Treatable Dementias

Although this article is filled with med-speak (sorry patients and friends), it is one I wrote about an issue I am passionate about.

Diagnosis and treatment of some of these diseases that lead to impaired cognition and thinking will slow down or in some cases reverse dementia symptoms to a varying degree. If you or someone you are close with is exhibiting signs of loss of memory and becoming functionally impaired, consider sharing this list with their primary care doctor (if it isn't me)  in the evaluation of potentially treatable conditions that may prevent further irreversible brain damage. Most of these conditions are rare but they should be considered by your doctors at the same time that a diagnosis of Alzheimer’s type dementia is entertained and treated. Treatments for Alzheimer’s type dementia generally will not result in further aggravating these secondary causes of dementia, so it is OK to start treatment for this most common type of dementia while evaluating and investigating for these other more rare causes.

1)      Mass lesions: tumors, and hematomas seen by getting a CAT SCAN of the head or MRI- usually large or in critical areas causing easily seen changes by the time they cause dementia.

2)      Hydrocephalus: Normal Pressure Hydrocephalus (NPH) other communication and obstructive causes.

3)      Infections: Syphilis, parasites, AIDS, Lyme disease can cause slow onset dementias

4)      Demyelinating diseases: MS, and MS imitators (especially collagen vascular diseases)

5)      Metabolic disorders:

-          Acquired- the usual suspects- Vitamin B12 deficiency, advanced liver kidney glucose and electrolyte imbalances, hypothyroid disorder ( basic chem. 20, CBC, TSH, B12, SED Rate etc blood tests)

-          Inherited: Wilson’s Disease, etc- rare

6)      Pseudodementia (especially depression)

7)      Other neurodegenerative conditions- treated like Alzheimer’s disease

8)      Vascular dementias: treated with cholesterol, blood pressure and blood sugar control in diabetics

-          Cortical: multiple medium to large strokes- significant rapid step like losses of function- classic vascular dementia

-          Sub cortical; True Binswanger’s disease asn other disorders of leukoariasis- (“UBOsis” on MRI) – diffuse small vessel arterial disease

-          CADASIL (cerebral autosomal-dominant arteriopathy with sub cortical infarcts and leukoencephalopathy); the notch3 gene mutation

9)      Collagen-vascular diseases

- Rheumatoid arthritis, Systemic Lupus, Systemic Scleroderma, Polymyositis/Dermatomyositis, Polyarteritis nodosa, etc.

Mini mental screening 30 point test;

21-26 mild, < 20 moderate < 1-10 severe

Cerefolin NAC for pre dementia Mild Cognitive Impairment

Electronic Medical Records - The Trouble with Tribbles

 

Electronic medical records (EMRs) are slowly transforming the delivery of healthcare. EMRs are intended to securely keep track of a patient's entire medical history in a computerized format. By keeping these records electronically, they are easily accessible; have the potential to help identify the most cost effective treatments; and can make navigating through the healthcare system much safer and more efficient.

The potential benefits of EMRs, such as substantial healthcare savings and the ability to share a patient's health information to avoid unnecessary testing and prevent medication errors, sounds appealing to most physicians yet many healthcare providers remain hesitant to implement an EMR system.

One of the challenges of implementation is cost. Although financial incentives are being offered by the Medicare Program and President Obama's Stimulus Package, there are still significant expenses involved for physicians with the purchase of software, infrastructure, installation, and maintenance. Indirect costs are also realized in training staff on data management and entry. "Medical decision making" data entry, in particular, is very time consuming and by far the most expensive aspect of converting to electronic records.  There are huge amounts of older patient data stored at insurance companies, hospitals, pharmacies, and laboratories that need to be cultivated, shared, and checked for accuracy by the patient with the help of a skilled clinician in order to have a complete patient profile.

Incorrect information can lead to a cascade of inefficiencies.  If a patient is wrongly identified as having an allergic reaction to X-ray dye, for example, a red flag alert comes up on the chart anytime the patient goes to a medical facility. If an emergency situation arises where the best test requires the use of X-ray dye, hours are wasted trying to identify the truth and avoid liability. Currently, even if identified, there are few mechanisms available to correct this misinformation in organizational computer systems.

An experienced primary care provider who knows the patient well and has all medical information flowing through their office is the obvious entity to input and screen new information important for medical decisions. Primary care shoulders the largest burden of "raw" data vetting and, therefore, the cost of implementing an EMR. Unfortunately, these are the same practices that are the least financially capable of absorbing these expenses.

Another challenge of physician office based EMRs is the inability to collaborate back and forth with local labs, hospitals, and other doctor's offices. Any interconnected central repository that could communicate effectively in a standard medical decision based format is still many years away from being a reality. The potential is real, but it will need strong leadership and national standards to achieve this lofty goals.

Currently, less than 30 percent of physicians have installed an EMR system. So, if a physician seems slow in adopting health information technology, show some compassion.