Mrs. H presents to my office for follow-up of her blood pressure and refills. I have taken care of her for many years. She is a delightful lady who lives alone in her condo ever since her husband died many years ago. She has one daughter in California. She still drives and takes care of herself without difficulty.
Mrs. H tells me “I was thinking I need to update my will. Now that my husband is gone and things have changed so much, I really need to do that”. She does not have an attorney, so I give her a list of some of the elder law attorneys in the area.
During the visit, I noticed that Mrs. H is slightly more repetitious than she has been in the past. She had difficulty remembering who her eye doctor was, and I noted from the pharmacy records that she is behind on her refills; her last supply of 90 days’ worth of blood pressure medicines was four months ago.
As part of my exam, I asked her to draw a clock and set the hands to 10 after 11. She was able to do that without difficulty. However, when I asked her to remember three words for several minutes, she could only remember one word. The rest of her physical and neurologic examination was normal.
Thoughts? Is this normal aging? Is she having a bad day? Or is there something more worrisome going on? Cognitive problems in older adults can present with very subtle changes and findings. In fact, patients can get into the middle stages of dementia before it becomes apparent to friends, family, or even their physicians. To make matters worse, memory issues can be covered up by patients who are professionals, have high educational attainment, or good social skills.
For Mrs. H, I explained my concerns with her memory issues. She is agreeable to get some blood work and a CT scan of her head. Both of these came back normal. We discussed something called neuropsychological testing, which is a several hour battery of paper and pencil cognitive tests.
Neuropsychological testing provides a more detailed baseline of a person’s strengths and weaknesses which can assist in the diagnosis. For example, Mrs. H only recalled one of three words, which if forgetting would suggest Alzheimer’s. Neuropsychological testing helps differentiate between different types of memory problems such as forgetting (present in Alzheimer’s) and difficulty recalling (present in vascular and Lewy Body disease). Such degree of detail, as in Mrs. H’s case, is not always necessary to make a diagnosis. Neuropsychological tests take several hours; they remind people of school tests. Most people find them exhausting. They are best reserved for younger people with early onset dementia and/or well-educated folks who may do fine on the screening tests given in the office, but have a dementia percolating below the surface.
The key to deciding about neuropsychological testing is no different than ordering any other test. Will it change the management? However, these can be very hard on people and she wanted to hold off on this for the time being.
Mrs. H was happy to have me call her daughter and express my concerns. Her daughter likewise shared my concerns with some things slipping through the cracks; bills getting paid late, confusion over finances, etc.
Mrs. H was seen by a neurologist who agreed with my assessment that she had early-stage Alzheimer’s disease. Her symptoms at present consist of short-term memory loss, some issues with insight and judgment. He recommended that she only drives during the day in very familiar neighborhoods.
Mrs. H presents to your office to update her will. She is very chatty and personable. She is perhaps a little confused about some of the more complex issues in her life. Do you go ahead and update her will? What are your next steps?
Dementia is an increasingly common illness that strikes primarily older adults. Think of dementia as the umbrella term, with Alzheimer’s disease being about two thirds of the space under the umbrella. Dementia is a descriptive term that describes the condition where someone is having problems in cognition, and is no longer able to independently take care of themselves. If we believe someone has a dementia, our next step is to try to identify the underlying disease that is causing the dementia. In most cases, Alzheimer’s disease is present. The next two most common causes are Lewy Body disease and vascular disease. And then there are rarer diseases, such as frontotemporal disease that can result in dramatic personality changes, and Primary Progressive Aphasia, where people lose the ability to speak. For the purposes of this article, we will focus on Alzheimer’s disease.
According to the Alzheimer’s Association (Alz.org) there are ten warning signs to watch for.
Not every person gets all of these symptoms, and some people may have had issues with these for years; we all know that person who can’t read a map or find a new location to save their life.
The important thing to note is that these are not changes that are part of “normal aging”. It is important to get a medical evaluation by a geriatrician or neurologist specializing in dementia for reversible or modifiable causes (e.g. vitamin B12 deficiency, depression, anticholinergic drugs) of the cognitive problems being experienced. Additionally, there are several medications that can be helpful, especially early in the disease process.
Unfortunately, Alzheimer’s is a progressive disease, and unless the patient dies from something else, they will eventually lose the ability to care for themselves, and will need total care at the end of their life.
Understanding this issue is imperative for patients and families. Deciding on the durable power of attorney for healthcare and thinking about how to finance increasing care needs in the future are especially important.
One of the more challenging aspects of dementia care is the driving issue. We all know how much independence driving gives us. However, driving is one of the more cognitively complex things that we do in our daily life. Someone with early dementia is likely not going to be a good driver, and since most dementias are progressive, the decision to retire from driving is best made before something tragic or life threatening happens. Physicians in almost all states are able to notify Department of Motor Vehicles about patients who refuse to stop driving.
So what do you do with Mrs. H and her will? One thing that I wish we all did more frequently would be to pick up the phone and have a discussion with the primary care physician or neurologist. In medicine, we ask the question, is the patient able to make an informed decision about a specific item at this time? It may be reassuring if the family is involved and in agreement, but does the family have Mrs. H’s best interests in mind?
We would likely agree that Mrs. H would be able to make some changes in her will, as long as her family was involved and in agreement. However, if she was trying to leave her entire state to some flaky charity, then we may have to reconsider.
CLE 90 mins | Free for Members | CC
This is the first of a series of webinars focusing on handling the various stages of dementia and the legal issues that arise. Webinar 1 will describe how to recognize the symptoms of dementia.
