The Harvard University Dementia
Comprehensive Update from May 28-31 in Boston was exhilarating! It was a
gathering of the most innovative and prestigious clinicians and researchers in
geriatric and brain health. The authoritative update focused on common clinical
problems associated with brain injuries, dementia, problem behaviors, caregiving,
and the challenges and recommendations associated with obtaining a definitive
diagnosis.
Dedicated
researchers and committed, ethical clinicians gathered to disseminate the
latest in dementia research. The intensive course was designed for an informed
audience of professionals, but it is my intent to present the material to my
readers, who are comprised of informed and general readers. We are making
strides to understand the brain but there is so much we do not know, and that
is humbling. Therefore, I have created the following case study to illuminate
some of the material without being too technical.
Bob, who is a 77-year-old
widow and retired structural engineer, was invited to spend Christmas at his
sister Gertrude’s home. Their other sister, Lucy, was also invited. They had
not seen Bob in two years. The sisters picked him up at the airport and they
knew right away that something was off. Lucy told Gertrude, “His face looks a
little flat. Expressionless. And he is answering yes and no instead of using
complete sentences!”
First, Bob slept
all day and wandered around at night, blaring the television and roaming all
over the house. He had developed abnormal eating habits. Bob only ate corn
flakes with milk, refusing to eat or drink anything else including the special Christmas meal. He even refused to eat his favorite side dish, oyster dressing,
although Gertrude prepared it especially for him. The sisters also discussed
Bob’s hygiene. A snappy dresser and always well-groomed, Bob arrived disheveled,
wore the same clothes, and never bathed during his seven-day visit. Finally,
they noticed that Bob had difficulty with word finding and sentence structure.
They contacted
his daughter, Ashley, and the three of them discussed Bob’s observable changes
and next steps. Ashley, who resides ten miles away from her dad, denied that
there was anything wrong. “He’s just getting old. He’s just turning into a
curmudgeon, that’s all. Leave him alone!” Ashley promised her aunts that she
would arrange for follow-up with his primary care provider. Although Bob was
offended that his sisters and daughter think he is “senile,” he reluctantly
agreed to see his physician, and he protested, “You are all blowing it out
of proportion.”
Familiar
scenario, right? Most of us have had a similar encounter and moral dilemma with
a family member or friend. We do not want to interfere, but we know that
something is off and requires follow-up. Bob’s physician listened to Ashley’s
concerns (this is known as an “informant report”) and performed a medical exam and
cognitive assessment. He explained to Ashley and Bob that he needed to make a
referral to a neurologist, Dr. Sharp, who specializes in dementia.
Dr. Sharp used
the DETeCD-ADRD CPG and the Northwestern CARE-D Model to evaluate Bob’s
condition. Nicknamed the CPG, the Clinical Practice Guideline (CPG) for the
Diagnostic Evaluation, Testing, Counseling, and Disclosure of Suspected
Alzheimer's Disease and Related Disorders (DETeCD-ADRD) is a
structured and patient-centered tool for evaluation of Alzheimer’s disease or
dementia.
Below is a more
detailed breakdown. The CPG is a seven-step model that is tailored to each
individual. The core elements are:
1. Establish
shared goals with care partner and patient.
2. Medical
history from patient and care partner.
3. Structured
multi-domain systems review including cognition, ADLs, behavior, and sensorimotor
evaluation.
4. Biopsychosocial
history and risk factors.
5. Exams
include medical, mental status assessment, psychiatric, and neurological.
6. Three-step
diagnostic steps and formulation require evaluation and integration of the
data.
a.
Determine cognitive-functional status
b.
Characterize cognitive-behavioral syndrome
c.
Determine likely cause
7. Communicate
findings to patient and care partners. Develop a shared care plan and path
forward (Atri et al., 2024).
The CARE-D Model,
used in conjunction with other diagnostic tools in clinical practice, divides
dementia into five categories by gathering details from both patient and
family. They are memory, visuospatial, behavior/emotion, executive/attention, and
language (Morhardt et al., 2015).
Finally, Dr. Sharp
ordered a non-contrast brain MRI to evaluate atrophy patterns,
neurodegeneration, cerebrovascular disease burden, hydrocephalus, and
micro-hemorrhages. Although the radiologist read Bob’s MRI, Dr. Sharp followed
best practices and evaluated the brain MRI himself for clinical staging and
interpretation of the results.
Bob’s condition
was diagnosed as Alzheimer’s Disease and Dr. Sharp advised that Bob should
immediately start taking Aricept and Namenda. Both Bob and his daughter,
Ashley, balked about taking the prescriptions, but Dr. Sharp said, “These are
not a cure, but disease-modifying drugs. It is important to start these drugs
now. Giving the right drug at the right time is essential, as it slows the
progression of the disease.” He also told Ashley that the drugs would help with
problem behaviors. He added, “Learn to redirect, tell white lies, and diffuse.”
Dr. Sharp’s staff provided Bob and Ashley with resources to help them navigate
caregiving and long-term care services, and community support. Ashley joined a
support group for families of Alzheimer’s and dementia patients.
Resources:
Atri, A., Dickerson, B.C.,
Clevenger, C., Karlawish, J., Knopmen, D., Lin, P., Norman, M., Onyike, C.,
Sano, M., Scanland, S., Carillo, M. (2024). Alzheimer's Association clinical
practice guideline for the Diagnostic Evaluation, Testing, Counseling, and
Disclosure of Suspected Alzheimer's Disease and Related Disorders
(DETeCD-ADRD): Executive summary of recommendations for primary care. Journal
of the Alzheimer’s Association. First published: 23 December 2024. https://doi.org/10.1002/alz.14333
Morhardt, D., Weintraub, S.,
Khayum, B., Robinson, J., Medina, J., O'Hara, M., Mesulam, M., & Rogalski,
E. J. (2015). The CARE pathway model for dementia: psychosocial and
rehabilitative strategies for care in young-onset dementias. The
Psychiatric clinics of North America, 38(2), 333–352.
https://doi.org/10.1016/j.psc.2015.01.005
