How is the Memory Disorders Clinic at the University of Colorado Anschutz Outpatient Pavilion connected to the Rocky Mountain Alzheimer’s Disease Center?
Dr. Jonathan Woodcock: The Memory Disorders Clinic is a key component of the Rocky Mountain Alzheimer’s Disease Center. We provide clinical services and also coordinate clinical research.
What do new patients need to do to be seen here?
Dr. W: They need to arrange a referral from their primary care physician or from the neurologist who is seeing them. They should ask that physician to forward any records about their prior evaluation, and they should also include any relevant blood test results and any brain imaging studies.
Is it okay if they don't have brain imaging studies?
Dr. W: Yes. If they don't have brain imaging studies already, we’ll decide whether they are needed when we meet with the patient.
How does the new patient prepare for that first visit, emotionally?
Dr. W: They need to clarify in their own minds what their questions are and what questions they want us to address. If they’re confused about that for any number of reasons, including possibly the problem they have, they need to discuss that with their loved ones.
You ask patients to complete history and health questionnaires, including one in My Health Connection. How important are these questionnaires for the visit?
Dr. W: Completed questionnaires help us cover all of the questions that we need to have answered. They also help us to get to know the person better, including their medical and social backgrounds, which we feel is essential to completing a comprehensive evaluation.
Would you describe what happens during a typical first visit with a patient who is coming in with memory concerns?
Dr. W: The doctors will talk with them about why they're here, ask a lot of questions, and do what usually is a fairly brief neurological examination. We may spend some time doing short cognitive tests to get a better sense of the patient's cognitive strengths and limitations. Then the doctor will discuss findings, usually make recommendations for either tests, or specific therapies, possibly including medications, or all three.
How long does it take?
Dr. W: It can take quite a while, probably around one-and-a-half to two hours.
Because the clinic is part of a hospital affiliated with the University of Colorado, you use a team approach to seeing patients. What is this like from the patient’s viewpoint?
The patient will be seen by, and their case will be evaluated by, more than one practitioner, which I believe is to their advantage. On this campus, we have many interrelated parts. Dr. Christopher Filley and I are on the faculty of the University of Colorado School of Medicine in the Department of Neurology, and we are training neurology fellows in this specialty area. We have nurses on our team, including a nurse practitioner, who understand dementia care. And very often, we refer to neuropsychologists for more complete cognitive assessment, and to cognitive therapists. Any or all of those specialists may be a part of the patient's clinic visit. It’s a collaborative effort. That's part and parcel of being seen at a university medical center.
Let’s talk about diagnosing memory disorders. The most common question about memory issues is, what’s the difference between Alzheimer’s disease and dementia? How do you answer?
Dr. W: We get asked this all the time. The word “dementia” refers to the symptoms of memory loss, which often show up as conditions that affect daily living; things like forgetfulness, confusion, and changes in judgment and personality. These symptoms might be caused by a variety of pathological diseases, and statistically, Alzheimer’s disease is the most common, but there are others. While we often associate these conditions with getting older, they are not part of normal aging, and people come to see us because they recognize that things really are not quite right.
Sometimes we joke with patients about whether it's “Old Timers” or “Alzheimer's”, but I think people understand they're coming in for a comprehensive and, really, highly technical medical evaluation. We will give them the best and most accurate information about their medical condition, and part of our job is to distinguish between normal changes related to aging, which affect everyone, with pathological processes, such as Alzheimer's disease, and with other forms of dementia.
We have seen that a confirmed diagnosis of Alzheimer's disease is made after death through brain autopsy. How are you able to make a diagnosis of Alzheimer’s disease before death?
Dr. W: The terms that we use to make a diagnosis range from possible to probable to confirmed Alzheimer’s disease. And you’re right, a confirmed diagnosis comes from autopsy, or sometimes through biopsy if we think the possible cause might be something that’s treatable, such as an infection or an inflammatory condition. If we don't have tissue, then we would make the diagnosis of either possible or probable Alzheimer's disease, or any other dementia diagnosis, on the basis of the clinical presentation.
And how do you approach that clinical presentation?
Dr. W: The most important piece of information we gain about the patient is a history of their illness — when the symptoms began, what the symptoms were, what the problems and strengths of the patient are, and how this has developed over time. When we meet the patient, we see how they speak, the speed of their mental processing, their physical activities. Then we do a neurological examination looking at motor, sensory, reflex function, looking at their gait, how they move, their muscle activity, and what we call their cranial nerve reflexes, which are related to eye movement, swallowing, that sort of thing. These observations tell us a lot about how the nervous system is functioning and where difficulties might be arising. Then, we will do a screening mental status test, which will give us information about how they handle memory, language, visual spatial functions, calculations, attention, judgment, things like that. We may augment that with neuropsychological testing. We often will do a brain imaging study, usually an MRI, to make sure that the patient hasn't had a stroke in the past, that they don’t have a previously undiagnosed brain tumor, and that they don’t have hardening of the arteries within the brain. We would then also rule out certain other possible explanations, such as vitamin deficiencies and infections, using blood tests.
Sometimes one hears that diagnosing Alzheimer’s disease is a matter of ruling out, rather than ruling in.
Dr. W: A lot of people say that this is a diagnosis of exclusion. It really is not, for those of us who do this diagnostic process a lot. For people who haven’t learned the subtleties of the different dementia presentations, it can be a diagnosis of exclusion. But it's possible to recognize the syndrome that is the constellation of signs, which can be very typical for Alzheimer’s disease or one of the other forms of dementia. People don't always show a typical presentation or meet all the typical diagnostic criteria. So if someone doesn't have the typical presentation, then we may not be able to reach a probable diagnosis, we may only be able to reach a possible diagnosis or we may have a more general diagnosis. For instance, we may say that someone has mild cognitive impairment or dementia, but it's not specified to type.
A lot of people are afraid to go to a neurologist for fear they will be told they have Alzheimer's disease. How do you address that fear?
Dr. W: I think the best way to approach any difficult situation is to have the most information you can about it. We have a lot of experience in guiding people in dealing with a new diagnosis as well as in making adjustments in their lives, so that they can have as full a life experience as possible, even with the diagnosis. We do not want people to live in fear — constricting or limiting their activities because they're afraid, because of symptoms that they're having, or because of the disease process that has been diagnosed. And with these complicated memory issues, families often need to make longer range plans for managing care and resources. So we discuss all those things and try to make sure patients and families have access to information that will help them live their lives with full access to meaningful, enjoyable activities.