Introduction
Senior Moments. At a certain point in our lives we start to experience these events. We joke about them, or we tease colleagues about having them when an indiscriminate component here or there slips our mind after a sleepless night or a stressful week, but we do not take it seriously unless it becomes chronic.
For example, I could not remember what the round, wonderfully flavorful spice on our chicken breasts might be during Thanksgiving dinner. Was it pink peppercorn? No, of course not. But the word eluded me for several moments, until I had found a source to Google the name. Capers! It was right on the tip of my tongue, but it would not burst forth. Was this problem with word finding a symptom of something serious? How would I know? We do not routinely test for Alzheimer’s, although we frequently check for hypertension and diabetes. Unfortunately, all three diseases kill.
Should healthcare providers be screened for Alzheimer’s disease and encroaching dementia as readily as we screen for important physiological findings? Should we all be repeating Person. Man.Woman.Camera.TV to check recall? How do we know when we have progressed from the random senior moment to significant disease?
The Issue
Families may often be the first to notice their loved one has started to decline. They notice a loved one will omit simple tasks or have difficulty with remembering where items have been placed. They may forget to feed a pet or have problems with taking medications on time. Family members may notice that grooming has slipped a bit, and clothing or dress is not as precise as it has been. Perhaps appointments have been forgotten and important dates, such as birthdays are ignored.1
Meals may be skipped altogether, or snacks may be substituted for healthier options. People with early to middle Alzheimer’s/dementia may suffer from a lack of attention to detail. Hobbies may no longer draw the attention they once held. One of our family members began to watch nothing but the Weather channel on TV for hours, which may seem odd, but the repetition appears to be soothing.3
However, the most important lesson to remember before leaping to an assumption of Alzheimer’s (according to a neurologist at the U.S Department of Veteran’s Affairs) is to rule out physiological causes for mental deterioration first, e.g. to assure that laboratory values and brain imaging are within normal limits. Many physiological findings, including diseases of the liver, kidney, and heart may mimic cognitive changes in older patients. Additionally, prescription medications, depression, anemia, infection, and vitamin deficiencies could lead to a loss of energy and alterations in day to day functioning.4
Incidence and Prevalence
Alzheimer’s is the 6th leading cause of death in the United States. In addition to being one of the leading causes of death, Alzheimer’s is also quite costly. Aside from the COVID-19 pandemic, the cost of Alzheimer’s may be one of the costliest to face the entire globe (and the United States!) in the next few decades. It is estimated by year 2050, costs associated with Alzheimer’s and dementia could amount to $1.1 trillion. Unfortunately, Alzheimer’s is the only disease of the top 10 causes of death that cannot be cured or slowed.
However, early detection is important. 1 in every 10 Americans over the age of 65 has Alzheimer’s, and of those that are diagnosed, 2 of every 3 are women. Typical life expectancy after diagnosis is 4-8 years. Although early diagnosis may not significantly alter life expectancy, appropriate disease management with Alzheimer’s does makes a difference, especially as the disease begins to progress. Alzheimer’s disease does not exist in a vacuum. Individuals with this disease typically have comorbidities, making disease management much more complex.
Testing
Shortly after President Trump gave a speech to West Point cadets in early summer, the world became riveted with the concept of mental health and functional capacity. As it appeared that President Trump seemed to walk slowly down a ramp when exiting from his speech and held a glass of water with two hands, the media seemed to focus on whether these events were significant.
At that point, everyone became aware of the MoCa test (Montreal Cognitive Assessment Test) that President Trump volunteered to have as an assessment of his mental fitness for office. The MoCA is a routine screening test that is widely used by physicians to test for cognitive impairment in older adults in the United States. The test takes approximately 10 minutes and can be administered by a trained healthcare provider. It includes items such as a clock drawing, identifying drawings of three animals, word recall, putting a list of digits in the proper ascending or descending order, counting backward by serial sevens, etc., among other tasks. A perfect score on the MoCA is 30, but a score of 26 or above is considered normal.4
Testing for Alzheimer’s disease is varied and runs the gamut of tests that can be downloaded and administered at home, such as the SAGE test (self-administered gerocognitive examination) to the MMSE (Mini-Mental State Examination), which is widely used and administered by physicians since 1975. There is also the Mini-Cog, which takes only 3-5 minutes to administer and includes a clock drawing test and a 3-item recall.3
A clock drawing test is performed by providing an individual with a blank piece of paper and asking them to draw a clock with hands at ten minutes past eleven o’clock. The test evaluates the individual’s verbal understanding, spatial knowledge, visual memory, and abstract thinking. Are they able to finish the clock and place the hands in the correct position? Are the numbers correct, and in appropriate ascending and descending order? A clock drawing may be a rapid and inexpensive clue to determine if the need for more detailed testing is warranted.2
The SAGE test can be used at home and then brought to a physician for evaluation. The SAGE test was developed by researchers at the Ohio State University Wexner Medical Center. The test has 12 questions that cover items such as memory, language, cognition, and problem-solving. Questions may be as simple as “how many nickels are in 60 cents?” or “write down the names of 12 animals”. Each time the test is downloaded from the University website, it is slightly different, so it can be utilized to evaluate deterioration.2
Conclusion
While we do not currently screen healthcare providers or our patients for Alzheimer’s disease, statistics suggest the financial burden of this disease befits us to consider adding a Mini-Cog or Clock drawing test to annual physicals. With the wide range of testing, including at-home (SAGE) evaluation, we could begin to screen individuals as easily as we test for hypertension and diabetes.
We should be alert to colleagues or family members at risk for Alzheimer’s disease long before they become a danger to themselves or others. If the prognosis at time of diagnosis is 4-8 years, we need to diagnose Alzheimer’s disease early. Only then will we be able to optimize disease management, and add value to those years, for both the individual patient and the family.
Websites:
- Alz.org “Tools for early identification, assessment, and treatment for people with Alzheimer’s disease and dementia.” 1998 National Chronic Care Consortium and the Alzheimer’s Associations, Revised May 2003.
- Dailycaring.com “SAGE test: 15 minute at-home test for Alzheimer’s.” Daily Caring Editorial Team Daily Caring, LLC.
- Verywellhealth.com “Screening tests used for Alzheimer’s and other dementias.” Rosenzweig, A, medically reviewed by Apetauerova, D., updated July 31, 2020, Verywell Health.
- Wellnessalerts.berkeley.edu “What is the Montreal cognitive assessment test?” Editorial Staff, August 10, 2020. UC Berkeley School of Public Health.
