Care for the Most Vulnerable
According to the Alzheimer’s Association, Alzheimer’s disease is the most common cause of dementia in people over 65 years old. Unfortunately the numbers are rising at an alarming rate. The number of those in Massachusetts living with Alzheimer’s is currently more than 130,000 people, being cared for by approximately 337,000 caregivers. That number is expected to increase by 25 percent in the next eight years.
Because Cape Cod has an older population than the rest of the state, the local numbers are even more concerning. Approximately 15,000 people are currently living with some form of dementia on the Cape and Islands, according to neurologist Sean Horrigan, DO, at Neurologists of Cape Cod in Hyannis.
These numbers alarmed Dr. Horrigan and earlier this year, he and his colleagues had a meeting to discuss what to do about this growing crisis. Now that their office has expanded from just two neurologists when Dr. Horrigan started working there eight years ago to six physicians and a nurse practitioner specially trained in neurology, they knew they were better able of tackling the issue.
The group decided to make their office at 46 North Street the Memory Care Center of Cape Cod.
“This past year we really made it a priority to become our community’s focal point for patients and families living with Alzheimer’s disease and other related dementias,” Dr. Horrigan said. “Our most vulnerable patients, in my opinion, are those living with a dementing illness.”
One of the most important aspects of care is identifying these patients.
“It’s really shocking to me that approximately 50 percent of Americans with Alzhiemer’s disease are not even diagnosed,” he said. “Right now, we are simply not doing our best job. We’re not catching this disease soon enough. If we can detect and diagnose earlier, we can do more to help our patients and their families.”
To address this issue, Neurologists of Cape Cod have been working with Kumara Sidhartha, MD, medical director of the Cape Cod Healthcare Physician Hospital Organization (PHO) and Cape Cod Healthcare Accountable Care Organization (ACO), and Gemma Jones, director of Clinical Integration at the Cape Cod Healthcare PHO, to publish an Alzhiemer’s disease dementia care guideline for all primary care providers on the Cape.
This care map helps providers better screen and diagnose those individuals living with a cognitive impairment.
Some of the Hyannis neurologists will be giving talks at Cape Cod Hospital, Falmouth Hospital and at primary care offices to discuss how to best screen for cognitive impairment and what tools to use. The premise is that just as doctors regularly screen for high blood pressure, high cholesterol and diabetes, they should also be screening for memory loss with a five-minute mental status exam to identify any signs of cognitive impairment.
It is now recommended that all patients, age 65 and older, take a test known as the Mini-Mental State Examination on an annual basis. This exam score ranges from zero to 30. Anyone who scores 25 or less on this exam should be referred to the Memory Care Center for further cognitive testing.
Neurologists of Cape Cod is also planning to offer community talks to help educate the public about the risk factors and early signs of cognitive impairment. Warning signs include a person having new problems with managing their medications, trouble handling their personal finances, and getting lost on the road while driving.
“I also consider it a red flag if someone in their 60s suddenly begins to experience new issues with depression, anxiety or hallucinations,” Dr. Horrigan said. “Early stages of dementia can be hidden by some for a time. If someone without prior psychiatric illness has family now worried about their emotional well-being, this may be the first and only sign that they are struggling with early dementia. This very scenario happened within my family,” said Dr. Horrigan.
His mother-in-law, who lives in Rhode Island, was a registered nurse and began having difficulty at work. She’s a long-time widow who has lived alone for years. She had always been an eloquent speaker and a very social person. When she began having greater anxiety and frustration about her work performance, her family assumed that work-related stress was the cause. Her family encouraged her to see the primary care doctor and later a psychiatrist to help treat her anxiety. Two years later, she was diagnosed with Alzheimer’s disease.
“Early on, this disease can be variable in presentation,” Dr. Horrigan said. “Every patient has a different story. There are some patients with a delay in diagnosis because they have such a high cognitive reserve to begin with. They can be quite educated. They can be savvy in social settings with a knack for conversation. You have to dig a little deeper. You eventually find that there are growing problems affecting their day-to-day living.”
It’s Not Always Alzheimer’s
Not everyone who is forgetful is suffering from Alzheimer’s disease, according to Dr. Horrigan, and the Memory Care Center can help pinpoint the problem.
“First and foremost, there is age-appropriate forgetfulness,” he said. “I think that’s important to understand. We all experience memory loss that does not necessarily interfere with our quality of life. We have office visits with concerned patients who may have misplaced something around their house one too many times or worry that they are having more word-finding difficulties when talking to family, friends and coworkers. Add on a family history of Alzheimer’s disease, they are now understandably worried that they are experiencing early signs of dementia.”
At the Center, Dr. Horrigan performs a thorough neurological and mental status exam. He also orders routine labs because there are several reversible and treatable conditions that can cause changes in cognitive status. Examples include thyroid disease, vitamin deficiencies, infectious causes, psychiatric illness, learning disablilities, autoimmune disorders, sleep apnea or other sleep disorders.
It’s also routine to order MRI or CT imaging to look for any patterns of brain atrophy and to better assess cerebrovascular health and brain function. Brain imaging can help identify strokes, tumors and other less common problems that can cause dementia. There are several factors to consider that can influence how well a person’s brain functions as they get older.
If It Is Alzheimer’s
If the diagnosis is Alzheimer’s disease, there are only four medications in the United States for memory loss.
“These medications don’t slow the disease down dramatically, but their use can lead to a very modest improvement in cognition and overall disease outcome. It’s appropriate for patients to be on some of, or a combination of, these medications,” said Dr. Horrigan. “With use of these medications, we are trying to help improve and maintain quality of life.”
Neurologists also talk to patients and their families about lifestyle modifications that can slow the disease. If a person has a dementing illness, it is still very important to exercise often, eat a healthy diet, not smoke and drink alcohol in moderation or, preferably, not at all. Being socially engaged is also critical.
“When I meet a patient with cognitive difficulties, I am very concerned they are at risk for faster progressing dementia if they are socially isolated,” he said. “If they are not getting out of the house, if they are not on the move, if they don’t have a strong support center with family and friends, I worry that their disease will worsen more quickly. These patients are the members of our community most at risk.”
For this reason, the Memory Care Center of Cape Cod has developed working relationships with the Alzheimer’s Family Support Center of Cape Cod, which holds hour-long counseling sessions onsite at Neurologists of Cape Cod’s office to educate families about the course and complications of dementia, as well as all the community resources that are available to help them. The neurologists also have many of their patients enrolled with Visiting Nurse Association of Cape Cod, which has consolidated HopeHealth Alzheimer’s and dementia services under the VNA parent organization, Cape Cod Healthcare, umbrella.
These invaluable community resources teach people about home care options, adult day care services, volunteer and discount transportation, elder care programs, elder law legal counsel and the many family support groups available throughout Cape Cod. These services help families plan for the present as well as the future, as the disease progresses.
“Most caregivers have a pretty good plan A,” Dr. Horrigan said. “But most need help coming up with a better Plan B, like when something happens to a patient’s caregiver, especially if that person is an elderly spouse also struggling with ailing health.”
Memory Center Future
It is a challenging decision and discussion to take away a driver’s license from a patient. To simplify this process and remove all questions about whether it is necessary, the Memory Center of Cape Cod will soon be utilizing a clinically-certified driving cognitive assessment tool. The program, known as DrivABLE, will be added to their list of services in 2019. This program will help assess when a person living with a cognitive impairment needs to stop driving. This program will eventually be available to local healthcare providers and the general public.
The Memory Center of Cape Cod has also been expanding access to research. Many of Dr. Horrigan’s patients and their family members who are at risk of developing dementia have expressed interest in participating in clinical trials or observational studies. Both McLean Hospital in Belmont and Brigham and Women’s Hospital in Boston have treatment and research branches to study Alzheimer’s and other dementias. The hospitals also have grants to help pay for transportation costs for those who want to participate.
Continuing research and clinical studies are the only hope to find a cure, so the Memory Center of Cape Cod has reached out to both hospitals to establish a relationship. In the future, Dr. Horrigan hopes to be able to start a satellite office on the Cape and do trials at their own office.
“We’re very proud of what we do at our clinic for all of our patients and