a powerful new Alzheimer’s diagnostic test (the new brain scan) on the block, and now we’re all
going to have to decide if we want to use it or not. (My colleagues at GeriPal.org seem generally skeptical.)
is an especially relevant question for a outpatient geriatrician like me: I’m
often confronted with the complaint of memory problems, I do a fair amount of
diagnosing dementia (usually on my own, with the occasional referral to a
memory clinic or neurologist), and I do a lot of counseling of patients and
families, usually over the span of months to years.
other words, I field memory complaints and dementia diagnosis as they appear in
the primary care clinic, and with the aging population surging into Medicare, I
essentially do what front-line generalists will need to do for millions of
elders over the next 10-20 years.
would I order this scan, for someone with memory problems? How would this help
or hinder me, and the families I’m trying to help? What kinds of benefits and
harms will we get for the extra cost of this test, given that there is
currently no cure for Alzheimer’s and not even any reliable ways to slow the
progress of this devastating disease?
scan. It’s a good story, and if you haven’t read it yet, you should.
it’s the story of trying to confirm the presence or absence of Alzheimer’s
in my world, the story is about how to help people with memory impairment. Which
is not quite the same story, and involves slightly different questions. In
particular, I don’t just think “Is it or is it not Alzheimer’s?” What I think
- Is this
With patients, I usually explain that dementia means developing permanent
brain changes that make memory and thinking skills worse, to the point
that daily life skills are affected. I then explain that Alzheimer’s is
the most common underlying cause of permanent brain changes.
- Is anything
making this person’s cognition worse than it would otherwise be? It’s
especially common to find that medications (such as benzodiazepines for sleep) are making older people worse. Several other medical conditions
(i.e. hypothyroidism, depression) can worsen cognition and should be
checked for as well.
- Any special
neurological features that I should make note of? I briefly
check for signs of parkinsonism, hallucinations (common in Lewy-Body
dementia), or neurological changes suggestive of subtle strokes. But
otherwise I don’t spend too much time trying to pin down the underlying
dementia, unless something strikes me as distinctly odd. Overall, I find
the principles of helping patients and families with dementia are
basically the same for the most likely causes of dementia (Alzheimer’s,
Lewy-Body dementia, vascular dementia).
patient and family, of course, have their own questions and concerns. They
certainly do often ask if it’s Alzheimer’s. But we shouldn’t answer that
question too narrowly. Many people don’t understand the difference between
Alzheimer’s and dementia (I’ve had people tell me “Thank God it’s notAlzheimer’s” when I broke the news of likely dementia). But overall, what scares
them is the specter of progressive cognitive disability.
of all, in my experience patients and families want to know:
is going on?
should we expect for the future?
this get worse? How fast?
kind of help is there? Are there treatments?
will we manage?
to the article. What would’ve happened to those patients if they hadn’t had the
scan? And what is still left undone or unresolved after the scan?
Awilda Jimenez, the woman featured at the start of the Times story, who becomes
forgetful at age 61. Here’s how things usually unfold when I see someone like
- I make a preliminary assessment of cognitive
abilities. I use a combination of office-based cognitive test, like the
Montreal Cognitive Assessment, and asking about function, especially IADLs like finance and driving. The article doesn’t say how Ms. Jimenez scored
on these (one hopes they were checked before offering her the scan), but
it’s not uncommon for someone with early Alzheimer’s to score 24 on the
MOCA and have problems with memory and finances.
- I also look for exacerbating factors, like
medication side-effects, or other illnesses. Let’s assume I find none.
Let’s also assume the neuro exam is generally benign (other than the
- I then explain to the patient and family that
there does seem to be evidence of problems with memory and thinking. If
the problems are fairly prominent, we start to discuss the diagnosis of
mild dementia, and that it’s probably Alzheimer’s. If the problems are
subtle and things feel inconclusive to me, or if the family wants more
evaluation, we talk about referring for neuropsychological testing, to get
further insight into the cognitive problems.
- Let’s say the neuropsychological testing comes
back indicating deficits; a common conclusion is that the findings “may
be consistent with an early dementia such as Alzheimer’s.” Then I get to explain to
patient and family that it’s probably dementia, probably Alzheimer’s,
could be vascular or another, generally slowly gets worse but occasionally
seems to stop
happens over the next 6-12 months.
psychoactive medications and other common causes of delirium. I also encourage them to look for dementia support groups, and try to point them towards resources for learning more about living with dementia.
other words, as things currently stand, evaluating memory impairment in someone
who’s early in the dementia process often ends up with our telling patients
that they probably have something bad: mild dementia, most likely Alzheimer’s.
uncertainty is frustrating for clinician and patient. (It’s even worse when the
deficits are in the range of mild cognitive impairment, or in that “is this
affecting daily function?” gray area.) So it seems that the new brain scan
should be a boon, with its ability to give a definite yay or nay on whether
Alzheimer’s is present.
patients and families can cling to the hope that maybe it’s not Alzheimer’s,
maybe it won’t keep getting worse, maybe it’s something else. I have seen
patients and families resolutely set aside the possibility of Alzheimer’s (why
dwell on the possibility of something horrible coming into your life), and
other families obsess over the issue for months.
they take, in most cases, the cognition keeps getting slowly worse, and 1-2
years later the family is enmeshed in caring for someone who has become quite
cognitively disabled. At that point, they are trying to survive and we clinicians
are trying to help them maintain the best quality of life possible.
to the new scan. I would briefly summarize the benefits and burdens as follows
(for patients in the mild/early stage of symptoms):
- Reduces period of clinical uncertainty for
those patients who in fact have Alzheimer’s.
- With a positive scan, families could more quickly move into grieving, acceptance, and hopefully planning for the
upcoming challenges. (Engagement!)
- Although there is no cure and drugs don’t
tend to delay progression very much, clinicians can and should focus on the many ways to optimize
the person’s function. Caregivers can focus on getting from coaching and support.
Other clinicians should be alerted to the diagnosis and modify their work
- A negative scan in someone with
symptoms would presumably spur a search for the real problem.
- Takes a fair bite out of the payor’s wallet.
Currently the scan is paid for out of pocket.
- Offer an explanation for cognitive impairment
in those patients who don’t have Alzheimer’s.
- Identify co-existing vascular disease or other
cause of progressive dementia.
- Identify and modify factors worsening
cognition, like medication side-effects or other illnesses.
- Tell patients how quickly their dementia will
progress, and what kind of help they will need in a year. The progression
of Alzheimer’s is highly variable from individual to individual.
- Provide dementia education and support to family
short, whether we’ll benefit from the scan really depends on how much families
and clinicians benefit from eliminating that period of uncertainty, as well as
on our ability to provide good dementia evaluation, management, and support to
patients and families.
most dementia patients currently get sub-optimal medical care, and their
caregivers get inadequate coaching and support.
If the scan helps bring people to the resources they need earlier, and
more effectively, I’ll be for it. But if it turns yet another radiologic money
suck and everything else continues as usual, I’ll be disappointed.
In a nutshell:
However, using the new scan to get an answer to that question sooner rather than later could eliminate a lot of the uncertainty and watchful waiting that families and clinicians currently experience.
If (and this is a big if) this helps patients and families access better dementia care sooner, the brain scans could be quite beneficial.