« The Dual Agenda: April 30, 2015 Issue

Eldercare Voices

Managing Dementia in the Primary Care Setting

Angela Hanson, MD

There are currently 5.3 million Americans living with dementia, and this number will go up to 18.5 million by 2050. Alzheimer's disease is the most common form, and other types include vascular dementia (from strokes), Lewy Body Dementia (related to Parkinson's disease), and Frontotemporal Dementia. Age is the biggest risk factor for developing dementia, but some types can be seen in younger and middle-aged persons. 

How is dementia different from normal aging? As we age, changes occur in our brains that affect how we learn and remember information. Mild troubles with short-term memory can increase with age; we all occasionally forget where we put our keys or why we walked into a room. Also, it can sometimes take longer for an older person to learn new information. Dementia, though, is different from normal aging, and is caused by progressive loss of brain tissue, also called atrophy. It is diagnosed when memory troubles become more common or serious. People with Alzheimer's disease will ask the same questions over and over, will frequently misplace items, and have trouble remembering the month or year.

What if you suspect dementia in yourself or a loved one? The first step is to visit your primary care provider. Not all memory loss is dementia, and your doctor may order blood tests to rule out medical conditions that can cause cognitive symptoms. Insomnia and mood disorders like depression can affect memory and thinking. A great many medications can cause confusion, so you should review all the medications you take, including over-the-counter medications, with your provider. He or she may then administer memory tests, order brain scans, and if needed, refer you to a dementia specialist. For any memory problem, it is good to bring a trusted friend or family member to the appointment to provide collateral information about how you are doing and to take notes on useful information your provider may share. 

When it comes to a diagnosis, it can be complicated. I tell my patients that diagnosing dementia is like prosecuting a criminal; you build a case based on evidence, but it's not usually just one test that makes or breaks the diagnosis. One reason for this is that neurodegenerative diseases from Alzheimer's take many years to develop. Therefore, brain images like cat scans (CT scans) or MRIs can sometimes look normal, especially in early stages of the illness. Other special scans, such as PET scans, that look at how well brain cells are functioning, can be more accurate but they are not always available. Detailed cognitive testing by a neuropsychologist can be helpful in sorting out whether memory concerns are due to normal aging or something more serious, and can often identify distinctive patterns of cognitive impairment that go along with certain diagnoses.

As a geriatrician, I think of managing dementia like a “syndrome”  that has a lot of moving parts.  First, do no harm. I make sure the person’s medications are appropriate, and that other medical conditions like diabetes are being managed properly. Each patient should have a good assessment of their mood: are they sleeping reasonably well, is there any sign of depression or anxiety? And finally, we discuss dementia medications. There are no cures for the most common forms of dementia, but treatments can help improve memory and mood in some people.  

Another important part of dementia care is providing support for caregivers. In our memory clinic, I continue to be amazed at the strength and resolve of caregivers, who are often older themselves and may have their own health problems. Caring for dementia involves caring for the entire family. The Alzheimer's Association is a great resource for families and caregivers dealing with a dementia diagnosis – even if the type is another form of dementia.

How can we prevent dementia? There are no guaranteed preventative measures.  However, we have learned a lot about healthy brain aging over the last few years. All things that keep the heart and blood vessels healthy also benefit the brain: treating high blood pressure, high cholesterol, and diabetes. Eating a healthy diet, which includes avoiding high amounts of saturated fat and processed sugars, and eating more fruits, vegetables, and nuts – like a Mediterranean diet – helps prevent dementia. Regular exercise can keep the parts of our brain involved in memory from shrinking as much with age. Continuing to be active socially and keeping an active mind is also protective: playing card games, doing puzzles and reading. There are a lot of 'brain training' games out there, but none of them have been proven to be the 'best' one, and I tell my patients to do things that they already enjoy. Finally, avoiding head trauma by wearing bike helmets and preventing falls is important, as well. 

As a community, we all can play a role in helping prevent, diagnose and treat dementia. Making communities safe and 'dementia friendly' takes knowledge and insight from a lot of different people and groups.  Public health policies that keep kids and young adults active will reduce the amount of dementia in the next generation. Advocating for persons with cognitive impairment and their families at the local, state and federal level is something we can all do to improve the quality of life for persons living with dementia, and their loved ones.

Angela Hanson, MD, is a geriatrician who specializes in the care of older adults with dementia. She completed her training in Internal Medicine and Geriatrics at the University of Washington.  Currently she is a member of the Memory and Brain Wellness Center care team at Harborview Medical Center.  Her research interests include understanding how dietary factors can affect cognition and Alzheimer's disease progression.