Saturday, August 10, 2013

Ten Things You Should Do When the Diagnosis is Alzheimer's

Alzheimer's Disease (AD) is, admittedly, sometimes tricky to diagnose.  Since a positive diagnosis can only be made post mortem upon examination of the ‘plaques and tangles‘ and deterioration/shrinkage of the brain, diagnoses of AD are often issued with the caveat, ‘probable’ AD.  However, for patients diagnosed with ‘probable’ AD and their caregiver spouses, such diagnoses are not probable ... they are very real. And those diagnoses are rising in record numbers as baby boomers age.  An estimated 5.3 million people in the U.S. already have AD, with those numbers expected to double in the next 20 years.  This year alone, global costs of dementia are expected to exceed 1% of world GDP for a staggering total of $601 billion dollars, with more than half of that number solely due to Alzheimer's, the most common form of dementia.

Primary care physicians, internists, neurologists, psychologists, and psychiatrists are all doctors who may make probable AD diagnoses for their patients.  I am the spouse/caregiver of an AD patient.  My wife wasn't diagnosed with AD until age 63,
but she had been demonstrating many AD symptoms by age 61. For two years, however, those symptoms had been incorrectly attributed to stress, anxiety, or depression.  It is obvious to spouse/caregivers in my weekly and online support groups that doctors can and should be doing a better job of diagnosing AD sooner ... and a much better job of providing their patients and spouses with a lot more information at the time of diagnosis.  Here's a "Top Ten" list of things that I and most caregivers I know wish doctors would do when issuing a diagnosis of AD.

1.  Do not use only objective data to try to make a correct diagnosis.
Members of my support group literally laugh out loud when someone brings up the MMSE (Mini-Mental State Examination), perhaps the most widely used measure to help diagnose Alzheimer's.  Doctors should understand that this test, and others like it, measure only selective elements of memory and cognition.  Some AD patients will do relatively well on these tests on any given day even when that patient's ability to function in the ‘real world‘ is continuing to decline.  Answers to questions such as what day of the week it is, what is today's date, etc. may simply be dependent upon whether or not the patient watched the TV news that morning or looked at that day's newspaper in the office.  Patients may be able to recall a series of random numbers in sequence on a particularly good day yet be unable to recall their own phone number or date of birth.  On a ‘good day’ a patient may be able to spell the word ‘world’ backwards yet be aphasic during conversations at home.  Objective test results will vary day to day and should be, at best, only one very limited measure used to reach a proper diagnosis.

2.  Rely more upon the observations of spouses or significant others.
If you live with someone 24/7, you know  when something is wrong with your wife or husband.  More often than not, it is a worried spouse or significant other who first brings AD concerns to the doctor's attention.  More often than not, it is the worried spouse insisting upon a thorough examination of their husband or wife due to fears of probable AD.  Doctors should not dismiss these concerns lightly.  Many spouses/significant others also keep logs or journals to document their concerns for doctors, but if the doctors do not see similar symptoms themselves during their brief office visits, these concerns are often ignored.  It is the rare AD patient whose spouse/significant other hasn't seen multiple signs of AD for a long period of time prior to any official medical diagnosis.  Doctors should ask more questions of spouses/significant others and listen to what they have to say.

3.  If not an expert in AD, refer your patient to a doctor who is an expert.
Often it is the family primary care physician or internist who is the first to suspect a change in their patient's condition or the first to be approached by the patient or spouse with concerns.  If in unfamiliar territory, the PCP or internist should refer patients to a neurologist or geriatric psychiatrist with experience diagnosing and treating AD patients.  In some geographical locations, a referral to a nearby Memory Disorder Clinic or Alzheimer's Disease Research Center would be worthwhile.  Too often, it seems, a PCP/internist may correctly diagnose the patient but then give incorrect or incomplete information due to lack of awareness.  Or, worse, a PCP/internist may suggest that a patient has MCI, Mild Cognitive Impairment, thereby relieving the concerns of the patient and/or caregiver who had worried about a probable AD diagnosis without then continuing to explain that, for many people, MCI is simply the first stage of Alzheimer's ... and, for many others, MCI will eventually lead to AD.

4.  Understand that no two patients with AD react exactly the same.
We have an expression in my support groups:  “If you know one person with Alzheimer's, then you know one person with Alzheimer‘s."  Each caregiver can provide a different description of exactly what is happening to their spouse.  Are there similarities?   Of course ... there are many.  But many does not equate to all.  And, just as important, patients with AD do not all decline in the same manner.  Some stabilize at certain stages for long periods of time before conditions worsen.  Some suffer slow incremental declines whereby symptoms continually worsen gradually over time.  Others follow what I refer to as a ‘cliff fall/plateau' pattern.  They seem to ‘fall off a cliff‘ every few months with a significant worsening of one or more symptoms, then reach a plateau where the decline stops for several months, and then seem to fall off another cliff.  And still others seem to manifest combinations of patterns of decline at different times.  Doctors should explain these different patterns to their recently diagnosed patients, and their spouses, so they may be better prepared for what may come their way.

5.  Explain that we currently do not know how to effectively treat AD.
Although some may disagree and suggest that being too honest with a diagnosis will send some caregivers and/or patients into increased denial and/or result in feelings of total despair, I firmly believe that patients and caregivers are entitled to know just what they are dealing with ... despite the lack of an optimistic future.  Be honest with patients about this disease.  Explain that AD is a degenerative, fatal disease for which there is no cure.  Explain that as a terminal disease, the patient will not get better over time and symptoms will continue to worsen regardless of any treatment they undertake. Also explain that all current research indicates that remaining mentally active, improving one's diet, engaging in daily physical exercise, and a whole host of other activities may improve the quality of life and even reduce chances of heart or vascular disease ... but none of these interventions will stop the worsening progression of AD.  Explain that for some patients, medication will not do anything to help, but for some they may slow down the rate of cognitive decline for 6 months, a year, maybe two years at best.  Explain, however, that after that period of time, even if they had been effective in slowing the progress of this disease to that point, they will no longer be effective and the patient will continue to suffer cognitive decline whether still taking those medications or not.  I have started referring to all medications designed for Ad patients as having the same label ... Hope.  Doctors continue to prescribe them, and patients continue to take them, long after they can possibly still be effective.  Why?  Because doctors and patients hope that, in their individual case, the medication will work despite what the research shows.  Even when the cost of that medication results in financial hardship, many patients will continue taking ineffective medication because they hope that is better than taking nothing.

6.  Inform your patients about clinical trials.
If your patient lives in an area where there are clinical trials underway testing the efficacy of potential new treatments for AD, inform your patients and their spouses of how they can learn more about those trials.  If you are knowledgeable about one or more trials, feel free to explain why you think a particular trial might be worth considering.  But at the very least, please inform your patients and their spouses about the existence of such clinical trials.

7.  When the AD diagnosis is made, tell your patients not to drive anymore.
In a handful of states, physicians are required to report the names of patients diagnosed with probable AD to the Department of Motor Vehicles.  The DMV is then responsible for re-assessing that person's ability to continue driving.  Currently, the vast majority of patients diagnosed with AD continue to drive.  I think that a diagnosis of AD should mandate removal of a driver's license within a reasonable period of time, 3-6 months at most.  I disagree with the Alzheimer's Association, the American Academy of Neurology, and other organizations that feel that the decision of whether or not to continue driving should be left to the patient.  Wrong!   Why do I say this? Simply because we know that anyone diagnosed with AD already has, or will have, impaired judgment and reasoning skills that affect safe driving.  Multiple decisions and processing skills are in play each time someone gets behind the wheel of a weapon of limited destruction, which is what an automobile really is. Impaired drivers may still easily pass their driving test on any given day.  However, doctors know that at some point these same AD-impaired drivers who are passing these tests will suffer declining skills that will prevent their ability to drive safely.  It is not a question of if this will happen ... the only question is when this will happen.

Why must we wait for a person with AD to damage his/her automobile or that of another, cause property damage to an innocent person, injure him/ herself or others in an accident, or possibly cause the death of others, or possibly get lost while driving when all of these occurrences are easily preventable before they happen?  Without a doubt, when to take away the keys from someone recently diagnosed with Alzheimer's is often the single most difficult decision to be made.  This signals an awareness of disease and a loss of independence; it may have severe implications on that person's ability to continue working or continued enjoyment of retirement.  And that is why I suggest a period of 3-6 months be provided for that recently diagnosed patient to come to grips with his/her new reality and time to make plans to deal with the situation  perhaps arranging for someone else to drive that person to/from work or making some other alternate plans for transportation.  If we know that a person diagnosed with AD is going to decline more over time, why not admit the obvious?  And the obvious is that someone diagnosed with Alzheimer's simply should not be behind the wheel of a moving vehicle. In my support groups, we often suggest to ‘newbies’ who are first dealing with this new reality, “Would you feel comfortable with your grandchildren in the car while your AD spouse is driving?"

Too often one hears in support groups how caregivers implore their AD spouses to stop driving because they have observed firsthand that their spouse is no longer driving safely.  However, their AD spouse will often respond, “But the doctor never said I had to stop driving."  Please, doctors, take this very emotional and combative issue out of the hands of spouses.  Take responsibility for telling your AD patients that they must stop driving!

8.  Upon diagnosis, refer your patient and spouse to local support groups.
Sadly, support groups are not uniformly provided throughout this country.  Some cities and some states have local and state associations that provide a multitude of support groups for both the patients, their spouse/caregivers, and for non-spouse caregivers, often through branches of the Alzheimer's Association, the Alzheimer's Foundation, or hospitals.   If there are such groups near where your patient and spouse live, please refer them to those groups or organizations.  And if not, please consider speaking with leaders of your state's associations to have such groups formed.  Also, become aware of the excellent online support groups available that you can recommend. Spouses can go to such places as for information and chat rooms, or to sites such as for a wealth of AD information and a blog site for reading and posting comments.

9.  Upon diagnosis, refer your patient’s spouse/caregiver to print resources.
Eventually, over time, all spouses learn about some good books that they should read to gain insights into this horrible disease.  Good books, like a good support group, will inform and empower spouses/caregivers.  Too often, spouses/caregivers say, “I wish someone had told me about that sooner when my spouse was still in the early stages so I could have prepared myself for the " ____________.”  (One can fill in the blank with so many choices ... difficulties when traveling, incontinence, wandering, raging, etc.)  If you are unfamiliar with good books to recommend, then at the very least prepare a one or two page informational handout to give to your patients at the time of diagnosis.  This handout can also list several websites such as those noted above, and phone numbers of local organizations ... branch offices of the Alzheimer's Association and the Alzheimer's Foundation, for example ... that can provide patients/caregivers with additional information about the disease, support groups if available, and suggested books to read.

10. Tell your patient and spouse/caregiver what they need to know sooner.
If there is one message that must get through to doctors above all others, it is this:  It is extremely important for the doctor to tell both the patient and the spouse/caregiver not what they may want to hear, but what they need to know.  Doctors must be brutally honest when discussing the progression of likely AD symptoms so patients and their spouses/caregivers will know what to expect.  Providing false hope that medications or life style changes or anything else will prevent certain death is disingenuous.  Doctors must present the scenario of symptoms and behaviors that most, if not all, AD patients will experience as their disease progresses through mild, moderate, and severe stages.  Doctors should explain that whereas the progress of AD after diagnosis can be as fast as four years and as long as twenty years, the average person with AD only lives for eight to ten years after diagnosis.  Doctors should explain how important it is for spouses to discuss end-of-life plans now, while the AD patient is still generally able to process rational thought.  Doctors should suggest that the patient and spouse seek out an eldercare attorney who can help them with decisions that must be made with respect to having a current will, living will and health care proxy, and durable power of attorney.  Doctors should suggest that their patient and spouse begin having discussions on how/where/when to provide assistance as the  disease worsens.  Should care be provided at home with hourly or full time health care aides?  In an assisted living facility?  In a nursing home?  An eldercare attorney will also discuss financial ramifications of such choices and suggest other options, but the doctor should get the ball rolling on end-of-life decisions and care because traumatized patients and spouses may not understand that this is something that needs their attention sooner rather than later.

Some doctors, I'm sure, will suggest that to hold these  discussions as soon as the patient is diagnosed is TMI ... Too Much Information.  And I agree.  The diagnosis may not be well received by either the patient and/or the spouse, resulting in reactions ranging from anger and shock to disbelief and denial.  However, I am suggesting that this information be provided in a follow-up visit no more than 2-4 weeks after diagnosis, once the patient and spouse/caregiver have had a chance to absorb hearing the words, Alzheimer’s Disease, and the bleak prognosis.  Waiting longer is a disservice to both patient and spouse/caregiver because information on stages of this disease, medications, clinical trials, driving, support groups, helpful books and resources are most helpful if provided sooner rather than later.

Alzheimer's is a horrible journey not just for the patient ... it's also horrible for the spouse/caregiver.  Doctors can make the journey so much easier for patients and spouses if they would heed This ‘Top Ten‘ list. Do you want to leave your patients and their caregivers with some hope when they leave your office after such a horrible diagnosis?  Of course you do.  Do you want to maintain a relationship with your patients/caregivers after diagnosis?  Of course you do.  However, just like a good marriage must be based on trust, so too must a doctor/patient/caregiver relationship be based upon trust.  If you feel my ‘brutally honest approach’ will backfire with respect to your patient and the patient's spouse/caregiver in their efforts to seek out the help they need to get through this disease, then perhaps you may need to cover this information during the course of several visits over a period of several weeks or months.  But, please, do cover it all because to do less is not just disingenuous.  To do less is to give your patients and their spouses/ caregivers false hope.  And that, in my opinion, is worse than no hope at all.  So, doctors ... please ... act upon some of these suggestions for dealing with your AD patients and their spouses.  Thank you.
Originally submitted titled, "An Open Letter to Doctors, Ten Things ..."  Published in American Journal of Alzheimer’s Disease & Other Dementias, March, 2011, Vol. 26, No. 2, pp. 93-96.  Access at:

1 comment:

  1. I think that earlier diagnosis of Alzheimer's Disease will be of great benefit to the aging population.Not only will early treatment help slow down the illness, but a lot can be learned about prevention.The elderly is a large group of people who have a lot to offer. I am very pleased to hear about any kind of research being done in this needed area.

    Alzheimer Clinic