Primary care clinicians often have long-established relationships with their patients and are in an ideal position to observe potential signs of a cognitive problem. And, when patients are worried about changes in their memory or thinking, they often bring that concern to their primary care doctor first.
It is important to take these concerns seriously and to assess the patient as early as possible to determine the potential cause of impairment. The National Institute on Aging's publication titled Assessing Cognitive Impairment in Older Patients: A Quick Guide for Primary Care Physicians can help healthcare providers to talk with patients and caregivers about their concerns, assessment, and diagnosis.
As a person gets older, changes in the brain can affect memory and cognition. The extent of these changes varies from person to person. Your patients may be worried about their memory, and many may fear dementia disorders such as Alzheimer's disease.
It is important not to ignore changes in an older person's memory or personality, or assume it's just a normal part of aging. Whether memory and cognition problems are reported by the patient or a family member or observed by you, the issues should be noted in the patient's chart and followed up with screening and assessment.
Not all cognitive problems are caused by Alzheimer's disease. There are a variety of other possible causes such as side effects from medications, metabolic and/or endocrine changes, delirium caused by other illnesses, or untreated depression. Some of these causes can be temporary and reversed with proper treatment. Other causes of cognitive problems, such as dementia, cannot be reversed, but symptoms can be treated for a period of time and families can be prepared for the future.
Some older people have mild cognitive impairment (MCI). People with MCI have more memory problems than normal for their age, but their symptoms do not interfere with their everyday lives. Older people with MCI are at greater risk for developing Alzheimer's, but not all of them do. Some may even go back to normal cognition.
Determining When to Screen for Cognitive Impairment
Older adults, particularly those who express concerns about their memory or show signs of a cognitive problem, should be screened. An assessment is actually a required part of the Medicare Annual Wellness Visit. While screening is not enough to diagnose a cognitive impairment like dementia, it is an important first step and may uncover problems that are reversible or treatable.
The Dementia Screening Indicator is a basic risk assessment tool that can help guide your decision about screening. In general, you should screen for cognitive impairment if:
- the patient, relative, or caregiver expresses concern about changes in the patient's memory or thinking
- you observe a potential issue
- there is a medical history of type 2 diabetes, stroke, depression, or another health issue that increases risk for cognitive issues
- the patient is age 80 or older
Talking with Your Patient about Screening
If your patient has immediate concerns about being diagnosed with Alzheimer's disease or another dementia, explain that the issue may not be Alzheimer's disease and reiterate that some problems with memory and thinking are treatable.
You can also explain that an accurate diagnosis of Alzheimer's disease or other cognitive problems can help your patient and his or her family to plan for the future. Early diagnosis offers the best chance to treat the symptoms, when possible, and to discuss ways of positively coping with the condition, including discussing care options. A relatively early diagnosis allows patients to make financial plans, prepare advance directives, and express informed consent for clinical research.
Patients and family are more likely to consider participating in research after talking to a doctor about what a clinical study involves, as well as the benefits and risks. There are clinical trials for people who have Alzheimer's disease or MCI, those with a family history of Alzheimer's, and healthy people with no memory problems or family history of the disease. You can learn more about what trials are available on the clinicaltrials.gov website, or use NIA's clinical trials finder.
"You mentioned having trouble with your memory."
Mr. Jones had always been a meticulously organized man. But during his last doctor's appointment he appeared somewhat disheveled and had problems answering many of Dr. Ross's questions. Mr. Jones asked Dr. Ross to repeat himself several times and had trouble recalling certain, common words. Mrs. Jones expressed concern about her husband getting disoriented in the neighborhood they had lived in for 50 years. Dr. Ross knows it's time to find out what is causing Mr. Jones's memory problems.
Conducting a Screening in the Primary Care Setting
You may worry that you don't have time to screen your patients for cognitive issues. It usually takes 10 minutes or less for trained staff to initially assess a patient using readily available screening tools.
You can use NIA's Instruments to Detect Cognitive Impairment in Older Adults database to search for instruments that meet your needs. Many of these tools are brief and easy to administer.
Cognitive impairment screening tools include the Ascertain Dementia 8 (AD8), Mini-Cog, and Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Some of these tools are intended for use with the patient (i.e., Mini-Cog); others are designed to collect information from a caregiver, family member, or other companion (i.e., IQCODE); and some can be used both with the patient and informant (i.e., AD8).
Because testing may provoke anxiety, it might be best to do any formal screening during the latter part of the appointment. Try to present the screening in the context of concerns the patient has expressed. Providing support and encouragement during the testing can decrease stress.
The tests or interviews should be conducted with the patient alone so that family members or companions cannot prompt the patient. You may also glean information from your patient's behavior in your office or from telephone interactions with staff. Family members who may contact you about the patient are another source of information, but be sure to obtain the patient's permission to speak with these individuals.
You may want to invite the family member or close companion to come to the visit, and after the private patient screening, ask the person to contribute additional information. People who are mildly impaired often have strategies to compensate for their memory loss. Taking a family history from a relative is one way of determining if there are persistent or worsening memory problems.
If the screening suggests the need for further evaluation, you can recommend that your patient see a specialist such as a neurologist, geriatric psychiatrist, or neuropsychologist for a more detailed diagnosis. Depending on your location, a local memory disorders clinic or Alzheimer's Disease Center may also be an option for referrals. You can provide comfort by reassuring the patient that you will still be involved in his or her medical care.
Communicating with a Confused Patient
Working with patients who are cognitively impaired presents an ongoing communication challenge. For instance, they likely will have trouble following any instructions about their care, including how and when to take prescriptions. Make sure someone can closely monitor care management, and try to involve a care partner whenever possible.
Here are some tips for effectively working with and communicating with cognitively impaired patients.
- Try to address the patient directly, even if his or her cognitive capacity is diminished.
- Gain the person's attention. Sit in front of and at the same level as him or her and maintain eye contact.
- Speak distinctly and at a natural rate of speed. Resist the temptation to speak loudly.
- Help orient the patient. Explain (or re-explain) who you are and what you will be doing.
- If possible, meet in surroundings familiar to the patient. Consider having a family member or other familiar person present at first.
- Support and reassure the patient. Acknowledge when responses are correct.
- If the patient gropes for a word, gently provide assistance.
- Make it clear that the encounter is not a "test" but rather a search for information to help the patient.
- Use simple, direct wording. Present one question, instruction, or statement at a time.
- If the patient hears you but does not understand you, rephrase your statement.
- Although open-ended questions are advisable in most interview situations, patients with cognitive impairments often have difficulty coping with them. Consider using a yes-or-no or multiple-choice format.
- Remember that many older people have hearing or vision problems, which can add to their confusion.
- Consider having someone call the patient to follow up on instructions after outpatient visits.
- If the patient can read, provide written instructions and other background information about the problem and options for solutions.
- Address potential issues of driving, getting lost, and home safety each time you see the patient. And, encourage regular physical activity, social activity, hobbies, and intellectual stimulation, as well as a healthy diet. Some studies link these approaches to the maintenance of cognitive function.
Some patients may prefer a cautious, reserved explanation. You might consider saying something like, "You have a memory disorder, and I believe it will get worse as time goes on. It's not your fault. It may not help for you to try harder. Now is an opportunity for you to start making financial and legal plans. It is best to do this before your memory and thinking get worse. Some patients may prefer more precise language and appreciate it when a doctor uses specific words like Alzheimer's disease.
The American College of Physicians Foundation and Alzheimer's Association have produced an 11-minute video, "Disclosing a Dementia Diagnosis," that might be helpful. Written materials can also be helpful. NIA's Alzheimer's Disease Education and Referral Center has free tools and publications you can give to your patients. Local resources can be found using the Eldercare Locator.
If possible, schedule additional time for the appointment so that you can listen and respond to the patient's or caregiver's concerns. The Alzheimer's Association or other supportive organizations can provide information about planning, social services, and care.
Ask the patient if there is a family member or friend who can help with medical, legal, and financial concerns going forward. Make these arrangements early, and assure that the patient has given you formal authorization to include the care partner in the conversation about your patient's care. Keep that person's name and contact information in your notes for future reference.
Informing family members or others that the patient may have Alzheimer's disease or any cognitive impairment may be done in a telephone conference or group meeting, which should be arranged with the consent of the patient. Let everyone know that you will continue to be available for care, information, guidance, and support.
Consider how your practice can coordinate and integrate care for the person and family across the many specialists and services that will be involved.
Working with Family Caregivers
All family caregivers face challenges, but these challenges are compounded for people caring for patients with Alzheimer's disease and other dementias. Including Families and Caregivers has suggestions that can help. Here are some approaches that are especially useful:
- Explain that much can be done to improve the patient's quality of life. Measures such as modifications in daily routine and medications may help control symptoms. If appropriate, bring in a palliative care consultant to help the patient with symptom management.
- Let caregivers know there is time to adapt. Decline is rarely rapid. Provide information about the consumer resources and services available from local organizations, as well as support groups.
- Help caregivers plan for the possibility that they eventually may need more help at home or may have to look into residential care.
- Encourage caregivers to get regular respite especially when patients require constant attention. Ask if the caregiver, who is at considerable risk for stress-related disorders, is receiving adequate health care.
For more information on Alzheimer's disease and other dementias, contact:
A service of NIA, the ADEAR Center provides resources for healthcare professionals, as well as information, publications, referrals, and a clinical trials finder for patients, families, and caregivers.
This national voluntary health organization supports Alzheimer's disease research and care and offers information and support to patients and families. It has local chapters with community information, including referrals, support groups, and safety services.
The Foundation brings together groups around the country, including assisted living organizations, community services agencies, State agencies, and others, to collaborate on education, resources, and program design and implementation for people with Alzheimer's disease, their caregivers, and families.
The Eldercare Locator offers referrals to and information on services for seniors by geographic location.