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Early Alzheimer's testing is important

By Debbie Gardner

PRIME Editor

My favorite aunt doesn't know me anymore.

She lives happily in her own world, a world that has robbed her of her memories, the ability to recognize family and friends, even to remember what day it is or what meal she's just eaten.

For the past five years that world has encompassed the small memory impairment ward of a local senior living facility.

She has dementia. It might be Alzheimer's Disease, but without a brain autopsy the definitive test to confirm that condition we can't say for sure.

She lived alone before we moved her to the facility and I've often wondered if, even though the family visited every Sunday evening, we missed or possibly dismissed as loneliness and advancing age the early signs of her mental decline.

The signs that might have given us more time to plan, to start a memory-preserving drug earlier in her decline, to let my aunt make some of the decisions that now have fallen on our shoulders, for herself.

Should we screen everyone?

It appears I'm not the only person who has wondered if earlier testing for memory disorders might make a difference in the lives of patients and their families.

Late last fall, a consortium of memory disorder experts convened in Washington, D.C., to discuss precisely that same question should a routine screening for Alzheimer's Disease at age 65 become the accepted norm for today's medical practices?

The event's title was the provocative statement: "Why Are So Many People with Alzheimer's Disease Still Undiagnosed?"

In response to that question the panel, which included Dr. Paul R. Solomon, a psychology professor at nearby Williams College in Williamstown, Mass., and director of the Bennington, Vt.-based Memory Clinic as well as executives from the Health Policy Institute, National Alliance for Caregiving and Clinical Alzheimer's Disease Research at the Farber Institute for the Neurosciences, presented a case for early screening and released a consensus statement.

That consensus "encourage[s] all adults 65 years and older, either independently or through the support of loved ones, to seek out memory screenings during their physical examinations and on a routine basis thereafter based on individual risk factors."

The group also proposed that a mandatory memory disorder screening be incorporated into the "Welcome to Medicare" physical that is given to new beneficiaries at age 65.

"It is massively underdiagnosed," Solomon said of the growing prevalence of Alzheimer's and other memory disorders among America's aging population. "Only half of those who have it know it, and only one-quarter are getting treatment."

He went on to say that early screening could identify "two and a half to three million [Alzheimer's and other memory disorder sufferers] who don't know they have it."

This lack of information is costly on many levels, to the tune of "150 billion dollars a year," according to Dr. Richard Stefanacci, founding executive director of the Health Policy Institute. Businesses suffer when employees miss work for caregiving duties, consumers suffer when automobile insurance rates rise in response to accidents caused by confused elders and state budgets suffer when untreated elders enter nursing homes instead of receiving care at home or in less costly settings.

But what exactly is an early screening, and will a cursory, routine testing in a primary physician's office really make a difference in the lives of patients and caregivers?

The mini-medical

"Different diseases cause dementia," said Barry W. Rovner, M. D., director of Clinical Alzheimer's Disease Research at the Farber Institute, another presenter at the Alzheimer's discussion. "Alzheimer's is the most common form . but dementia is also caused by depression, hypothryoidism, B12 deficiency."

And all of these conditions warrant evaluation by a physician.

He said a diagnosis of suspected Alzheimer's Disease is made only when memory impairment is coupled with other cognitive impairments, such as difficulty with language or learned behaviors such as driving a car.

And he said the oft-presented argument that primary care physicians don't have the time to perform a basic memory screening on patients is "not valid."

"It's not valid that [physicians] don't have time to screen," Rovner said. "It doesn't take much time . physicians spend more time listening to the heart than screening the brain."

He said simple screening tests such as having a patient draw the face of a clock, or recall three words after five minutes, or name as many animals as they can in one minute can be added to a routine visit without significantly increasing the time spent with a patient.

Rovner did acknowledge that many doctors may feel they are not ready to do this type of screening.

"They may not have the training, may not have the resources, may not be familiar with the community resources [to help patients] and may not have access to [the patient's ] caregivers," he said.

But, he said, it's still the "physician's responsibility to screen for [Alzheimer's] and also to say 'I know this disease, I can treat it and I can help you through the course.'"

But is it really practical?

Dr. Benjamin Liptzin, chairman of the Department of Psychiatry at Baystate Health and a professor of psychiatry at Tufts University, told Reminder Publications that he agrees with the idea of early dementia screenings in principal, but has reservations about the practicality of including the test in the "Welcome to Medicare" exam.

"If I were a primary care physician with an aging practice, that's one of the things I would have on my list," Liptzin said of screening for dementia.

But, he questioned, would that screening take the form of a "30-second screening . how's your memory . a seven-minute screening or a 20-minute screening?"

He said Baystate offers complete memory screening tests and plans for treatment and disease management, if necessary for individuals and caregivers who have genuine concerns about identifiable memory loss.

He also expressed puzzlement about exactly what would be done with the information obtained from these proposed early screenings.

"What would you use it for?" he asked. "We're using it mostly for research [right now]."

He said that though there's a great deal of current research into Alzheimer's Disease, and clinical trials of medications that may prove helpful in treating people before they develop symptoms, there's nothing new to offer patients at this moment.

"I don't think it's reasonable to recommend [the 'Welcome to Medicare' screening] as a reasonable public heath screening because we don't have treatments for pre-symptom conditions," Liptzin said. "But I think the public and physicians need to be increasingly aware of the [Alzheimer's] epidemic that will come as the baby boomers age."