Primary Care of the Psychiatric Mental Health Client II

Neurocognitive Disorders and the Geriatric Patient Video Transcript

Donald A. Davidoff, PhD: As a kind of rule of thumb, the care of our geriatric population doesn't belong to just one discipline. A single psychiatrist, single neurologist, a single psychologist is not going to be able to assess all the variables that are necessary in order to make a proper diagnosis. And the proper diagnosis, of course, is the key to good treatment. So places like a memory disorders clinic are essential. I know in Boston, we have a wealth of these clinics. There's one at the Mass General, there's one at the BI Deaconess, and of course ours at the McLean. I know unfortunately in many parts of rural America, that's much less possible.

Well, you bring up a very good question. There is no really medical management in that there are no medications that either halt the progression or even slow the progression of these difficulties. So the treatment revolves around a bio-psycho-social approach where you begin to think about and begin to talk to the patients about, for example, social interventions. The more active an individual is socially the more interactive they are, the longer it's going to take for these cognitive difficulties to catch up.

You may want to look at diet, for example. We know that one glass of red wine may have a protective effect for Alzheimer's, but we know that drinking in general is not very good for the long-term of cognition. Likewise, looking at the different medications that a patient is on. Talking about exercise, exercise, the ACTIVE study, which came out a number of years ago, spoke to the fact that certain kinds of exercise done actually for a really minimum amount of time each week will have protective effects going over 10 or 12 years.

So this whole biopsychosocial approach is what we're left with because the medications haven't caught up. And when I first got involved in doing work around geriatrics, which was now a good 30, 35 years ago, the rule of thumb was, "Oh, we'll understand Alzheimer's in five years and we'll have a medication to prevent this in 10." And with each passage of 10 years, you hear, "Oh, 10 more years, 10 more years."

I was actually at the International Alzheimer's Conference in Toronto last year, where for the first time they're beginning to rethink what Alzheimer's is and that in turn will allow us to reconceptualize. So I think we're making real progress here, but the progress has been slower than any of us would have liked.

Well, the issue of whether everybody should be screened is a separate issue from the question you asked. And when you think about it, people are living longer and longer. When Bismarck talked about the age of 65 being the demarcation point, and of course the original Social Security Act making that more solid, less than two or 3% of the population lived past the age of 65. Today, 14% are living past the age of 65 ... I'm sorry, 14% of the population is over the age of 65. And within another five years, 20% of the population will be over the age of 65. And while medical science hasn't been wonderful in extending age per se. 2000 years ago, the oldest old person lived to be about 100 and today the oldest old person lives to be about 100, but more and more of us are living closer and closer to that limit.

That being said, it means Alzheimer's disease is a real epidemic with about 5.4 million in the United States having Alzheimer's. And so knowing that you're going to live long and knowing that about 40% of the population of 85-year-olds has Alzheimer's, what that tells you is that not that you need to go run and get a screening, but that you need to begin thinking about those things that you can do now to decrease the potential of you getting this illness, or at the very least of prolonging the onset of this illness.

So one should think about healthy lifestyles from the time one can start thinking, because the more we know about the progression of Alzheimer's, the more we understand it to be a lifelong process. That the development of plaques and tangles, the accumulation of amyloid and tau in the brain starts in the 20s. And so if you have about a one in two chance of having Alzheimer's when you're 85, you want to lead a healthy lifestyle. You want to be active both physically and socially. You want to constantly challenge yourself intellectually, whether that's with playing games like Scrabble, or whether that's by reading books and going to museums. All of this is essential.

The issue of a diagnosis, of a diagnostic visit, only if there are problems that are beginning to manifest. And then part of having an interdisciplinary team means that one can begin to tease out what is part of the life span, if you will, versus what might be something that could be intervened with.

We had a guy in the clinic not too long ago who on testing looked like he was beginning to dement, and it turns out that as we looked into what was going on with him, he had very high levels of mercury. He had a history of ADHD and there were two or three other things wrong with them. And so by intervening on all of these things that we could intervene on, six years later, he's functioning pretty well. So hence the importance of a clear diagnosis, but not until there are problems and issues.