dementia (link)

"The Detection of Dementia in the Primary Care Setting," Archives of Internal Medicine, Oct. 23, 2000 (link)

Alzheimer's Assn. (link)

American Academy of Family Physicians Scientific Assembly, 2010 (link)

"AAN Guideline Summary for Clinicians: Detection, Diagnosis and Management of Dementia," American Academy of Neurology (link)

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