All That is Demented is not Alzheimer’s

She was, and is, a close and cherished friend. Someone decided she had Alzheimer’s.  At least somebody said she did.  She had wonderful plans for retirement.  Now the retirement community she had been dreaming of did not seem to want her and her husband around.  She has just made the decision (I don’t know with who’s help) that it is a better idea she does not drive. She would surely not remember the details of how the diagnosis was made.  I wonder if it had been made properly.  Probably not.

In these days when people cut back medical costs and truncate diagnostic tests mightily, I have to wonder if anybody gave her a thorough workup for this malady. It is a diagnosis of exclusion. There are many other possible causes of dementia.  Ethically, humanly, I start wondering if types of dementia for which simpler and stronger treatments are available have been eliminated.  The game has changed.  I remember a Family Practice journal summary of how to “work up” a patient suspected of having Alzheimer’s from the past that was a guide to follow: This isn’t it.  Whenever I see an article with “pragmatic” in the title it really means “Synonym for “cost cutting.”

I lived through an era which said you need to eliminate every possible and easily used robustly treatable dementia before making the diagnosis of “Alzheimer type dementia,” which is like announcing “It’s down hill from here all the way down.” Here is the most complete list of causes of reversible dementias I have ever seen. There are a multiplicity of illnesses of many types that can cause dementia.  If you treat those illnesses, the dementia can get better. Things infectious and vascular and metabolic (like thyroid ).  Of course you get “psych testing” and neuroimaging and such.  But people are cutting back funds and searching for less. Some folks have nutritional deficiencies. ( I have seen B12 alone reverse dementia).  I have not seen systematic testing for fungi or syphilis or AIDS virus for dementia in the U.S.  I did see, many years ago in the rural midwest, a sweet little woman with a little cognitive loss who got better when treated for some residual syphilis, which she traced back to one wild night with a traveling salesman.

A tumor can cause dementia if it has a “metastasis” from the tumor before it is visible.  Our friends in India recommend a total body scan and a mammogram for all women to find the primary tumor. The article I cited above with wildly impressive data tables, is from India. Where I have just instructed my husband to take me if I ever start looking demented. I love the Indians.  They say all Alzheimer’s is treatable. If it is really that, with nursing and practical environmentally sound interventions.  This is true.  I have ordered them for patients.  Everything from signs in the home to hand-held computers. My personal friend who has been labeled “Alzheimer’s” has not even had that. I am enraged beyond words. How many people in assisted living or nursing home should not be there in the first place? How many people can keep their brains functional longer, and combined with the wisdom of experience, make powerful contributions to science and technology and to society?  Not to mention make powerful emotional contributions to our families and communities? HIV is now exquisitely treatable.  The problem was once patients unaware of the diagnosis.  Now patients are aware of the diagnosis, but decline treatment, often because of cost. I am ready to shout wailing invectives. Technology advances.  Greatness?  We have put The value of human life below the value of money.

I am increasingly worried we have created in America a health care system that is incapable of caring for Americans at a world class standard of care, and that is giving suboptimal care to the aging.  Lots more people will be older. Let’s start from zero with human kindness.  Let bad health outcomes happen to someone who society does value (certainly more than it does a senior female psychiatrist) and maybe, just maybe, someone besides me will see the bigger picture. The Indian Review says one person, worldwide, is designated “Alzheimer” every seven seconds. Whether that is correct or incorrect is yet to be determined.