America is getting older. As the population’s age creeps upward, primary care physicians need to be thinking more and more about Alzheimer’s Disease (AD). This was the fundamental message of physicians Richard S. Isaacson, M.D, and Charles Vega, M.D., as they jointly addressed the Pri-Med Conference audience in a session focused on the current state of affairs in AD.
“The single greatest risk factor for Alzheimer’s disease is, of course, age,” they noted.
Dr. Vega, a Health Sciences Clinical Professor at the University of California at Irvine’s Department of Family Medicine and Assistant Dean for Culture and Community Education Executive Director at UC Irvine’s Program in Medical Education for the Latino Community, began with a criticism of primary care providers in terms of AD:
“Generally, we are not doing a great job of screening for cognitive impairment among at-risk individuals, even those who are symptomatic,” he said, noting that while nearly all PCPs agree that brief cognitive assessments are beneficial for senior patients, only 1 in 7 seniors regularly receive such assessments, according to research conducted by the Alzheimer’s Association.
Dr. Issacson, Director of the Center for Brain Health and of the Alzheimer’s Prevention Clinic at the Charles E. Schmidt College of Medicine of Florida Atlantic University, noted that primary care physicians should be aware that the spectrum of AD is shifting:
“Soon we’re not going to be just thinking about Alzheimer’s as the dementia phase, but we’re going to be thinking about it as the earliest mild cognitive impairment phase. We will be talking about ‘pre-clinical’ or ‘pre-symptomatic’ Alzheimer’s, in which amyloid begins to accumulate in the brain, but there are no symptoms as yet.”
Driving home the importance of this shift, Dr. Issacson noted that there are an estimated 46 million Americans that have pre-clinical or pre-symptomatic AD.
The presenters used a theoretical case study of a patient named “Polly” to delve into the practical aspects of patient management. “Polly” and her situation were described as follows:
- Polly is a 67-year-old African American woman with a past medical history of hypertension and “borderline” diabetes. She presents to your primary care clinic for her annual check-up. Her husband is with her today.
- She drinks 1-2 glasses of red wine on weekends and she does not smoke. She was a junior high math teacher prior to retiring a few years ago.
- Given a family history of dementia, she expresses concern about experiencing “forgetfulness.” She forgot her niece’s birthday party last month. Her husband has noticed she seems to occasionally repeat stories when they are conversing in the evenings. She has lost her keys a few times over the past couple of months.
Dr. Vega began, asking his audience to consider is the patient exercising? Is she overweight? He noted that modification of lifestyle factors like these could still make a difference in terms of the rate of cognitive decline in a patient like Polly. Dr. Vega also noted that it’s not too early to begin coordinating a team approach to Polly’s care:
“We can start getting that team together. It can include family and friends, but also a healthcare team—a neurology team, a gerontology team, a social work team, mental health services.”
Dr. Vega said this is also the time for a family to consider taking that big trip they have long discussed or moving forward a major family event, so that the patient can get as much out of it as possible.
Dr. Isaacson add that, as is the case with most diseases of aging, the answer in Polly’s case is going to be a combination of pharmacologic and non-pharmacologic approaches.
“Lifestyle interventions are critical. A few targeted vitamins and supplements could be helpful, but we really need to think about Alzheimer’s in terms of a global approach.”
Dr. Isaacson said that everyone patient presenting with signs of cognitive impairment should have some sort of brain imaging done.
“Specifically, everyone should have an MRI. CT scans are fine. They’re basic and they’re quick, but the discernment of a CT scan in truly helping with diagnosis is marginal at best.”
Dr. Isaacson also recommended that primary care physicians be as specific as possible in their communications with radiologist when ordering a test like an MRI:
“When ordering an MRI, we often ask the radiologist, ‘Is there shrinkage of the hippocampus?’ You can actually write on the requisition that the person is suspected of Alzheimer’s and ask if they have atrophy of brain areas related to AD. You can have the radiologist offer you some kind of feedback.”
Finally, doctors Isaacson and Vega did mention aducanumab, the controversial AD drug approved by the FDA last year. Dr. Vega described it as a “potential disease modifying therapy,” in contrast to older drugs for AD that “just slowed down the process.” Both doctors expressed excitement about AD treatments that are currently in phase 3 trials.
In concluding, the speakers reminded audience members that primary care physicians are well positioned to help with the all-important early and accurate diagnosis of AD. They also reminded their audience to be watchful for the underdiagnosis and misdiagnosis that tends to occur most frequently in minority populations.