Alzheimer Disease: Referral to a Specialist

Alireza Atri, MD, PhD: That actually leads me to think, what would prompt somebody who should get an expedited evaluation? What types of symptoms, along with maybe cognitive, should prompt this evaluation as more rapid?

Bradford C. Dickerson, MD: I think Lynn was just talking about these atypical presentations. I think the vast majority of primary care clinicians, and I hope Mary would agree, would be comfortable with diagnosing and managing the patients with more typical presentations of Alzheimer disease or Alzheimer with cerebrovascular disease, or these common mixed pathologies that we’ll talk more about.

But when a patient presents with a primary language problem as their main issue that’s affecting their functioning, or a visual problem where they’ve gone to the eye doctor multiple times, gotten multiple prescriptions, and they’re still having problems and it turns out it’s because there’s a problem with the way the brain is processing what they see, these unusual presentations are often types of situations where the primary care clinician, or even sometimes the specialist within neurology or psychiatry, might refer to a subspecialist. These are very difficult cases to diagnose, and they often require specialized resources in care planning and management.

I think when the patient is presenting with what looks like a dementia syndrome but it’s one of these very uncommon syndromes that maybe the clinician hasn’t seen before but has heard about and may hear from the neuropsychologist, “This is what this patient might have,” that often would warrant a subspecialist referral.

Many of the patients with these atypical syndromes are younger. A lot of times patients under the age of 70 or 65, which is our traditional cutoff for what we define as early onset dementia—if a person is under the age of 65—many of them have atypical syndromes. Even if they present with a more typical syndrome of memory loss with executive dysfunction, problems with organization and planning, they often have special needs and don’t fit into the care planning and resource development for management that typical older patients may fit best with.

A lot of the young onset, under the age of 65, patients would benefit from subspecialty referrals. And then if a patient has a more rapidly progressive condition, often defined as progressing from a proximate symptom onset to at least mild dementia within 6 months, that usually warrants an expedited evaluation by a subspecialist—often a neurologist, sometimes a psychiatrist, and usually including a neuropsychologist. So a multidisciplinary referral that really aims to try to identify whether this patient has a more rapidly progressive form of one of these conditions we’re talking about today, Alzheimer disease or frontotemporal dementia, or in some cases, they may have a different brain disease altogether. It could be infectious, like Creutzfeldt-Jakob disease. It could be inflammatory. It could be cerebrovascular. It could be neoplastic, or possibly paraneoplastic. So the differential diagnosis is broad, not just including neurodegenerative diseases. When a patient is really having one of these rapidly progressive courses, I think an expedited referral to a subspecialist, and often a team, is warranted.

Alireza Atri, MD, PhD: Great. I agree.

Transcript edited for clarity.