Caring for Patients With Dementia Demands Special Skills

As the baby boom generation grows older and the number of patients presenting with dementia -- whether from Alzheimer's disease (AD) or another cause -- increases, family physicians are being called on to diagnose and manage this progressive disorder on an increasingly regular basis.

According to the Alzheimer's Association, 5.4 million Americans currently live with AD, making it the sixth-leading cause of death in the country. And this number does not account for additional patients diagnosed with Binswanger's type dementia, dementia with Lewy bodies or a more generalized form of dementia.

Although the burgeoning need for dementia care may be self-evident, making the diagnosis -- or even the decision to screen at all -- is not quite as clear-cut. The U.S. Preventive Services Task Force currently concludes that the evidence is insufficient to recommend for or against routine screening for dementia in older adults. The task force does, however, recommend assessing cognitive function if cognitive impairment or deterioration is suspected.

Family physician Daniel DeJoseph, M.D., of Lawrence, Mass., said that because FPs cannot take a pass on diagnosing and managing these issues, he routinely assesses functional status in all of his elderly patients.

"When a patient presents with a change in functional status -- usually instrumental activities of daily living (IADLs) first, such as the ability to pay bills, go shopping, etc. -- or if a patient or family member expresses concern about functional or memory impairment, I will perform a cognitive screening test," DeJoseph told AAFP News Now.

According to DeJoseph, his initial go-to is a four-page hand-out (About PDFs) on dementia diagnosis and treatment developed by the American Geriatrics Society (AGS).

"Currently, I use the animal naming test, which has good sensitivity (88 percent) and specificity (96 percent) when the cut-off for normal is 15 animals named in a minute, and the Mini-Cog, with scores of 0-2 (a positive screen for dementia) having 76 percent sensitivity and 89 percent specificity for dementia," he said. "If these tests are abnormal, I proceed to a full cognitive assessment."

Barry Brent Simmons, M.D., a family physician practicing in Philadelphia, said he also follows the AGS recommendations.

"I will do a cognitive assessment on any patient in whom I suspect memory problems if the family has concerns about memory or if the patient has any concerns about memory," Simmons said. "The AGS recommendations give good guidance on lab and imaging studies to order as an addition to the cognitive testing, such as when and when not to get an MRI."

It's important to remember, too, that family members can play a key role in making an early diagnosis of dementia, said FP Alan Adelman, M.D., of Hershey, Pa.

"Oftentimes, (family members) are going to be your best source of information on what is going on with the patient," he said. "I have been fooled many times by patients who come in alone for an office visit. They do not volunteer any cognitive issues and can carry on a conversation, but then you talk to family members and what they tell you is happening at home is hard to believe. That just doesn't always show up in a normal office visit."

A potential hurdle in making a dementia diagnosis cropped up last year when the National Institute on Aging (NIA) and the Alzheimer's Association revised the guidelines on diagnosis of Alzheimer's disease (multiple articles) to redefine AD as comprising three progressive stages. According to a recent study (abstract) in the Archives of Neurology, the revised criteria could compromise physicians' ability to diagnose very mild and mild AD dementia.

Simmons shrugged off that concern, however, saying that although the revision might cause problems for some in the medical community, it should not be an issue for FPs who work with these patients.

"Essentially, with the new diagnostic guidelines, the lines between mild cognitive impairment (MCI) and early Alzheimer's are blurred," he said.

"This does have an impact on research activities focusing on MCI, but in clinical practice, it doesn't have as much impact. The drugs we use for Alzheimer's, such as donepezil, are used by many clinicians for MCI, as well, and I think most clinicians make the decision to do a drug trial based on the level of impairment and patient preferences more than the label put on the cognitive impairment."

DeJoseph agreed, emphasizing that family physicians' focus should be on pursuing --rather than labeling -- any evidence of cognitive impairment in their patients, with the goal of initiating treatment and other support at the appropriate time.

"It is important to keep in mind that dementia is categorized by a gradual onset of symptoms and a continuing decline of function," he said. "The patient's functional status declines as the disease progresses.

"This progression is delineated on the FAST (functional assessment staging) scale, with which I would encourage all FPs and residents to become familiar. On this scale, mild cognitive impairment corresponds to a FAST 3, and the AGS quotes an annual conversion rate to dementia syndrome of 6 percent to 15 percent."

Patients with dementia generally become eligible for hospice by the time they reach the FAST 7 stage, DeJoseph added, and may benefit from palliative care services in stage 6.

Managing other health conditions in a patient with dementia cannot be approached in the same way as in other patients, according to DeJoseph.

"Since dementia is usually a disease of the elderly, patients with dementia can have many medical comorbidities," he explained. "It is the FP's job to transition care from disease-centered to patient-centered. Specifically, there are different, more relaxed, treatment goals for chronic diseases, such as diabetes, in patients with dementia. Patients with dementia are at a greater risk for adverse drug events, polypharmacy and other iatrogenic morbidities."

And when it comes to ensuring that patients -- and their caregivers -- receive the support and services they need, practicing as part of an interdisciplinary team can be essential, DeJoseph noted.

"I would encourage all FPs to strive for an interdisciplinary care model, including a clinical pharmacist, psychologist, and social work, to assist and support the patient and family/caretakers," he said. "The FP needs to help the patient get as much support as possible."