In this issue we ask the question, "Who should provide medical care for the person with dementia, the primary care physician or a geriatrician?"; Geriatrician Judith Ahronheim presents both sides of the issue.

If you are concerned about an elderly relative or friend who has memory loss, and are seeking the help of a physician, where should you turn? To the primary care physician or a specialist? If a specialist, what kind?

A primary care physician (internist or family practitioner), who knows your relative well, may be the place to start, especially if the doctor has treated many older patients and takes their concerns seriously. Older adults should avoid a doctor who practices “medical ageism,”—an approach that includes, “What do you expect at that age?” Rather, a doctor should address each concern in keeping with the goals for that particular person. Not everything can be cured, but everything can be managed.

The primary care physician should be able to perform an appropriate work up for memory loss and should be prepared to follow your relative and work closely with you, your family, or other involved people on an ongoing basis. If not, the doctor should assist you in finding someone who will. You can contact the NYC Chapter for a referral to a major medical or university center specializing in diagnosing AD and other dementias. Whichever physician evaluates your relative should perform a complete physical examination (from head to toe) to detect anything that could cause reversible memory problems. The physical should include a neurological examination, which includes (among other things) checking facial movements, strength of arms and legs, reflexes, walking, and memory. The physician should also look for signs of depression. Most important is a careful history obtained from a reliable informant—a family member or friend who knows the person well and can supply information about how he or she is actually functioning. The history should include a careful review of medications, to look for substances that can impair memory or cause confusion. The physician will do blood tests to look for any other evidence of disease that could be impairing memory, and might order a CT or MRI scan of the brain.

When should you seek care from someone other than the regular physician? If you have misgivings about the doctor’s ability to perform a good evaluation, or whether the doctor has the patience to deal with complex elderly patients, or if you would prefer to start with a specialist, you should strongly consider seeking the help of a geriatrician. Geriatricians are internists or family practitioners who have taken one or more years of additional training in geriatric medicine and hold a “Certificate of Added Qualifications in Geriatric Medicine.” Usually primary care physicians themselves, geriatricians can evaluate and care for a wide variety of medical problems that afflict older adults, and have special expertise in caring for people with cognitive and physical impairments. Although you are looking for help regarding the memory problem, the geriatrician will also be prepared to do a complete geriatric assessment during the first or subsequent visits. This assessment will identify coexisting problems that are common late in life and are closely interwoven with cognitive disorders, so that your relative can be treated as a coordinated whole. The geriatrician can act as a gate keeper and orchestrate your relative’s care, which may include helping to coordinate or simplify a regimen of medications prescribed by others. Finally, a geriatrician is familiar and works closely with other geriatric professionals and has knowledge about accessing community resources that will be useful to patients and their families on an ongoing basis.

Other specialists, such as psychiatrists and neurologists, sometimes are consulted to assist in diagnosis and management. However, they generally should not enter the case until after the geriatrician or other primary care physician has conducted an evaluation. Ideally, it should be the physician rather than the family who initiates the referral to a specialist. Geriatricians, who are skilled in managing and prescribing for Alzheimer’s disease and other dementias, may still consult these specialists if the cause of the cognitive problem is unclear, or if they need assistance in prescribing for troubling symptoms. If a psychiatrist is needed, geropsychiatrists are favored by geriatricians, because they have had additional training in care of the elderly, and are skilled in prescribing medications in doses tailored for elderly people.

Although it might sound like a great idea to find a geriatrician, your relative might strongly resist going to a new doctor. That might be perfectly okay, and often ideal. But if you think you would like a second opinion or additional help, don’t hesitate to let the doctor know you would like a geriatric consultation. If it’s “only a consultation,” and if it is recommended by your relative’s trusted physician, things should go smoothly. You can find a geriatrician by contacting the American Geriatrics Society or the Gerontological Society of America or by calling the NYC Chapter.

— Judith Ahronheim, M.D.

Judith C. Ahronheim, MD is currently Professor of Medicine and Chief of the Division of Geriatric Medicine at the State University of New York-Downstate Medical Center in Brooklyn, and Adjunct Professor of Medicine at New York Medical College. Recently a faculty scholar of the Open Society Institute’s Project on Death in America, Dr. Ahronheim has published articles and textbooks geriatric medicine, clinical bioethics, and end of life care, and is a frequent lecturer to health care professionals and the community at large.

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