Screening for Alzheimer's can be complex process (part 2)

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Newsday.com

By DENISE M. BONILLA denise.bonilla@newsday.com

Even some doctors are hesitant to make the diagnosis, experts said.

"It has been said that because there is no cure physicians don't want to go to the trouble of coming up with a diagnosis and leave with the families with this new label," said Dr. Gisele Wolf-Klein, director of geriatric education for the North Shore LIJ health system. "But we don't have cures for a lot of diseases that we deal with.. . . I think in many ways it is incumbent upon the physician to come up with a diagnosis that will explain some of the patient's symptoms."

Wolf-Klein said it's also important to get an early diagnosis so that the patient can be started on drug therapies that can slow down the progress of the disease.

"What I tell my families is if I can slow down the progress so that mom is not that much worse a year from now than she is today, would that be all right for you?" Wolf-Klein said. "And of course families are delighted with that."

But many physicians are untrained in diagnosing Alzheimer's or even in the nature of the disease itself, Wolf-Klein said.

"The medical schools are so overwhelmed by the demands of the curriculum that geriatrics is often relegated to the back burner," Wolf-Klein said. "They could go through four years of training without ever having had a lecture on Alzheimer's disease. So when they move on to their residency problem, they just have absolutely no insight as to how to proceed with a diagnostic work up and the management of a patient with dementia."

Even the methods which doctors use are limited, experts said. Many begin their assessment of cognitive skills with a 30-point test known as the Mini-Mental State Examination (MMSE). The questions include asking the patient the date, to count backward from 100 by sevens and to copy a drawing of two interlocking pentagons.

Although this test has become the de-facto standard first-step in diagnosis, it can be inaccurate, said Jennifer Manly, associate professor of Neuropsychology in Neurology at the G.H. Sergievsky Center and the Taub Institute for Research on Alzheimer's Disease and the Aging Brain at Columbia University.

"The problem with it is . . . people who are culturally different don't do well on it and it has nothing to do with whether they are demented or not. People who have lower education - nothing to do with whether they are demented or not," Manly said. "People who are culturally in the dominant culture, people who are well-educated, they all do well on that test, even if they have dementia. As a screening measure it's not very sensitive but it is very specific in the people who it's meant to be administered to - well-educated, white, older people."

Doctors and patients alike need to have an understanding that this test is not intended to be a complete diagnostic tool but simply a screening measure, Manly said. "The standard of care is a full neuropsychological test battery and that really is the best thing to do if you have worries about your memory," Manly said.

Tests such as the MMSE can be useful to begin that initial dialogue about dementia, experts said, and it's one of the tools used in the Alzheimer's Foundation of America's National Memory Screening Day. During this event - which takes place on Nov. 17 this year - various sites around the country offer free, confidential memory screenings to those concerned about memory loss.

"If we start this process earlier, it makes the whole course of the illness easier," Vogel said. "If they're not so confused and they're not so threatened and they start to accept and find the right caregiver or we find the right program, the rest of this journey is far simpler."



To find a site for National Memory Screening Day: