Dr. Agronin: The first priority is to establish some rapport with the person and his or her caregiver. I emphasize the caregiver because if you don’t have a reliable informant you simply will not be able to do an accurate evaluation. There is a tremendous amount of uncertainty and misdiagnosis; it is a very complex evaluation to do for several reasons. Number one is that we have no simple, reliable, accurate test as of today to make a diagnosis of Alzheimer’s disease or any other neurocognitive disorder. We are getting closer, but when you look at the accuracy rates for Alzheimer’s disease, for example, it depends on looking at multiple sources of data over time. To me that relies on having some rapport with the individual so you can get a sense of the whole range of their strengths and limitations. You can get the most accurate information from the caregivers, and that helps put together the story. The other thing is that unlike many other disease states we can’t look at tissue; we don’t do a brain biopsy per routine, and even with the new imaging it only approximates what we are trying to look at in the brain. I have learned this lesson when we have done several clinical trials that involved autopsies, and the postmortem results of the brain biopsy are always a whole grab bag of different pathology. In several cases, the results were not consistent with what we thought the patient had after years of observation.
TCPR: Let’s say a patient comes in to the psychiatrist’s office complaining that his memory isn’t what it once was and he is worried that he has Alzheimer’s disease. How should the psychiatrist proceed?
Dr. Agronin: Memory concerns should always be taken seriously and psychiatrists should be able to do a basic workup. Obviously, the older the person is, the more likely there might be a memory disorder. But at any age, it is very important that we do an evaluation that includes basic lab work, an examination, and some questions about changes in mood and daily function—such as sleep and appetite—just to get a sense of whether there is depression or anxiety that could be a contributing factor. Psychiatrists should always ask about substance use because lots of older individuals are drinking more alcohol than they should be or that they may admit to. I find that this is often a hidden factor and sometimes, without an informant, you are not getting a clear history.
TCPR: If somebody is drinking, is the memory problem limited to the times when they are intoxicated or hung over, or does it extend to other periods as well?
Dr. Agronin: Well it depends. If someone has memory issues, often what happens is that they have their one cocktail and then an hour or two later they have what to them is their one cocktail because they have forgotten that they’ve had one before. I find, especially in couples in which this is a lifelong habit, the partner often doesn’t notice that there is an issue or a problem and they might even be part of it. There may be reversible factors that are either causing or worsening the memory issue, which can be addressed. With drinking, if there is no underlying brain pathology, memory problems may just extend to the time around which they are drinking. But individuals who are drinking more than they should have higher rates of falling and injury, which can contribute to memory problems. And, while alcohol might help people fall asleep initially, it disrupts sleep architecture and that, in turn, can have a negative impact on memory. Also, a lot of individuals are taking anxiolytics and/or sleeping pills at the same time they are drinking alcohol, so you can have an additive effect. This is why you need to review all medications. Sometimes statin medications in a small percentage of people can cause some mental fuzziness. Narcotics and anticholinergic medications also can have significant effects on memory.
TCPR: You mentioned labs. Go through with us the basic labs that should be ordered in a workup.
Dr. Agronin: In general, it is rare to find a lab value correlating with a cognitive disorder. But what you are looking for are lab abnormalities that point to certain conditions—severe anemia, hypothyroidism, and parathyroid issues such as an adenoma leading to excess calcium in the blood—all of which can lead to some cognitive problems. If someone is diabetic, I would look into how well their blood sugar is controlled, and hypertension might indicate that someone is having small strokes. Individuals with both hypertension and diabetes are some of the highest risk individuals for vascular dementia and Alzheimer’s disease. So these are everyday factors that can loom very large in terms of causes, or probably more likely, exacerbating factors.
TCPR: So we do our basic labs and we don’t find anything obvious. The patient is complaining of some kind of memory loss. How do we determine if this is a normal part of aging, mild cognitive impairment, or early Alzheimer’s dementia?
Dr. Agronin: In early stages, it can be impossible to know. So for psychiatrists, what I recommend is to have some screening instrument: either the Mini-Mental Status Examination (MMSE), the Montreal Cognitive Assessment (MOCA), or the Mini-Cog. Have someone in the office trained to conduct the screening so they do it consistently and can be rather expeditious with it. If someone fails the Mini-Cog, or if on the MMSE or the MOCA they are scoring below 25 to 26 or they have a higher score but they have very significant complaints, then I would refer them to either a memory center or a geriatric psychiatrist or neurologist who specializes in neurocognitive disorders to do a more thorough evaluation. The important things for psychiatrists to look for would be: is there any depression or anxiety that might be compromising memory or other cognitive function? Individuals with severe depression can have a pseudodementia in which their concentration and attention and motivation are so poor due to the depression that their memory suffers as well. With those individuals, once you successfully treat the depression, their memory should get better. Though it should be noted that some research indicates that they are at a much higher risk for later developing dementia or that depression may itself be a prodromal symptom of neurocognitive disorders including Alzheimer’s disease (Alexopoulos GS et al, Am J Psychiatry 1993;150(11):1693–1699). It’s important for clinicians to realize that even if there is depression and even if it does appear to be affecting cognition, it still might be comorbid with an actual neurocognitive disorder. Sometimes the mistake that psychiatrists make in these cases is that they put someone on an antidepressant, but they may not follow up quickly enough and deeply enough to assess cognition once they have had a trial of the antidepressant. Often the depression goes hand-in-hand with Alzheimer’s disease or some other neurocognitive disorder.
TCPR: What kind of neuroimaging should these patients have?
Dr. Agronin: An MRI is always best because it will show everything that you are looking for on a CT scan, but will also pick up smaller subcortical lesions. And what I am looking for, especially in more acute onset of cognitive changes, would be meningiomas, subdural hematomas, and lacunar infarcts.