Sunita Hanjura, MD, is a physician with Emerson Primary Care of Bedford. In this Q&A she explains the different methods for diagnosing, treating and coping with dementia.
If a patient tells you they are concerned about cognitive changes, how do you typically respond?
We often hear about memory loss from family members who begin to see the gradual changes of dementia, such as the person getting lost or forgetting how to dress themselves. It takes, on average, at least five years for families — or the individual — to even notice the changes. That is because they can be subtle. If I have any concerns, I will perform a short screening test, such as the Folstein Mini-Mental Exam or the Montreal Test for Cognitive Abilities. Each has been rigorously tested, so the results are meaningful.
For patients who have very mild cognitive impairment, and if the initial testing is normal, I might suggest neuropsychiatric testing, which takes two or three hours. It is important to rule out reversible causes of dementia, such as thyroid problems or vitamin deficiency, so a blood test is essential. We discuss all the results and decide if further testing is needed.
What further testing might be performed?
We can also perform an MRI to rule out vascular dementia or other neurological conditions. The vast majority of dementia cases are due to Alzheimer’s disease, but vascular dementia — caused by strokes, including silent strokes — is the second most common type. Others include dementia with Lewy bodies, frontotemporal dementia and dementia related to Parkinson’s disease.
I also evaluate for depression. The loss of focus and concentration that comes with untreated depression will sometimes mimic dementia. This is called pseudo-dementia, and it is important to identify so it can be treated.
We can now also use PET scanning at Emerson to identify amyloid — the protein known to cause cognitive symptoms in the brains of individuals who have Alzheimer’s disease. With this imaging test, we are able to provide people with clearer information on how advanced the disease is. In some cases, we can consider starting treatment earlier.
Are the medications for Alzheimer’s disease effective?
They can be effective, because they tend to stabilize symptoms. But they are not a cure. There are two well-known medications — Aricept and Namenda. If people choose, I will start them on one or both medications. The combination of both appears to have a greater impact.
There is also a tremendous amount of ongoing research. Clinical trials are underway looking at monoclonal antibodies targeting the amyloid protein. The accumulation of amyloid is a key component of the neurodegeneration caused in Alzheimer’s disease. Research is also focused on tau protein, which appears to play a role. It is my hope that one day we will have treatments available, which will lessen the fear surrounding Alzheimer’s disease.
Do you guide patients and families on planning for the predictable decline that occurs with dementia?
Yes. Most people with dementia continue living in their homes. Some are fortunate to have strong family support, but others may not. I work with families to set up a support structure to make sure people are safe and able to get the help they need to remain in their homes. Determining driving safety or safety in the home is also very important. In addition, I may need to assess the individual’s competency. When someone is no longer competent to make decisions, it is time to activate their healthcare proxy.
Do you have patients whose lives proceed fairly well despite a diagnosis of Alzheimer’s disease?
There are many people who are well supported by family — sometimes a spouse, children or grandchildren. Many husbands and wives are committed to caring for each other at home. People manage to play bridge, go to church, and have a social life. If they live alone, they might have home health aides who visit regularly, or they have neighbors who watch over them. Many love listening to music and enjoy gardening. I’m amazed at how some people are able to maintain happy, productive lives.
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