
James M. Ellison, MD, MPH
James Ellison, MD received his medical degree from UCSF in 1978 and trained in psychiatry at the Massachusetts General Hospital (1979-1982).
Swank Center for Memory Care and Geriatric Consultation, ChristianaCare
Warning signs of cognitive decline, such as forgetting conversations or missing appointments, could be early signs of Alzheimer’s disease or another form of dementia. They could also represent a treatable condition, such as a medication side effect or depression. Either way, it’s important to figure out what’s wrong, why it’s happening, and what to do. This article provides helpful information on the range of health care providers, including specialists, who may become involved in Alzheimer's care.
Mr. Thorne,* a successful car salesman, took no pleasure in the approach of his 68th birthday. Fatigue, discouragement, and forgetfulness overwhelmed him. After recognition as “top salesman” on his lot for over a decade, he had slipped far down the roster. He knew his memory wasn’t what it should be, because he was forgetting conversations, missing appointments, and misplacing things. He was taking too much time to complete his paperwork and other tasks that had always been easy. Each day he felt more concerned, though he tried to protect those around him by covering up his worries and mistakes. He remained careful about his general health and took his blood pressure medication every day. He wasn’t sleeping well. His wife, aware of his distress, urged him to get help. But where should he start?
*Mr. Thorne’s name and details have been changed to protect confidentiality.
Mr. Thorne’s concerns, unfortunately, are common ones among aging adults—although he is experiencing his symptoms at an unusually young age. Alzheimer’s disease (AD) and other dementias affect only a low percentage of adults in their early 60s, but by age 85 as many as 50% of people are affected. Warning signs of cognitive decline, which include symptoms like Mr. Thorne’s, should be taken seriously and not ignored. They can represent treatable conditions such as adverse medication effects, substance use, sleep problems, metabolic disorders, or depression. They can also be the early signs of AD or another progressive cognitive disorder. Either way, it’s important to figure out what’s wrong, why it’s happening, and what to do.
A primary care physician’s (PCP) practice is generally the place to start when questions about cognitive impairment arise, because these symptoms may be connected to other issues in a person’s total health picture. Primary care doctors and nurses are likely to know which initial questions to ask and which screening tests to do.
Depending on the symptoms, they may do a physical examination, draw blood, order imaging studies, and suggest consultation. Consultation with one of the following specialized professionals, often at the recommendation of a primary care clinician, can be valuable. This is especially true when dealing with a more complicated situation such as a person whose age is young, whose cognitive symptoms are unusual or confusing, whose medical or psychiatric histories are complex, or whose behavioral problems are making it difficult to care for them.
The most common specialists consulted for someone with memory or other cognitive symptoms include the following:
Mr. Thorne’s case illustrates how various health care providers might be involved in his care. He was evaluated by his primary care physician (PCP), who did a cognitive screening examination and identified Mr. Thorne’s cognitive symptoms as significant though mild. After more thorough assessment, she also figured out that the patient’s fatigue, sleep problems, and forgetfulness had become significant after he was changed to a new blood pressure medication.
This PCP was very experienced in the care of older adults, so she did not consider it necessary to get input from a geriatrician. Blood tests and neuroimaging tests were normal. Mr. Thorne’s symptoms improved only partially after a change in medication, but the PCP asked for neuropsychological testing a few months later. The neuropsychologist’s findings, in the context of all the other information available, suggested that Mr. Thorne’s difficulties were more than a medication effect. He was likely experiencing early Alzheimer’s disease.
This was very upsetting news for Mr. Thorne and his wife, and the PCP referred the couple to a geriatric psychiatrist to provide further information about dementia and supportive counseling. A psychiatrist rather than psychologist was chosen in this case, because the PCP suspected Mrs. Thorne might require antidepressant treatment.
The psychiatrist, over several sessions, worked with the couple to facilitate their communication and help them adjust to this stressful information about Mr. Thorne’s condition. He assessed Mrs. Thorne for depression and a decision was made to defer medication treatment for her symptoms, which seemed to be a temporary adjustment. He discussed the pros and cons of currently available AD medications for Mr. Thorne and gave the Thornes information regarding clinical trials that might be appropriate for Mr. Thorne to consider.
The psychiatrist then referred them to a geriatric care manager who assisted them in planning for a future when additional supports might become necessary regarding financial planning, residential considerations, transportation, and advance care planning.
James Ellison, MD received his medical degree from UCSF in 1978 and trained in psychiatry at the Massachusetts General Hospital (1979-1982).
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