Understanding the Health Care Team in Alzheimer's Disease

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.

Common Problems

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 Good Starting Point

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.

Who are the Specialists?

The most common specialists consulted for someone with memory or other cognitive symptoms include the following:

• Geriatrician
  
  Geriatricians are physicians skilled in assessing and managing the medical problems that affect older adults. They may work as primary care clinicians or as specialists. Their knowledge of the “geriatric syndromes” such as cognitive changes, polypharmacy (unraveling the benefits and risks of the multiple medications an older adult might be taking), depression, fatigue, or frailty make them valuable consultants when you need to consider the contributions of medications and medical illnesses to an older person’s ambiguous symptoms. They take the “broad view” and may put together the big medical picture especially well. Many primary care physicians who do not identify themselves as geriatricians (which requires special certification) nonetheless are skillful in managing the medical needs of older patients. 


• Neurologist
  
  Neurologists are specialists in the diseases of the nervous system. There are many subspecialty areas in neurology, so be sure to find a “cognitive neurologist,” “behavioral neurologist,” or a general neurologist who has experience and expertise in assessing cognitive symptoms. Neurosurgeons are not the same as neurologists. They are experts in operating on the nervous system and are generally consulted after a potential surgical need has been identified. Clinical trials, which may involve testing new medications or diagnostic tools for dementia, are often run by a neurologist or a psychiatrist.


• Psychiatrist/Geriatric Psychiatrist
  
  Psychiatrists specialize in the assessment and treatment of mental disorders. Cognitive symptoms live in the “borderland” between neurology and psychiatry because they  are often seen with neurologic signs and diagnostic results but also are usually accompanied by behavioral and emotional changes that a psychiatrist is skilled in recognizing and evaluating. Not all psychiatrists are expert evaluators of cognitive disorders, but psychiatrists with advanced training in Geriatric Psychiatry specialize in the emotional and behavioral conditions of older adults. Some geriatric psychiatrists and nurse clinical specialists specialize in dementia care, especially in the evaluation and management of behavioral symptoms of dementia such as mood changes, emotional outbursts, agitation, hallucinations or delusions, impulsivity, aggression, and inappropriate behavior. The primary care physician, neurologist, or psychiatrist may play an important role in assessing an individuals decisional capacity and need for a surrogate decision-maker when decisional capacity is impaired. 


• Psychologist
  
  Psychologists are trained to provide various kinds of assessment and psychosocial treatments. Referral to a psychologist may be made for psychotherapy, including caregiver support. Talk therapy can help a person and a caregiving system adjust to the diagnosis of dementia and to address the practical concerns, relationship stresses, and emotional reactions that can occur.


• Neuropsychologist
  
  Many psychologists perform comprehensive evaluations using reliable and standardized tests, and neuropsychologists are the psychologists who are specially trained to evaluate cognitive disorders. They are particularly valuable in assessing the severity of memory loss or other symptoms, helping to figure out the cause of the symptoms, measuring progress or decline over time, identifying areas of strength that can be reinforced, and designing a non-medication treatment approach.


• Speech and Language Therapist
  
  Speech and Language Therapists can play an important role in helping cognitively impaired individuals affected by difficulties in communication and/or swallowing. They can help individuals improve their speech and improve their ability to express their needs even when they can’t find the right words. Both Speech and Language Therapists and Occupational Therapists may be trained to provide “Cognitive Rehabilitation Therapy”. Cognitive Rehabilitation Therapy systematically identifies and provides structured exercises aimed at remediating difficulties with memory, executive function, visuospatial problems, and other areas of cognitive difficulty.


• Occupational Therapist
  
  In addition to providing Cognitive Rehabilitation Therapy, Occupational Therapists may be helpful in assessing home safety, suggesting environmental modifications to increase safety, and planning activities to facilitate the care of cognitively impaired people.


• Physical Therapist
  
  Gait difficulties, balance problems, recovery from injury or surgery, and planning of a physical activity program are all special skills that Physical Therapists can contribute to a treatment program.  


• Elder Law Attorney
  
  Planning for the management of financial affairs and the financing of care, preparation of an advance directive and will, execution of a Power of Attorney document, and application for guardianship are all areas in which an Elder Law Attorney can save a family time, effort, and money by providing expert assistance.


• Geriatric Care Manager
  
  Geriatric Care Managers, often trained initially in nursing or social work, specialize as “contractors” of geriatric services. They can be valuable members of a caregiving team because they can assess what social supports are needed in order to cope effectively with present stresses and plan for the future. Be sure to look for a geriatric care manager who is certified by one of the agencies that assures a high standard of service.

Mr. Thorne’s Health Care Team

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.