Dr. Barak Gaster: How to Pick Up on Early Signs of Alzheimer’s Disease

Receiving an Alzheimer’s diagnosis is often a long, complex process, with many individuals facing delayed diagnosis or even misdiagnosis for years. A key reason for misdiagnosis could be the amount of training doctors are receiving on cognitive decline. 

University of Washington’s Dr. Barak Gaster is trying to fill that gap in his work directing the Cognition in Primary Care Program, which trains doctors to improve dementia diagnosis and care.

“Many primary care providers, like myself when I was in medical school,” he explained, “were not trained to diagnose cognitive decline, and the testing process is still relatively complex.”

Gaster joined Being Patient founder Deborah Kan in a conversation on why diagnosing Alzheimer’s is so difficult to diagnose, particularly in its early stages. He also shed light on the barriers physicians face in recognizing mild cognitive impairment and how primary care providers can improve diagnosis and care for those experiencing cognitive decline.

Read or watch the conversation on our YouTube to learn his practical advice for patients and caregivers seeking diagnosis, as well as his take on why these challenges exist and what can be done to improve the diagnosis process.

Being Patient: We’ve spoken to many people who had difficulty getting diagnosed. It often starts with a diagnosis of mild cognitive impairment. Doctors seem more comfortable giving that diagnosis, and people often feel relieved hearing it’s “only MCI.” Why are some doctors reluctant to mention the word “Alzheimer’s?”

Dr. Barak Gaster: It’s really complicated. The brain is complex, and when it starts to break down due to neurodegenerative diseases like Alzheimer’s, it happens gradually. We’re still learning how to identify mild cognitive impairment because it’s often subtle.

Diagnosis relies on cognitive testing and interviewing an observer, usually a family member or friend. Many primary care providers, like myself when I was in medical school, were not trained to diagnose cognitive decline, and the testing process is still relatively complex. There’s also a psychological challenge involved, as the diagnosis is difficult to grapple with, which can make doctors hesitant to have that conversation.

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Being Patient: We know the value of getting a baseline to track cognitive health over time is highly recommended, but is that the gold standard of care?

Dr. Barak Gaster: The idea of getting a baseline is valuable, but it’s complicated and time-consuming to implement for everyone. We don’t have a standardized way to get a baseline on every patient. The most common tool used is the Montreal Cognitive Assessment (MoCA), which takes about 10 to 15 minutes to administer. Ideally, we need a more efficient tool—perhaps something digital that can be used in 15 to 20 minutes. But it’s important to note that cognitive assessment alone isn’t enough.

You also need input from an observer, someone who knows how the person is navigating the world, and an understanding of other health factors, like medications or medical conditions. All these components come together to make a proper diagnosis.

“The idea of getting a baseline is valuable, but it’s
complicated and time-consuming to implement for
everyone. We don’t have a standardized
way to get a baseline on every patient.”

Being Patient: How can families detect early signs when the person experiencing the decline may not be aware (of them)?

Dr. Barak Gaster: That’s exactly why the observer’s role is so critical. The person experiencing cognitive decline might not realize what’s happening, but family members or friends will notice signs like repeatedly asking the same question or having trouble with familiar tasks. These observations, combined with cognitive test results, are essential for making an early diagnosis.

Being Patient: What warning signs should people look out for, and what do you teach primary care providers to watch for?

Dr. Barak Gaster: The Alzheimer’s Association has a great resource called 10 Warning Signs [and Symptoms] of Alzheimer’s. We’ve taken that and condensed it into three main warning signs for primary care providers. These are: losing short-term memory, such as asking the same question repeatedly within a short time; having difficulty completing complex tasks, like following a recipe; and becoming disoriented in familiar places, such as getting lost on a route you’ve taken many times. If these signs are present, they should prompt a cognitive evaluation.

Being Patient: That’s really helpful. I also want to ask about the MoCA test, which you mentioned earlier. I gave my mom the MoCA test every day for two weeks, and her results varied greatly. But she consistently struggled with the clock-drawing portion of the test. Is that part of the test a good indicator of cognitive decline on its own?

Dr. Barak Gaster: The clock-drawing test is valuable because it requires multiple cognitive processes, like understanding time and spatial reasoning. But neurodegenerative conditions manifest differently in different people, so we need to assess multiple areas of cognition to get a full picture. The variability you saw in your mom’s results highlights why we can’t rely on a single snapshot or test. It’s important to look at the bigger picture, including observer input and other health factors that may affect cognition.

“It’s important to look at the bigger
picture, including observer input and
other health factors that may affect cognition.”

Being Patient: Many people believe Lewy Body Dementia is the most misdiagnosed form of dementia. Often, patients are diagnosed with Alzheimer’s, only to find out years later it’s actually Lewy Body Dementia. Why is it so hard to diagnose?

Dr. Barak Gaster: It’s true that Lewy Body Dementia can be difficult to diagnose because its symptoms overlap with Alzheimer’s. Most people with dementia have a mixed form of the disease. One key sign of Lewy Body Dementia is visual hallucinations early in the course of cognitive decline. If a patient is experiencing visual hallucinations, they should be referred to a specialist for further evaluation. But overall, diagnosing the type of dementia is complex and often requires a specialist’s input.

Being Patient’s Guide to Lewy Body Dementia

Being Patient: Can a neurologist tell the difference between different types of dementia from brain scans?

Dr. Barak Gaster: Generally speaking, MRIs and CT scans won’t provide enough information to differentiate between types of dementia. These scans may show brain atrophy, but diagnosing specific types, like Alzheimer’s, typically requires more advanced tests, such as PET scans to detect amyloid plaques or other biomarkers. It’s a complex process that involves many sources of information.

Being Patient: For people who are worried about memory loss, what questions should they ask their doctors to ensure they get a proper diagnosis?

Dr. Barak Gaster: First, bring a close friend or family member to the appointment. Observer input is essential for making a proper diagnosis. Second, come prepared with a narrative of the memory issues or other cognitive concerns you’ve noticed. Third, make sure to list all medications, including over-the-counter ones, as certain drugs, like sleep aids, can affect cognition.

“Observer input is essential for
making a proper diagnosis.”

Being Patient: Can you tell us more about your Cognition and Primary Care Program and how it’s helping primary care doctors improve dementia diagnosis?

Dr. Barak Gaster: I’ve been a primary care doctor for over 25 years, and about seven years ago, I realized I wasn’t confident in diagnosing dementia. Since then, I’ve developed expertise in dementia care and created the Cognition and Primary Care Program. The program trains primary care doctors to evaluate cognitive decline, diagnose MCI and dementia, and counsel patients and families on maintaining brain health. We’ve rolled it out in the Seattle area, and we’re now expanding to other regions.