The Misdiagnosis of Alzheimer's Disease

Contributed by: Dennis Fortier, President, Medical Care Corporation

Yesterday we commented on the common misdiagnosis of Lewy Body Disease, a problem often mistaken for Alzheimer's Disease.  In keeping with that theme, we look today at results from an international physician survey on Alzheimer's diagnoses.

Based on a survey of nearly a thousand physicians in five countries (USA, Japan, UK, France, and Italy), we are not doing a very good job at diagnosing Alzheimer's disease in clinical practice.  In fact, about half of all physicians agreed that the disease is "often misdiagnosed" and that diagnoses are "always or often" made too late to treat in a meaningful way.

None of this is news to regular readers of this blog as late detection of cognitive impairment is one of our frequent themes.  However, the survey revealed an interesting perspective from the physicians, in terms of "why" they feel diagnoses are so commonly late.

According to the physicians surveyed, the major contributing factors to late diagnosis are:

• lack of a definitive diagnostic test;
• lack of communication from patients/caregivers; and
• stigma

Not mentioned among their reasons is the one glaring problem that primary care physicians confess to me on a regular basis.  I hear frequently from physicians that investigating memory complaints takes too much time, and often leads to a diagnosis of a problem they don't feel they can treat effectively.  This perspective often leads them to "just keep an eye on the concern" until symptoms worsen and the need for medical intervention is clear.  As the survey noted, this is "too late".

Managing the cognitive health of an aging population is a complex problem, and a difficult one to approach within the confines of our current "fee for service" healthcare system.  As new models evolve, like the Accountable Care Organizations described in the Healthcare Reform Act, we will have an opportunity to greatly improve our standards of care in this important field.

The Economic Burden of Memory Loss

Contributed by: Dennis Fortier, President, Medical Care Corporation

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Memory loss is costing our nation billions of dollars annually.  This is an easy argument to build and the widely published data are compelling from every conceivable perspective.  But today, I am citing a new publication in the Archives of Internal Medicine, because it has been broadly covered in the general press.

According to a study conducted by the VA Medical Center in White River Junction, Vt., more than 600 primary care physicians were surveyed and the results confirmed much of what was strongly suspected.  About 42% of the physicians admitted that their patients receive "too much care" and 28% indicated that they order too many tests and too many expensive referrals to specialists.

The key driver of these expensive habits?  Fear of malpractice lawsuits was indicated by an alarming 76% of physicians.

This is an important concept in the brain health space because the early boomers are now reaching the age of risk for Alzheimer's disease and are well into the risk-prone years for stroke.  Combine that demographic trend with rising awareness about Alzheimer's disease, and we see the number of memory and cognition related complaints climbing steeply in primary care settings.

A standard work-up for such complaints involves blood work and an MRI scan of the brain, which can cost between $1500 and $2000. However, because subtle declines in working memory and processing speed are common in a healthy aging brain, the vast majority of brain scans ordered due to a memory complaint are negative. This means primary care physicians are aggressively ordering unnecessary tests in this space.

Some simple math shows that this could become a devastating economic problem for our healthcare system.  With 120 million people aged 65+, performing a work-up on even 1% of them would cost the nation about $2.4 billion. Given that about 80% of people aged 65+ have concerns about their memory, this is a scenario that could get out of control quickly.

The challenge is that, not working up a memory complaint on a patient in the early stages of Alzheimer's disease is akin to letting the disease progress without treatment.  That approach is obviously costly in both economic and emotional terms.

The solution is expand the adoption of better "memory assessment tools" in primary care so that physicians can effectively discern normal aging from cognitive decline caused by an underlying medical condition.  A review of the medical literature shows that new cognitive assessment tools with sophisticated computer scoring are pragmatic and cost-effective in a clinical setting.  More importantly, they can greatly improve healthcare in a fiscally prudent manner.

Alzheimer's Diagnostic Accuracy: Theory vs. Reality

Contributed by: Dennis Fortier, President, Medical Care Corporation
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The reports on diagnosing Alzheimer's disease are maddeningly conflicting.

Research in academic journals makes it clear that a primary care physician can achieve a high level of diagnostic accuracy by following published guidelines.  However, journalists report every day that Alzheimer's disease can only be definitively diagnosed with an autopsy.  So which is it?

It turns out that both statements are correct.

Definitive vs. Clinically Acceptable
It is technically true that an autopsy is required for a "definitive diagnosis".  However, in the world of practiced medicine, we rarely operate with definitive diagnoses for any disease or condition.  Instead, we rely on "clinically acceptable" diagnoses that are accurate about 85%-95% of the time.  The emphasis on "definitive", or 100% accuracy, is actually quite misleading since it establishes an unrealistic standard that is rarely met in the real world of medical practice.

As for the academic perspective, a clinically acceptable level of accuracy is indeed achievable by following published guidelines.  These guidelines involve a complete medical history including a review of medicines, neuro-psychological assessment, blood tests, and an MRI or CT image of the brain.  In some cases, a PET scan of the brain might also be required.

Diagnostic Guidelines
To paraphrase the guidelines: if a patient shows impaired short-term memory as well as impaired cued recall, is not taking any medications known to disturb memory, is not abusing alcohol or other drugs, is not depressed or suffering from anxiety, does not have any apparent or detectable infections, has no uncontrolled diabetes or hypertension, has a properly functioning thyroid and no particular vitamin deficiencies, has not suffered a recent head trauma, and has no evidence of strokes or tumors in the brain, then the physician can be quite confident that the patient has Alzheimer's disease.

Essentially, the hallmark forms of memory impairment need to be objectively confirmed by cognitive assessment, and other known causes of such impairment ruled out.  A family history of Alzheimer's disease, or a genetic test showing a particular predisposition, would add confidence to such a diagnosis.

Why the Different Perceptions?
The reason for the stark difference in the academic perception of diagnostic accuracy and the journalistic perception of diagnostic accuracy is "lag".  In this case, lag refers to the well documented time-gap between medical advance and implementation of medical advance.  In other words, medical research leaps forward much faster than physicians can learn about and implement new findings and guidelines.  Right now, there is a significant gap between best practices in the field of memory loss and the actual practices that physicians are using in their clinics.

Half of Alzheimer's Cases Misdiagnosed
Recent articles from CNN and WebMD have reported that about half of Alzheimer's cases may be misdiagnosed in clinics.  Oddly, this probably indicates progress from recent years when memory problems went largely undiagnosed and ignored, to current times when many memory problems are being improperly attributed to Alzheimer's disease.  Progressing from "doing nothing" to "doing the right thing half the time" is actually a favorable development.

With time, our over-worked physicians will gain a better command of emerging guidelines.  This will improve their collective ability to recognize problems and to accurately determine their cause before prescribing treatment.

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A better understanding and more awareness of Alzheimer's related issues can impact personal health decisions and generate significant impact across a population of aging individuals. Please use the share button below to spread this educational message as widely as possible.