Thoughts on screening for Alzheimer’s / dementia – and why seeking help early can help (sometimes).

Posted on Wednesday, December 16th, 2015

Would you want to know if your GP suspected you were in the early stages of dementia? Because they might not tell you. More than a quarter of GPs surveyed by the Alzheimer’s Society admit they wouldn’t refer people with suspected dementia because poorly resourced services mean an early diagnosis isn’t necessarily helpful. Indeed it may just mean people worry for longer.

I am part of a generation of doctors who were trained under the “catch it early” mantra, but the profession is far more cynical these days. What is the point of telling a patient they have a disease if there’s very little that can be done to influence its course, or their eventual demise?

The disadvantages are all too clear to see. While it is possible to be upbeat with someone who has cancer – most cases can be cured or controlled, at least in the short to medium term – it’s much more difficult to be positive when you are raising the spectre of dementia.

The first question your patient is likely to ask is what treatments are available? We may have medicines that can alleviate the downward decline in the short-term, but in all the years that I have been using them I have yet to be impressed by their impact. It is marginal to say the least.

But it is not all about therapy. If I had an incurable condition that was likely to impact on everyone that I love then I think I would want to know about it so that I could plan ahead. A bloody good holiday with my friends and family might be a good place to start.

And I would want to be sure that dementia was the underlying cause of my failing memory, irritability, or whatever else it was that first piqued my GP’s interest. Could I have something that is mimicking dementia, or hastening the decline? Something that is easy to treat. Not only do such conditions exist, they are actually quite common.

The first thing a GP might do is look at your medication history. Are you taking a drug that might be blunting your intellectual capacity? The list includes everything from sedative painkillers to sleeping tablets, but the group that often slips through the net is the anticholinergic family of drugs (see below) such as oxybutynin to help bladder problems.

Anticholinergics interfere with the action of the neurotransmitter acetylcholine, a chemical in the brain known to play a role in dementia. I have been wary of using them ever since prescribing oxybutynin to help an elderly patient of mine. Five days later her husband rang concerned that, while the new medicine meant his wife no longer had to rush to the loo, she had forgotten the name of their only daughter.

That was over twenty years ago and most of the worst offenders have since been superseded by cleaner medicines, but there are still plenty in common usage, including in over-the-counter remedies (see below).

The next thing I would want ruled out is an underactive thyroid or a vitamin B deficiency (B12 and folic acid). The former is more common in women than men but an easy fix with thyroid hormone supplementation, while the latter is a hot topic at the moment – albeit a controversial one.

Low vitamin B levels are associated with an increased risk of developing dementia and more rapid shrinking of the brain. And there is some evidence that supplementation can stop or slow this decline. Other research has suggested no such benefit, but as a bare minimum anyone with suspected dementia should be investigated for deficiency and put on supplements wherever it is found.

In practice it is often difficult to do these sorts of tests without explaining to the patient what you are looking for. But if you can get away with it, and your patient is in the earliest stages of dementia, I can understand why lots of my colleagues would prefer to keep their concerns to themselves.

 

 

Anticholinergic medicines can impair cognitive function and mimic or exacerbate early dementia

 

  • Common classes of anticholinergic drugs include antihistamines, bladder pills and antidepressants although newer generations tend to be much better in this respect.

 

  • Chlorphenamine (Piriton) has been replaced by once daily antihistamines like loratidine. Sedating antidepressants like dosulepin have been replaced by Prozac type drugs, and the latest generation of bladder pills (eg solifenacin) are slowly taking over oxybutynin.

 

  • But there are still plenty of out dated over-the-counter treatments that contain powerful anticholinergics, including the sedatives diphenhydramine promethazine found in sleeping aids like Nytol and cold and flu remedies like Night Nurse. The clue is the dry mouth.

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