Cognitive Problems: Often They’re Treatable
DEMENTIA AND SPECIFICALLY ALZHEIMER’S DISEASE DEMENTIA ARE FAR MORE COMMON THAN STATISTICS INDICATE
The statistic that 5.5 million people in the United States have Alzheimer’s disease dementia is an underestimate. My experience as a clinician-researcher shows that dementia and Alzheimer’s disease dementia are more common than providers generally realize. We may know plenty about our patient’s blood pressure or cholesterol lab values. However, we don’t often ask or examine whether our patient is having memory problems. This is understandable because for both the patient and the provider, the subject is hard and at times awkward to bring up in a typical clinical setting, and for the patient, a conversation about memory problems can seem extremely threatening. Still, if we are to address memory problems, we need to know about them, and we need to talk about them.
WAYS TO BROACH THE SUBJECT OF COGNITIVE DECLINE
When you bring up questions about memory, people immediately worry about losing their independence. This is an important point. It’s a sensitive subject, so the real challenge for us is to pay attention to how we bring it up.
I never ask, “How’s your memory?” because the answer I’d likely get would be, “It’s fine.” Instead, I’ll ask more neutral questions such as, “How are you doing managing things around the house?” With this kind of question, people are much more forthcoming. You may get responses such as, “I’m having a little trouble managing my checkbook.” “I forgot to pay a bill or paid a bill twice,” might be another. The follow-up question you might ask is, “Compared to what you used to do, have you noticed differences?” The answer may be, “Yeah, it’s just not the same.” When I get this kind of response, I don’t let it go. I follow up with, “Let’s find out what could cause this issue and let’s try to fix it.”
POSSIBLE CAUSES OF COGNITIVE PROBLEMS
If you’ve found that there is a problem, start by reassuring the patient that there are many possible causes for it that are highly treatable. This is important to explain to patients. Most patients will then likely comply and undergo the various examinations you order as part of the workup. Abnormal results for any of the following tests can be associated with confused thinking:
*Vitamin B12 level (Vitamin B12 levels often indicate whether the patient is getting adequate nutrition. Often we find that for an older woman who lives alone, every meal is nothing but toast and tea.)
* Blood sugar or hemoglobin A1c level
* Red or white cell count and differential
* Brain imagining (This might reveal a tumor or multiple little strokes – more common than you think – that could explain problems with cognition).
POLYPHARMACY CAN INTERFERE WITH COGNITION
One of the big things to explore with your patient is whether polypharmacy, that is, taking two or more drugs, is causing her to be less alert. The problem is, as your patient ages, she’s likely to be using an increasing number of medications. By the time she’s 50, she may be taking 5 drugs, and for each decade beyond that, we often find that she’ll be on an additional drug. A 60-year old may be taking six medications and a 70-year old may be taking 7 medications. Interactions among these drugs could easily be the cause of her memory problems. The more medications she’s taking, the greater the likelihood that this is happening.
EXPLORE REDUCING HER EXPOSURE TO POLYPHARMACY
Assess which of the medications are “negotiable” and which are “non-negotiable,” and openly discuss this with your patient. Typically, blood pressure medications and cardiovascular medications are non-negotiable and so is diabetes medication. In the interests of better cognitive function, evaluate how much of each medication is needed. Then look at all her medications including vitamins, muscle relaxants or antidepressants. Patients may find, as many others have, that when they take fewer medications, thinking improves.