What are key questions to ask during a follow-up visit for an Alzheimer's patient?

Key Questions for Alzheimer's Patient Follow-Up Visits

Follow-up visits for Alzheimer's patients should assess four essential domains: cognition, functional autonomy, behavior, and caregiver burden, with evaluations occurring every 6-12 months and more frequently for patients with behavioral symptoms. 1

Cognitive Assessment

• Ask about changes in memory, particularly the ability to learn and retain new information, which is most commonly impaired in Alzheimer's patients 1
• Inquire about other cognitive domains including executive function, attention, language, and visuospatial skills 1
• Use validated cognitive screening tools such as:
  • Mini-Mental State Examination (MMSE) as a primary tool for tracking cognitive changes over time 1, 2
  • Montreal Cognitive Assessment (MoCA), Modified MMSE (3MS), or Clock Drawing Test as reasonable alternatives 1, 2
• Ask about specific examples of memory lapses or cognitive difficulties in daily activities 2

Functional Assessment

• Assess changes in instrumental activities of daily living (IADLs) by asking about:
  • Management of finances 1, 2
  • Medication management 1
  • Transportation abilities 2
  • Household tasks including meal preparation 1
  • Shopping abilities 1
  • Technology use 1
• Evaluate basic activities of daily living (ADLs) including bathing, dressing, and toileting for more advanced disease 1
• Use validated functional assessment tools such as:
  • Disability Assessment in Dementia (DAD) 1
  • Functional Assessment Staging Scale (FAST) 1
  • Functional Activities Questionnaire (FAQ) 1

Behavioral Assessment

• Inquire about changes in mood, emotions, and social engagement 3
• Ask about neuropsychiatric symptoms including:
  • Anxiety, depression, apathy 1, 4
  • Agitation, aggression 1
  • Sleep disturbances 2
  • Psychosis (hallucinations, delusions) 4
  • Changes in personality 4
• Use validated behavioral assessment tools such as:
  • NPI-Q (brief version of the Neuropsychiatric Inventory) 1
  • Geriatric Depression Scale (GDS) 1
  • Cornell Scale for Depression in Dementia 1
  • Patient Health Questionnaire (PHQ-9) 1

Caregiver Assessment

• Assess caregiver burden, which is a major determinant of hospitalization and nursing home placement 1, 4
• Use structured scales such as the Zarit Burden Interview 1
• Ask about caregiver's own health and well-being 4
• Inquire about caregiver's ability to manage patient's symptoms and care needs 2, 4
• Assess caregiver's knowledge about available support services and resources 4

Treatment Response Assessment

• Evaluate response to medications (if prescribed):
  • Ask about adherence to medication regimen 5
  • Inquire about perceived benefits and any side effects 5
  • Assess functional capabilities compared to previous visits 5
• For patients on cholinesterase inhibitors or memantine, specifically ask about:
  • Changes in cognitive performance since last visit 5
  • Changes in ability to perform daily activities 5
  • Any adverse effects such as gastrointestinal symptoms 5

Safety Assessment

• Inquire about any falls or injuries since last visit 2
• Assess driving status and safety 2
• Evaluate home safety concerns 4
• Ask about wandering behaviors 1
• Assess medication management safety 2

Disease Progression Monitoring

• Compare current cognitive and functional status to previous visits 1, 2
• Ask about rate of symptom progression 1, 4
• Inquire about any new symptoms that have emerged 2
• Consider whether additional diagnostic testing is needed based on clinical changes 1

Communication Strategies

• Direct questions to both patient and caregiver, as communication issues are reported by nearly all Alzheimer's patients (92%) 3, 6
• Use open-ended questions when possible, as research shows patients with advanced Alzheimer's can respond to them 6
• Establish commonalities and speak as equals to facilitate expression of feelings 6
• Recognize themes with personal significance to help maintain discussion 6

Referral Considerations

• Ask if specialized services are needed based on new or worsening symptoms 4
• Consider referral to specialists for:
  • Atypical cognitive abnormalities 4
  • Prominent neuropsychiatric symptoms 4
  • Rapidly progressive symptoms 4
• Inquire about need for additional community-based support services 4, 7

Practical Tips

• Always obtain information from both the patient and a reliable informant 1, 8
• Focus on changes since the last visit rather than absolute performance 1, 2
• Not all domains need to be assessed at every visit, but all domains must be evaluated at least annually 1
• Document baseline status to allow for meaningful comparisons at future visits 2
• Remember that patients often want to discuss memory concerns even if they don't initiate the conversation 8