Dementia and aging

Doctors, Dementia, and Driving: Impaired Operators Behind the Wheel (and Behind the Stethoscope?)

Saturday, January 27th, 2018

My colleague, a seasoned primary care physician, admitted that he hadn’t seen it coming. Worse yet, despite his years of experience, he felt ambushed and hadn’t known what to do.

An eighty-four year-old retired librarian we’ll call Millie, though that wasn’t her name, came in for a six-month checkup. She had been my colleague’s patient for many years, and they had enjoyed a warm doctor-patient relationship. Other than mild dementia, Millie had been fairly healthy. Just fifteen minutes had been scheduled for her appointment, and my colleague expected a straightforward, routine visit. So he entered the examination room unprepared to find himself in the middle of a minefield.

The first inkling of a problem was that Millie’s daughters sat with her in the examination room, awaiting my colleague. Millie had always come alone, and there had been no occasion to meet any of her children before. Initially they sat quietly, appearing on edge. But not two minutes into the visit, the older daughter interrupted my colleague, blurting that THEY had decided that their mother was no longer a safe driver. They wanted her to surrender her car keys but she was being “unreasonable” and had refused. So they expected my colleague to “talk sense into her” and to “order her to stop” driving.

Before my colleague could react to this startling demand, Millie, who had always been mild-mannered, erupted in snarling outrage. Scolding my colleague, she reminded him that she’d started driving long before he was born and had a perfect record; not even a parking ticket. Hissing a rebuke, she declaring that she’d always suspected him to be a “treacherous quack” who couldn’t be trusted. And she threatened to find a new doctor and sue him.

Reading this account, were you as stunned as my colleague? Did you find the behavior of Millie and her daughter surprising? If so, then you might be additionally surprised to learn that situations like this are not rare. I’ve found myself in similar encounters more times than I care to remember.

Each year the number of older drivers increases. Until age sixty-four, people become safer drivers as they age. But after that, declining health, both physical and mental, begins taking its toll on many abilities, driving included. Some elders remain safe drivers into their late nineties. On average, though, older adults outlive their driving ability by seven years.

Many older drivers recognize when this happens and gracefully “retire” from driving. Others need to be convinced of the necessity. Physicians’ opinions often are sought as part of this process. Whether because of, or in spite of their doctors’ input, most initially reluctant older adults eventually quit driving “voluntarily”.

And then there are those, like Millie, who present a greater challenge. Unable to face facts (in Millie’s case, symptoms of dementia and a combination of psychological and family factors conspired against her), they steadfastly deny that there’s anything wrong with their driving. They refuse to quit, often becoming angry, unreasonable, hostile, or paranoid. Not knowing how to handle this, or where to turn for help, family members can become overwhelmed. Some seek guidance from geriatric psychiatrists.

Driving cessation can be an emotional crisis for older adults; many do not cope well with it. Some, like Millie, behave maladaptively, severely challenging healthcare professionals and family members alike. I’ve worked with many such patients. Their family members all say that the struggle to curtail their older relative’s driving is the most stressful challenge they’ve ever faced. Invariably they experience one or more symptoms of anxiety, dread, anger, resentment, depression, or insomnia. They’re afraid to let their relative drive, but they’re also afraid to take away his or her keys. These are thorny problems, and usually there is no solution anyone is happy about, doctors included.

From time to time my colleague sought “curbside” consultations from me, so later that day he called me for help with Millie. He was shaken up. No novice at handling emotionally charged, contentious, patient encounters, this one had flummoxed him. Discovering what he hadn’t known rattled him: he hadn’t known how to assess Millie’s driving ability; he hadn’t known what responsibility he had to report Millie to the motor vehicle department; he hadn’t known how to respond to the daughters’ demand that he “order” Millie to stop driving. Somehow, despite his years of experience, he’d not confronted a situation like this before. But physicians increasingly are facing such challenges, and most are no better prepared than was my colleague.

Studies show that physicians generally feel untrained and unqualified to assess mildly demented patients’ driving ability. You’d think this wouldn’t be the case given the aging of the population and the increasing numbers of older adults with mild dementia who still drive. But it is.

The vast majority of physicians has had no training in assessing driving risk and don’t know how to do it. They worry about their patients’ driving safety, but they also worry about the detrimental consequences of driving cessation: loss of independence, declining wellbeing, deteriorating health, and depression. And taking away the car keys can irreparably damage both family and doctor-patient relationships, making it that much harder to provide older adults the help and support they need.

Doctors have no clear guidelines for weighing these competing harms. Society has set no standards for how much driving risk is acceptable. We let teenagers drive, and they are very risky drivers, as a group. Older drivers, on the whole, are not worse drivers than teenagers, those with dementia being a possible exception. To make things even more impossible for doctors, studies show that the tests doctors can perform in the office (other than vision tests) do not reliably predict driving safety; a behind-the-wheel, roadside test, conducted by a driving professional, is the gold standard. Lacking “rules of the road” to follow, doctors often do not know the right course of action to take. Believe me, it’s a lot harder than it seems.

In my experience, family members desperately want to prevent their older relatives, whom they feel no longer drive safely, from getting behind the wheel. But they want to accomplish this with as little emotional trauma as possible. They don’t know what to do, don’t want to do the wrong thing, and don’t know where to find the help they need. All too often they feel left in the lurch by healthcare professionals. Geriatric psychiatrists often can help, and that’s why my colleague called me. He wanted to pick my brain, but he also wanted to refer Millie and her family, to me.

Unfortunately, few families have access to geriatric psychiatrists (that’s another, even more complicated story, for another day). So, what can you do if you are worried about an older driver? If you’re a family member (or other caregiver), start by seeing your relative’s doctor. He or she may be able to offer some helpful advice or guidance. But be realistic. Understand that you may be dealing with a complicated situation beyond the doctor’s expertise.

If you find yourself in this predicament, an excellent resource you can download and read to help you understand better what to do is A Clinician’s Guide to Assessing and Counseling Older Drivers, published jointly by the National Highway Transportation Safety Administration and the American Geriatrics Society. And if you are a physician, other type of healthcare professional or elder services worker, concerned about the driving of one or more of your older patients or clients, this is an excellent resource for you too.

Two weeks later Millie and her daughters came to my office for an appointment. Despite having no idea about why she had come to see me, Millie was her usual, pleasant, mild mannered self. She had no recollection of her recent encounter with my colleague, and had nothing but glowing praise for him.

In contrast, her daughter, yes, that one, the one who demanded action of my colleague, entered my office spitting nails and breathing fire. Not granting me even the two-minute courtesy she gave my colleague, she demanding to know whether I intended to order her mother to stop driving, or was I going to be as “lame” as the other doctors (She also wasn’t too pleased with a neurologist they’d consulted). Yikes!

Want to find out how I handled this situation? Watch for an upcoming post in which I’ll describe what happened, and I’ll discuss what geriatric psychiatrists can do to help older drivers and their worried family members.

Think Medications for Dementia Produce No Meaningful Benefit? Don’t Be So Sure

Saturday, January 14th, 2017

Currently available anti-Alzheimer drugs – donepezil (Aricept), galantamine (Razadyne), rivastigmine (Exelon), and memantine (Namenda) – are not the miracle cures patients hope for, and many clinicians are skeptical, and don’t prescribe them. Consumers nevertheless have heard that these drugs at least “slow it down”, and many accept this as better than nothing.

But do anti-Alzheimer medications “slow it down”? Unfortunately, scientists do not know for sure. Some research demonstrates actions in the brain of anti-Alzheimer drugs that could be helpful, but there has been no proof that these effects interrupt the disease process. Specialists who recommend these medications mostly believe that their benefits are limited to temporary improvement of symptoms, stabilizing their patients’ conditions for a time, before they resume relentlessly losing ground to dementia. What remains unknown is whether treated patients continue to decline at the same rate as before or slower. A new study provides reason to think that anti-Alzheimer drugs actually might slow down patients’ decline.

Last month French researchers published a study of patients with mild cognitive impairment.*  Mild cognitive impairment (you may hear it referred to as mild neurocognitive disorder) is a milder condition not severe enough to be considered a dementia. About half of the time, however, MCI is a preliminary stage of Alzheimer’s disease: such patients gradually get worse and sooner or later develop dementia.

In this French study, patients with MCI were treated for one year: half received donepezil (Aricept) and half placebo. At the beginning of the study, and again at the end of the year, patients had brain MRI scans, and the thickness of their cerebral cortex was measured. The cortex is the outer layer of the brain, where memory and other higher mental abilities reside. As Alzheimer’s disease worsens the cerebral cortex gets thinner and thinner. Researchers compared the amount of thinning in those who received donepezil with those who did not. The good news is that the patients treated with donepezil had much less cortical thinning than those who received placebo. In some brain areas, the cortex even got thicker! This finding suggests that treatment with anti-Alzheimer medications may actually slow down the rate at which patients decline

While encouraging, this study has many weaknesses, so it is far from a slam-dunk proof of anything. But it does provide another bit of evidence that anti-Alzheimer drugs may not be as worthless as many think. If these drugs do slow the rate of decline, the benefit might not be apparent early in treatment, but would be more and more obvious, and meaningful, as time goes on because patients stay further and further ahead of where they would have been without treatment. This is a different way to think about medical treatment, but nonetheless a meaningful one, especially for Alzheimer patients and their families.

Dementia, By Any Other Name, is Still Dementia

Tuesday, November 22nd, 2016

Have you adopted the DSM-5 nomenclature “major neurocognitive disorder”, or have you continued to use “dementia”, as I have? DSM-5 was released in 2013, introducing neurocognitive disorders, major and minor. In the years since, I’ve noticed that many psychiatrists, but not all, have adopted the new nosology. But other physicians, including primary care physicians and neurologists, and most geriatric psychiatrists, still use “dementia”. And ICD-10 uses the tried and true term “dementia”. Nevertheless, as a medical school faculty member, responsible for the training of medical students, residents, and fellows, I suppose I should toe the DSM-5 line, but I’m not going to do it. It’s a pet peeve.

It’s almost 2017, and you might wonder what took me so longer to get around to expressing my objections to the reclassification of dementia as a neurocognitive disorder. Fair question. Suffice to say I’ve been busy. “What could have been more important this this?” you ask. For one, there’s Medicare, moving target par excellence, source of endlessly changing rules, regulations, and (dis)incentives, and general bane of existence. And then there’s my book, Beat Depression to Stay Healthier and Live Longer: A Guide For Older Adults and Their Families, published earlier this year. It’s a terrific book and easy to read, if I do say so myself. I assure you that nary a page deals with ICD-10, but there is a terrific chapter, suitable for the lay public and clinicians alike, on the differential diagnosis of depression, covering the different types of depression, other conditions that masquerade as depression, and how to tell them apart. Ironically, I used DSM-5 terminology. I’d highly suggest getting a copy: no, not DSM-5, my book! Even before you finish reading this post, you may wish to order it on amazon.com.  You won’t regret buying my book, but, back to DSM-5 and dementia.

First my “minor” major neurocognitive disorder objections. I simply like the term “dementia” better. It’s traditional, having been in use for well over 100 years. Healthcare professionals all know what it refers to, and much of the public does. And it’s shorter and easier to say. “Major neurocognitive disorder” doesn’t exactly roll off the tongue.

And now my “major” major neurocognitive disorder objections. Actually I don’t object to “neurocognitive” for the category of syndromes, generally, but I don’t see the advantage for dementia specifically. True, “neurocognitive” does describe a major aspect of dementia. But is also seems too narrow, the most disruptive and disabling manifestations of dementia being their psychiatric and behavioral complications. And, and the same time, it also seems non-specific, schizophrenia clearly also being a disorder involving severe neurocognitive impairment. Had they asked me, I’d have suggested letting dementia be dementia, and calling the category of disorders “acquired disorders of widespread brain impairment usually first manifest in late life”. Nobody asked me, but, no matter, there’s always DSM-6 to look forward to.

What do you think? Send me a comment, and let’s start a discussion.   If you’d like to receive my online newsletter, please navigate to the contact page and leave your email address.

Do Anticholinergic Medications Cause Alzheimer’s Disease

Monday, May 2nd, 2016

DO ANTICHOLINERGIC MEDICATIONS CAUSE ALZHEIMER’S DISEASE?

 

It is beyond doubt that anticholinergic medications cause cognitive impairment. Much evidence also has accumulated that these medications are associated with Alzheimer’s disease, but there has been no proof of a cause-and-effect connection. You can read the educational article elsewhere on this website to learn more about anticholinergic medications.

A new study now shows that taking anticholinergic medications increases the chance that healthy, older adults will develop mild cognitive impairment (MCI) or Alzheimer’s disease. MCI is a milder condition that often represents an early stage of Alzheimer’s disease. Researchers found that higher exposure to anticholinergic medication was associated with worse subsequent cognitive function.

The most damning finding of this study was that use of anticholinergic medications also was associated with brain structural changes on MRI scans and functional changes on PET scans. These changes are the type seen in Alzheimer’s disease, an apparent smoking gun proving anticholinergic medications are one risk factor for Alzheimer’s disease. This study provides the most compelling evidence yet that adults in mid or later life should avoid anticholinergic medications if at all possible.

 

Shannon L. Risacher, Brenna C. McDonald, Eileen F. Tallman, et al, “Association Between Anticholinergic Medication Use and Cognition, Brain Metabolism, and Brain Atrophy in Cognitively Normal Older Adults”, JAMA Neurology. doi:10.1001/jamaneurol.2016.0580, Published online April 18, 2016. Accessed April 21, 2016.