Alireza Atri, MD, PhD: We have some thoughts about assessing elements of cognition, daily function, behavior, sensory motor function. Another important aspect of assessing the overall picture is risk factors—risk factors for neurodegenerative conditions, cardiovascular risk, or just cognitive dysfunction. What are some of the things you like to key in on, Brad?
Bradford C. Dickerson, MD: I think it’s always worth examining the family history. I don’t like to just say, “No family history of dementia,” or “No family history of neurologic or psychiatric syndromes.” I like to say, “Tell me about your mom. Tell me about your dad. What were their lifespans? What were their major health problems?” And really, I like to work out a pedigree for the family. This is particularly relevant when we’re dealing with someone who ultimately turns out to have a diagnosis of a dementia syndrome due to 1 of these diseases. Because inevitably, the question is, “Well, what is my child’s risk for the same disease?” And that’s really best established by thinking about whether the patient may have an autosomal dominant pedigree consistent with an inherited form of these diseases.
Those are pretty rare. Most of the time we’re talking about genetic loadings that are common in many late-life diseases. So I think establishing that family risk pattern is helpful. It often points toward cerebrovascular disease, so thinking about a patient’s cerebrovascular risk factors is always important. Those include not only family history, but also the personal health background of the patient with regard to whether they were a smoker, or had hypertension, hypercholesterolemia, diabetes, or other cerebrovascular risk factors that are also cardiovascular risk factors.
And then, thinking about general medical well-being. Does the patient have other medical illnesses? What are the treatments, either now or what have they been on? Did the patient have a cancer that is in remission but for which they received chemotherapy? Sometimes that can lead to problems with attention and other cognitive functions that may have been present since that treatment took place, that could be coloring the way they’re presenting now, even if it’s a decade or 2 later. Thinking about urinary problems, for example, and the treatment sometimes with anticholinergic medications. And the offending medications that Mary was talking about before are very important. Thinking about other medical conditions like thyroid function, sleep.
We talked a little bit earlier about how certain sleep disturbances can be associated with neurodegenerative diseases. But I think much more commonly, there are things like obstructive sleep apnea or less specific forms of insomnia that are getting treated in ways that might compound the problem, often with over-the-counter or prescription sleep aids. So I think not only the sleep problem itself has to be considered, but also the treatment, whether it’s a prescription treatment or over-the-counter treatment for the sleep problem.
And then thinking, importantly, about alcohol and drug abuse. I think we often don’t spend enough time on those discussions and often do really need an informant’s perspective on those discussions, even when the patient does not have a brain disease that we can identify because of under reporting. I recently saw a man in his 50s who I really thought had an early form of Alzheimer disease at a late, mild cognitive impairment stage. He had amnesia. He had some executive dysfunction. He and his family were open about the fact that he had a long-standing relationship with alcohol that was probably bordering on abusive. It was a fixed, stable couple of cocktails every day, with some wine with dinner, and a beer later on. It was a pretty substantial amount of alcohol that he had been consuming for many years.
And he more recently had started with recreational marijuana. It wasn’t a large quantity, but he was doing it on a daily basis. We did a work-up for what I thought might be an early stage of Alzheimer disease, and he was negative for everything. And we said, “Look, you probably need to get into a rehabilitation program.” And fortunately, he was able to find one that worked for him and now he’s doing better. He hasn’t fully recovered from those symptoms, but they’re not progressing. So I think that we always have to address those issues as personalized risk factors for other conditions that may be compromising a person’s cognition.
Alireza Atri, MD, PhD: Thank you. Lynn, what are some other things about life course trajectory, attainments, other things that you ask that may influence how you interpret and think about an individual and their performance and capacity?
Lynn Shaughnessy, PsyD, ABPP/CN: Everyone’s noted how there’s so much to assess in so little time. The benefit of neuropsychology is that we have a little bit more time to really dig deep, as far as family history goes, and so on—developmental history. And so, I’ll be assessing all of those things. Brad also mentioned something earlier, when someone comes into my office, oftentimes I’ll hear that they have memory problems. They have memory problems, but oftentimes it’s not actually a frank memory problem. That can bear out in the testing. But if someone is having some trouble with attention—they can’t bring in that information, or they can’t learn that information—thus they can’t remember it later. And so, oftentimes everything sounds like a memory problem, but getting to the bottom of that is helpful in determining what level someone is at, a syndrome, and their trajectory over time.
Transcript edited for clarity.