By Dr. Golnosh Sharafsaleh MD
In this post, I will go over what happens when a person is seen in a memory clinic. Generally, when a person is evaluated by a memory clinic, they have already seen their primary care provider for initial assessment of cognitive changes. These changes include the inability to learn new tasks, planning, memory loss, language skills, visual-spatial understanding, and carrying out primary day-to-day activities.
People 65 years and older are usually screened for dementia during a Medicare Annual Wellness Visit. Other times people are evaluated due to concerns from family members or caregivers. Primary care providers utilize standardized memory tests to assess a person for possible dementia.
Keep in mind that dementia is often underdiagnosed and challenging to diagnose. Consider reading my blog post, Could This Be Dementia, to learn about the warning signs of a possible cognitive disease. Alzheimer's disease is the most common type of dementia, followed by vascular dementia, Lewy body dementia, frontotemporal dementia, and other dementias. You can learn more about the different types of dementia by reading my blog post, Dementia is an Umbrella Term.
Memory clinics are usually staffed by professionals who understand memory disorders, including medical doctors such as geriatricians, neurologists, or Psychologists. Since I am a board-certified geriatrician who operates a memory clinic with geriatric colleagues, this post will focus on how a geriatric memory clinic works.
An evaluation in a memory clinic is not like a regular doctor's visit. Depending on the memory clinic process, a person can spend 1-3 hours during their first visit. In our geriatric memory clinic, we spend 60-90 minutes during the first session, followed by additional 30-45 minute sessions to ensure everything is covered.
When a person comes to our memory clinic, we start by obtaining a detailed history from the patient, family members, and other caregivers. This history includes understanding past medical problems that may contribute to memory loss, family history, changes in behaviors, the timeline of cognitive changes, medication history, and recent illness. A functional assessment is also completed looking at activities of daily living (ADLs) and instrumental activities of daily living (IADL's). This history helps us understand the causes of cognitive changes and the severity of a possible dementia diagnosis.
After a complete history and a physical examination, additional assessments are performed. These assessments include an evaluation for depression; sometimes, depression can be confused for dementia, followed by pencil and paper testing using standardized tools. These tools evaluate a person for deficits in attention, memory loss, abstract thought, ability to solve two-step commands, visuospatial problems, planning out tasks, orientation, and awareness of time, place, and situation.
Sometimes there are reversible causes of memory loss. Dementia specialists look at recent blood work, the medications a person is taking, and any recent medication changes. There is no routine blood work that diagnoses dementia; however, some testing can indicate a reversible cause of cognitive changes. For example, abnormal findings such as thyroid disease, vitamin deficiencies, kidney or liver disease can cause dementia-like symptoms. Doctors will check blood to ensure all reversible causes of dementia-like symptoms are managed.
Depending on initial findings, a dementia specialist may decide to obtain brain imaging. Brain imaging is generally ordered on patients 60 years and younger, those presenting with abrupt onset of symptoms, within weeks to months, history of cancer, or an abnormal neurologic exam. Imaging can include an MRI, CT scan, or PET scan. Brain imaging does not diagnose dementia but can help provide clues into causes and possible types of dementia.
In some instances, we may order a lumbar puncture, which involves spinal fluid analysis when there are concerns about rare types of dementias. With new emerging dementia treatments, the utilization of lumbar puncture and brain imaging using PET scans may become more routine.
After an initial memory evaluation, patients, family members, and caregivers meet with the dementia specialist to review the assessment and discuss additional testing, possible diagnosis and treatment options. Treatment depends on findings and diagnosis.
In a memory clinic staffed by geriatricians, physicians provide extensive information and education on diagnosis, testing, and treatment. The duration of patient visits depends on the operations of the memory clinic. Like I mentioned above, some memory clinic appointments can last up to three hours.
I personally individualize the memory clinic experience. I have recognized that my patients often suffer from exhaustion if the memory clinic runs over 90 minutes. Therefore, the way I see my patients is for a 60-90 minute initial evaluation. Suppose after history taking, examination, and memory testing, I sense the discussion with family members regarding diagnosis and treatment is upsetting my patient, I stop the visit. I then contact a family member or caretaker to summarize my findings and answer any questions. My patient then comes for a follow-up appointment about 4-6 weeks after their initial assessment. We review any new testing results during the follow-up appointment, such as blood work or brain imaging, treatment tolerance, and provide more education.
Dementia impacts every person and their loved ones differently, so follow-up exams and treatment is catered to the individual needs of my patients and their loved ones. Sometimes I may only see a patient every few months, other times every few weeks. Sometimes I may have to see my patient in their home or virtually. Occasionally a loved one may call me or just stop by because they need support and education without the patient.
Ultimately, as dementia specialists, we do what we need to do to support our patients and their loved ones. Often, the care we provide does not come in the form of a pill. Instead, it involves extensive education, suggestions on behavioral/social modifications, and coordination of care. Our goal is to ensure our patients are appropriately treated and loved ones understand the disease process.
I hope this post helps to clarify how a memory clinic operates. Check out other blog posts on www.goldenoakmedicine.com.