Tuesday, October 21, 2008
The difficulty of diagnosing Alzheimer's
Dr. Michael Camardi
Recent columns
About Dr. Michael Camardi
Dr. Michael Camardi is a geriatrician at Carilion's Center for Healthy Aging. Age Matters is his new Roanoke Times column, appearing the third Tuesday of every month.
Camardi has been with Carilion for about three years and was one of the experts who reporter Beth Macy spoke to for her series, “Age of Uncertainty.” He wanted to start this column to help answer questions he’s often heard as part of his job.
Camardi was founder and past medical director of the geriatric liaison program for Jacobi Medical Center (Albert Einstein College of Medicine) in Bronx, N .Y.
Camardi trained at Winthrop University Hospital (Stony Brook University Medical School), where he was chief medical resident. He has received numerous commendations for his contributions to education, patient advocacy, community relations and hospital administration.
If you have questions for Camardi, please mail them to him at Center for Healthy Aging, 2118 Rosalind Ave., Roanoke, VA 24014, or e-mail them to extra@roanoke.com with “Age Matters” in the subject line.
Dear Dr. Camardi: How do you know if someone is getting Alzheimer's?
I'm really worried about my stepfather because I've been getting phone calls from his landlord when he doesn't pay his rent. That's happened twice already, and when I asked him about it this time, he showed me some other bills and he just didn't seem to care about them. What can I do to find out?
-- New River
No single question in my practice brings such impact into people's lives as this one.
Personally, when I am dealing with this issue, I feel a real challenge to give as clear and unambiguous an answer as my art and science can allow. But all too often, that is not possible.
The reason: This is a progressive disease, meaning that it changes from time to time and, as such, the diagnosis can take time to solidify. Also, there is no one single test that currently can tell if a person has this disease.
The diagnosis is made through a systematic assessment to "rule out" other more treatable causes of the case presentation before someone is labeled as demented. And let me say that we in this profession take this "labeling" very seriously for all the implications it carries with it.
Studies have shown that in the hands of a skilled practitioner, the diagnosis of Alzheimer's approaches 80 percent to 90 percent accuracy. It is important for you to know there are approaches that can be tried to treat what is treatable, and also to try and manage some difficult situations. But the first thing to do is to bring stepdad to his health care provider for a complete physical and then ask the provider to consult with a geriatrician for an evaluation.
People often think that profound memory loss, sudden changes in mood and behavior, and marked difficulty in performing daily tasks are all part of aging. They are not. Many times, they are signs of other conditions such as chronic pain, over-medication (including over-the-counter preparations and herbals), drug interactions, thyroid disease, heart disease, alcohol abuse, depression or infection, among others.
A key question here is whether or not there is a family history of Alzheimer's (a genetic risk of less than 10 percent) or other psychiatric conditions that may have been misdiagnosed as Alzheimer's in the patient's past. .
When I see a patient for a dementia work-up, I focus on the following functional profile of an Alzheimer's patient in establishing the most important aspect of the diagnosis, a comprehensive medical history in trying to see "a day-in-the-life" pattern:
- Is the daily routine affected by memory loss? Is memory loss increasing in frequency?
- Are the usual and common tasks becoming harder? In this aspect, patients forget how to prepare a meal, make a bed, tie their own shoes, dial a phone number or pay the bills.
- Are the patient's responses to questions difficult to understand because of lapses in using the correct word choice?
- Has the patient experienced being lost in a familiar place such as their own street or even on a different floor of their home?
- Has the patient demonstrated examples of poor judgment, such as wearing an overcoat on a hot day?
- Does the patient show problems with abstract thinking, such as not being able to interpret the numbers on a bill?
- Does the patient misplace items in inappropriate places, such as putting the keys in a sugar bowl?
- Is the patient emotionally liable, in that their mood can swiftly change from rage to joy for no appreciable reason?
- Has the patient showed periods where his or her personality has drastically changed, ranging from confusion, apathy, fearfulness or withdrawal?
- Has the patient lost initiative and become passive to the point where they need prompting in order to become involved?
And here is the key point for me: The patient can't "snap out" of their confusion by themselves.
By this, I mean that we all have moments of confusion or lack of mental clarity, but we focus our concentration on reverting back to an integrated mental state and we can do so in a short period of time. The Alzheimer's patient cannot do this uniformly.
What I'm trying to do here is to paint a picture, a unifying presentation, if you will, of the patient's disjointed behavior so that it can be understood.
Please realize that this is important, not only for the medical diagnosis of the moment, but also to assist the family and their attorney to begin to explore future legal solutions that are in the best interest of the patient .
This is how I go about arriving at a diagnosis. Once done, I suggest that all involved sit down to begin the journey as a family down a sometimes very tough road.
I have seen it tear families apart -- but it doesn't have to. The situation calls for compassion, understanding, forbearance and tolerance. It is a call for bringing the best out of people, making you start to think about giving back to those who sacrificed so much and tried to do their best.
For those who think of it as a mission in giving, it can be surprisingly fulfilling.
Godspeed.
Dr. Michael Camardi is a geriatrician at Carilion's Center for Healthy Aging. His columns run on the third Tuesday of each month. If you have questions for Camardi, please mail them to him at Center for Healthy Aging, 2118 Rosalind Ave., Roanoke, VA 24014 or e-mail them to extra@roanoke.com with "Age Matters" in the subject line.
