May 1, 2019

What Keeps Me Up at Night – The Uphill Climb to Addressing Alzheimer’s Disease

Alzheimer’s dementia is currently the sixth leading cause of death in the US with expenses for care reaching $290 billion annually.

The Partners Population Health Perspectives blog aims to share the opinions and ideas of our leadership team on health care topics related to population health management. In this post, Brent Forester, MD, MSc, Chief of the Division of Geriatric Psychiatry at McLean Hospital, Medical Director for Behavioral Health and Evaluation & Research at Partners Population Health, and Associate Professor of Psychiatry at Harvard Medical School, shares his thoughts on an emerging epidemic and the new Population Health Memory Care Initiative.

Brent Forester, MD, MSc

I am often asked why I chose a career in geriatric psychiatry, a field that specializes in the care of older adults with depression, anxiety and Alzheimer’s disease, to name a few of the many psychiatric and neurological conditions that we assess and treat. Well, there are two main reasons: first, I love spending time with older adults, hearing stories of their life’s journey, enjoying the many wedding and holiday pictures I see when making home visits and appreciating all the incredible history they’ve experienced first-hand. My role models for successful aging were my two grandmothers who were both married to physicians, widowed in their late 60’s and then worked as administrative assistants at a dental office and undergraduate admissions office into their mid-80’s. I loved hearing about their world in Brooklyn, NY during the World War II years and memories of my parents as they grew up in a bygone era.

The second reason for my career choice is that geriatric psychiatry represents a specialty where the fields of psychiatry, neurology and internal medicine intersect, requiring detailed history gathering, like a detective, to determine the cause of a person’s presenting problem and subsequently develop a rational treatment approach.

The challenges of navigating this intersection of three medical professions is exemplified by a person who is developing signs of memory loss and reduced ability to care for himself, feels anxious and depressed and comes to the office with seven medical issues on the problem list while taking 12 different medications. A careful history taken from the patient and thorough conversation with the family and/or caregiver is critical to help inform subsequent testing and examination. Could this person be suffering from Alzheimer’s dementia, complicated by anxiety and depression; delirium from a urinary tract infection; medication side effects; a recurrence of a depressive disorder in later life OR all of the above at once?

What I did not fully appreciate starting out in this profession is the enjoyment and gratitude I would experience caring for individuals with Alzheimer’s dementia and their caregivers, despite the tremendous challenges of a rising prevalence of the illness, absence of systematic efforts at early diagnosis and limited availability of specialty treatment. As a geriatric psychiatrist over the past 20+ years, not only am I surrounded by the mounting evidence that suggests the United States is confronting an epidemic of Alzheimer’s disease and related dementias, I see daily the severe impact these diseases have on our patients, their families and caregivers.  While families and caregivers may learn to successfully cope with a family member who cannot recall their name or recognize who they are, they are often deeply stressed and overwhelmed when their loved one experiences more severe symptoms of dementia; such as being unable to sleep at night, wandering into the streets, yelling without provocation, or becoming physically violent.

Fortunately, many of the symptoms of dementia are treatable both with behavioral modifications and medications. On an individual patient level, I can assess and treat these behavioral complications of dementia despite the challenges they create for individual patients and their families. However, there are not enough specialist clinicians in the fields of geriatric psychiatry, behavioral neurology or geriatric medicine to treat the population with dementia in traditional outpatient settings. Specifically, our current health care system does not support the regular identification and management of dementia, much less allow for widespread treatment to mitigate the more troublesome behavioral complications. In fact, 50 percent of individuals with dementia go without a diagnosis, while those diagnosed are not recognized until the moderate stages of the illness when an individual with dementia can no longer drive or pay their own bills.

By the year 2050, the prevalence of dementia is expected to more than double from 5.8 million Americans in 2019 up to nearly 14 million Americans.

The traditional fee for service health care system is currently woefully unprepared to handle this oncoming epidemic of Alzheimer’s disease and the associated behavioral complications.  Although most primary care physicians would prefer to manage and treat their patients with Alzheimer’s disease and related complications, they often do not have the training, time or specialized support to effectively assess and treat their patients with dementia and support their caregivers.

We know we can, and we must do better.

In my role as a Medical Director for Population Health at Partners HealthCare, we are leading a system-wide initiative that aims to deliver high quality care for individuals with cognitive impairment by facilitating evidence-based assessment and treatment in the primary care setting, over the full illness trajectory, for both patient and caregiver. The Memory Care Initiative strives to improve patient health outcomes, including behavioral and psychological symptoms of dementia, caregiver stress, and reducing overall health care costs for individuals with cognitive impairment.

It will provide primary care clinicians access to tools and resources built into our Electronic Health Record (EHR) and will be supported by a collaborative care team of dementia experts, including a geriatric nurse practitioner and a dementia care manager supervised by a physician expert in the assessment and management of patients with dementia. This team will closely collaborate with the Alzheimer’s Association’s dementia care consultation program that provides valuable education and support for patients and families and serves as a link to community resources.

Fortunately, nearly a decade of research in other centers has demonstrated that a collaborative care intervention for dementia reduces caregiver burden, improves the behavioral symptoms of dementia and is cost effective in terms of avoiding unnecessary emergency room visits, hospitalizations and eventual placement into long-term care facilities. I am hopeful that the Partners Memory Care Initiative will be of tremendous benefit for patients, their family caregivers and, of course, our own clinical staff within primary care.

I’ve seen first hand the paradoxical relief experienced by a caregiver and patient when told that the confusing mix of memory loss, anxiety and difficulty with basic work tasks may be a result of Alzheimer’s dementia.  Knowing the explanation for such a change in someone’s ability to function independently and then working with a clinical team specialized in the ongoing care and support of individuals with dementia can dramatically improve quality of life for both patient and caregiver alike, despite the reality that Alzheimer’s disease is a terminal illness.

My mantra to patients and their families is to focus on what they can do despite this illness and not dwell on what they are no longer are able to accomplish. Social engagement, physical and mental exercise, a nutritional focus on the principles of the Mediterranean diet and remaining engaged in meaningful activities are the goals of care to improve quality of life for individuals with dementia. We are excited to launch this important integrated and collaborative Memory Care Initiative at Partners HealthCare so that individuals with Alzheimer’s disease and related dementias and their caregivers will experience a better quality of life and improved health care outcomes. After two decades in the field of geriatric psychiatry, I truly appreciate the opportunity to utilize a population health approach with colleagues from across our health care system to improve our ability to assess, treat and support individuals and their families impacted by the Alzheimer’s epidemic.

Brent P. Forester, MD, MSc, is the Chief of the Division of Geriatric Psychiatry at McLean Hospital, Medical Director for Behavioral Health and Evaluation & Research at Partners Population Health, and Associate Professor of Psychiatry at Harvard Medical School. He received his medical degree from Geisel School of Medicine at Dartmouth and has been in practice for more than 20 years. Dr. Forester is an expert in geriatric psychiatry, specializing in the treatment of older adults with depression, bipolar disorder, and behavioral complications of Alzheimer’s disease and related dementias.  He is a distinguished fellow of the American Psychiatric Association and is currently serving as the President-Elect (2019-2020) of the American Association for Geriatric Psychiatry. He has also served on the board for the Alzheimer’s Association of Massachusetts/New Hampshire.

© 2022 My CMS All rights reserved.