What to know about getting tested for Alzheimer’s and other forms of dementia

Q: What doctor should you see first? What is the process when it comes to getting tested?

A: You should see your primary care physician first. Without them, forget about it. They're the gatekeepers. Primary care physicians are essential. But, sometimes they may miss signs of dementia.

After age 65 and older, your annual wellness visit is an excellent time to do some of these cognitive screening tests. Medicare pays for this extended visit called the annual wellness visit, which is usually an hour long, where they go through all the different medical conditions. Now, as part of this visit, a lot of the clinicians that I'm talking to the primary care doctors can also do a cognitive assessment.

In our center, we have a robust education program that's focused on training primary care doctors, where we actually go out and reach them. We talk to them about the importance of doing some cognitive testing when they see patients [over the age of 65].

So, what can you do in a situation where you are the caregiver and you think their primary care physician is not necessarily seeing what is there? Ask for a referral to a specialist.

Q: If you an individual who is concerned about memory loss, what are the different kinds of specialists they might consider making an appointment with?

A: They should try to look at seek an appointment with any specialist that can help them, that can do an evaluation for them. It could be a neurologist. It could be a geriatric medicine doctor. A geriatric medicine doctor is somebody who has obviously specialized in internal medicine, but they also, after that, spent a year specializing in geriatric medicine. These doctors can do a comprehensive evaluation. The third person is the geriatric psychiatrist, part of their training is to evaluate people for Alzheimer's and dementia. So, a neurologist, a geriatric medicine doctor or a geriatric psychiatrist, are all good options to find [a specialist] who can do some more testing.

Q: Can you please tell me more about what specific kinds of tests a specialist might conduct if a patient reports memory issues want wants to be checked out for Alzheimer’s or other forms of dementia?

A: We do a comprehensive what we call a neurocognitive assessment. It takes about two hours to do. We ask a lot of questions to the patient, to the spouse, or the family member who knows them well. They also do paper pencil tests, where they we check for various types of cognitive symptoms.

Typically, at our center, we use something called as the MoCA, the Montreal Cognitive Assessment, and that gives you a cutoff. Basically, the score on the MoCA, the a total score is 30. Anyone who scores below 26, it can indicate that they're having some cognitive symptoms. It’s broken down into various domains. Whether this is more related to short-term memory, or is it more related to attention, or planning and organizational skills? Is it language impairment? It gives you various domains that give us information about what areas are the person is having difficulty. We do all those testing when the patient comes to see us for the initial visit.

Based on that information and the blood biomarker test, we say, okay, listen, seems like you are telling us that you have some mild memory symptoms. Let's say forgetfulness. Your blood test is high, elevated. Your cognitive test that we did is also showing that you're having some difficulty.

Now we need to investigate further.

We need to get a brain scan to really see if you have these amyloid plaques in your brain. Because if you do, we have treatments that can go and clear those plaques in 12 months, and so that's the next step. Then that's how it kind of follows.

What I suggest to to caregivers and to patients and to my primary care colleagues is that if if you're seeing somebody who sees there's a change in their their cognitive status or their functioning that is different now and they're having more difficulties, it is definitely important to get that checked out, get the blood test done. You don't want to waste time.

The sooner you're able to get this tested and it comes back positive. At least now you can come to a specialty center to see a specialist, like a neurologist who specializes in Alzheimer's or dementia or someone like me, I'm a neuropsychiatrist, so I do both neurology and psychiatry.

Q: Can you have more than one kind of dementia, like Alzheimer’s disease and another kind of dementia at the same time?

A: In fact, we see the second most common type of dementia after Alzheimer's, is what we call as mixed dementia, which means Alzheimer's and vascular, or Alzheimer's and like frontotemporal dementia. Absolutely, you can have more than just one type of dementia. It's called mixed dementia because it's mixed with two different things, right? Alzheimer's and vascular dementia is when you have like a stroke or a mini stroke that can cause dementia as well, based on what part of the brain the stroke was impacting. You could have Alzheimer's and vascular dementia. Actually, you can have one, two, or even three forms of dementia. You could have Alzheimer's, vascular, and Parkinson's dementia.

Q: How do you approach individuals who already have a mental health history or do screenings or tests people who may have mental health issues but have not yet been diagnosed?

A: We also check for things like depression or anxiety, because these conditions can also cause people to get more forgetful or have difficulty paying attention. We do a comprehensive evaluation.

Sometimes depression goes along with Alzheimer’s. A lot of patients that we see present with depression and alcohol.

I think it's important for people to get checked out. I will tell you why this is important. It's because for the longest time, you were say 65. You went to your primary care doctor's office, and said, "You know what, Doc? I'm getting a little forgetful. The answer you would get often is that ‘Oh, you're getting a little old. ‘Don't worry about it. It happens to everybody, right?’ And that's not true actually.

Q: How can someone know the difference about whether to be concerned about memory lapses or memory loss or not?

A: Yes, as we get older, the brain is also aging. This is an example. Let’s say you don’t not remember the name of a movie or a restaurant during conversations with family or a friend, but it might pop back into your head the next day or a few hours later. That's normal.

But if you are on a routine basis forgetting information, recent information. If your family said, ‘I just told you that, this morning,’ and ‘You ask me the same questions again and again’ or if you are misplacing things at home on a regular basis. If those kind of things are starting to accumulate, where it's getting a bit concerning. I think you definitely need to get yourself checked out and speak with your doctor. [If you are experiencing memory issues] consider getting the blood test in to start with. That would be a good starting point.

Q: Are Alzheimer’s rates increasing or it is being diagnosed earlier?

Both. The reason I say both is because the biggest risk factor for Alzheimer's is age. The longer people live, the more Alzheimer's we are seeing. For example, in the age group of 75 to 84, the rates of Alzheimer's are about 20 to 25 percent. One of four to one of five people has a diagnosis of Alzheimer’s.

In the age group of 84 and older, one out of three people have a diagnosis of Alzheimer's. As the population is aging, what's happening is that people are living into their 80s and 90s.

More and more people are living longer, so more and more people are developing Alzheimer's. In the U.S. we have an aging population, the population of 65 and older is going to double in the next 20 years. With that doubling of the population of 65 and older, you're going to find more cases of Alzheimer's just because of the number of people who are older.

Now, also in addition to that is the issue of diagnosis, maybe this is Alzheimer's, maybe it is a different type of dementia. Let's get you tested. Let's get a scan done. As the diagnosis rates have increased, the awareness is increased and more tests are being done.

Q: How accurate is the blood biomarker test, and the and MRIs, PET scans and other tests for Alzheimer's disease and other forms of dementia?

The blood biomarker test is a screening test for Alzheimer’s, not for other forms of dementia. Right now at this point, the biomarker test is not being used for diagnosing Alzheimer’s.

If the test is positive for a scan, that means you probably have amyloid plaques in the brain. The test is negative, it probably means you do not have amyloid plaques in the brain. There are about 20 to 25 percent of cases where the test comes back as indeterminate, which means it could not tell us if the results were high or low, so there is that 20 to 25 percent of results where it says that we couldn't really tell you if it is meeting the high threshold or the low threshold, and that's a problem.

If it's indeterminate [test result], that means you don't really know that if you have amyloid plaques or not. You would want to [consider] getting other, additional testing done [in that case.]

This Q&A has been edited for length and clarity.

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