COMMENTARY

Dementia Made Simple

Matthew F. Watto, MD; Paul N. Williams, MD

Disclosures

June 14, 2021

This transcript has been edited for clarity.

Matthew F. Watto, MD: Welcome back to The Curbsiders. I'm Dr Matthew Watto, here with my good friend, Dr Paul Williams. We are going to talk about "dementia made simple" from a great conversation we had recently with Dr Josh Uy. He's a geriatrician and he taught us all about his approach to dementia.

My first pearl for this episode is his approach to the patient with dementia. He has a super-easy way to group it into type of dementia. We've never been too sure how to do the subtyping in any way that made sense. He said that if the patient has a slow dementia (they talk slowly, walk slowly, move slowly) then it's probably going to be Parkinson's disease, dementia with Lewy bodies, or some type of vascular dementia. And the way he tells the difference between Parkinson's disease and dementia with Lewy body is by considering what came first. If the cognitive issues came first and then the patient developed some movement symptoms, it's probably dementia with Lewy bodies. If the movement symptoms came first and then years later they developed a dementia, it's probably Parkinson's with dementia. And Paul, that was just like, chef's kiss. Yes.

Paul N. Williams, MD: Exactly.

Watto: And then you had a question about frontotemporal dementia. Have you ever made that diagnosis?

Williams: Not yet. I'm still waiting for my chance now that I actually kind of know what I'm doing.

Watto: If it's a slow dementia, the differential is going to be either a vascular dementia or dementia with Parkinson's. If the patient is talking and walking at normal speed, then most likely it's going to be an Alzheimer's dementia or a frontotemporal dementia. The easiest way to tell whether you even need to worry about frontotemporal dementia is the patient's age. If your patient is over 65, don't worry too much about frontotemporal dementia. That comes on earlier. If they are moving fast — talking and walking at normal speed — and they are over 65, it's probably an Alzheimer's dementia. That's about the simplest breakdown of dementia I've ever heard. He did admit that it's good enough to get him in the ballpark 90% of the time. And Paul, that is an upgrade for me.

Williams: That's good enough for me.

Watto: What about you? What was your favorite pearl from this discussion?

The Triad Visit

Williams: I think you described him as a philosopher scientist or something equally grandiose. I agree, having listened a couple of times to the episode. But I really liked Dr Uy's approach in talking to the family of the patient. He characterizes this as a triad visit and made the point that you don't want to spend too much of the visit paying attention to one party more than the other. You don't want to exclude the patient and talk to the caregiver. And conversely, you don't want to talk exclusively to the patient and leave the caregiver out of the discussion. It should be this three-way conversation where everyone is included and involved in terms of the evaluation.

He also made the point that when you're discussing dementia, you should name the diagnosis and say it without fear or shame, like this is not something to be afraid of or to be ashamed of. Just say, "We're dealing with it and we have ways to help you." He said it's better to talk about the diagnosis openly (like so many other things) than to send someone home when they are thinking about it but don't actually have the diagnosis named for them. It provides some degree of psychological comfort just to be talking about it openly and naming it without hesitation or seeming afraid of it.

Watto: Yes, and that's analogous to talking about cancer or way back when we talked about fibromyalgia. Telling the patient that they have it to some extent is a relief because they know something's going on, and to give a name to it can sometimes be therapeutic.

Williams: Yes.

Watto: One other thing about the triad visit that I loved is that he says he sets up ground rules. Normally, there is a power differential between the caregiver and the patient. He makes a rule that the patient can interrupt when the caregiver is talking, but the caregiver should not interrupt when the patient is talking, which I thought was just amazing. These are the kind of facts that he dropped the entire podcast. You should definitely listen to the podcast if you want to hear more.

Pharmacologic Therapy? Not So Much

Watto: He said that in terms of medications for dementia, there may be statistically significant benefit that we can detect if we study them, but the clinical significance is not that great. In his opinion, these medicines are not worth tolerating the side effects. That has stuck in my head — it's something you can quote to people. Donepezil, for example, can cause bradycardia or gastrointestinal upset, and some of these patients are already losing weight from not eating well.

Williams: He made similar points about antipsychotics. If the choice is between using a medication and having someone institutionalized, he might reach for it. But he always uses the lowest possible dose for the shortest period of time because these medications have real, palpable, and significant side effects. Most of the time, it's not worth it. There are rare occasions when he might pull the trigger on them. But for the most part, the medications are not going to help and may cause real harm. It may feel like short-term benefit but may also actually hurt the patient.

Watto: I always weigh heavily before starting those medications and make sure I really discuss the potential implications with the family.

If you want some more knowledge bombs on dementia, please click on #268 Dementia Made Simple with Dr Josh Uy to hear the entire episode. This was a great one. And you can also join our mailing list and get a PDF copy of our show notes every week. Thanks for watching this video, and we will see you next time.

The Curbsiders are a national network of students, residents, and clinician educators from across the country, representing 15 different institutions. They "curbside" experts to deconstruct various topics in the world of medicine to provide listeners with clinical pearls, practice-changing knowledge, and bad puns. Learn more about their contributors and follow them on Twitter.

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