Burke Rehabilitation Hospital Memory Evaluation and Treatment Service: Diagnosis, Treatment and Ongoing Care in a Multidisciplinary Setting

Sunday, October 5, 2014

Troubling lapses in memory or judgment can be frustrating for patients, their families and medical providers. Physicians at the Memory Evaluation and Treatment Service (METS) at Burke Rehabilitation Hospital can diagnose various forms of dementia, provide curative treatment for non-progressive dementias and offer excellent supportive services for patients diagnosed with neurodegenerative cognitive disorders such as Alzheimer’s disease.

Pasquale Fonzetti, MD, PhD

Primary care physicians have tools to offer a preliminary diagnosis of memory loss; however, short cognitive exams, such as the mini-mental state exam or the mini-cog test, cannot determine the cause of dementias or suggest solutions. Additionally, busy providers may not be able to take charge of the behavioral, emotional, occupational and other interventions needed to help people with dementia live to their highest levels of functionality.

That’s where Burke comes in. When patients first visit METS, they undergo a thorough battery of evaluations, says Pasquale Fonzetti, MD, PhD, board-certified neurologist and Associate Director of METS.

(L-R) Pasquale Fonzetti, MD, PhD, Associate Director of the Memory Evaluation and Treatment Service (METS), and Barry D. Jordan, MD, MPH, Director of METS, discuss a patient’s neuroimaging, which helps them reach an accurate diagnosis and offer appropriate treatment options.

“We perform a general screening test, take a history and perform a general medical and neurological exam, a neuropsychological evaluation, screenings for depression, and assessments of activities of daily living [ADLs] and neurobehavioral symptoms,” Dr. Fonzetti says. “We collect information from the patient, family members and caregivers. To complete the diagnostic workup, we request brain imaging such as an MRI or CT scan, as well as blood work, to help us exclude treatable causes of cognitive decline.”

Evaluation of Memory Loss

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The METS program offers outpatient assessment and treatment of memory disorders. Here, METS Associate Director Dr. Fonzetti and Director Dr. Jordan consult on a current patient.

Forgetfulness is common for people of all ages, Dr. Fonzetti says. As long as lapses in memory — forgetting a name or failing to add an item in a checkbook tally — do not interfere with everyday life, people are probably not suffering from dementia. When memory loss begins to interfere with a person’s ability to hold down a job, enjoy a social life or stay at home safely, it becomes problematic.

“It’s a red flag when memory loss becomes an obstacle to what you want to do every day,” Dr. Fonzetti says.

People may immediately associate memory loss with Alzheimer’s disease; however, dementia refers to a wide group of brain disorders. All involve cognitive impairment, but they vary in terms of etiology, course, prognosis and treatment. For this reason, it is important that patients be referred to a center with experienced physicians who can make an accurate diagnosis.

“Burke Rehabilitation Hospital’s Memory Evaluation and Treatment Service [METS] has been active in the community for 12 years. We offer a comprehensive evaluation and treatment program for patients with memory loss, including cognitive remediation therapy, medical management of behavioral and psychological symptoms of dementia, and family services. We are happy to work with area physicians to help them manage the challenges of caring for patients with Alzheimer’s disease or other forms of dementia.”
— Pasquale Fonzetti, MD, PhD, board-certified neurologist and Associate Director of METS

“Before diagnosing Alzheimer’s disease, it is important to exclude reversible causes of cognitive decline, such as thyroid dysfunction, vitamin B12 or folate deficiency, metabolic problems, infections, and depression,” Dr. Fonzetti says. “Also, benign, slowly growing brain tumors and strategically located strokes can mimic Alzheimer’s disease — that is why it is recommended that patients have a CT scan or brain MRI to exclude focal structural abnormalities. Additionally, some medications may cause memory loss that resembles Alzheimer’s disease.”

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The METS staff (L-R): Sharon Singh, Assistant Coordinator; Kathy Byrnes, RN, Clinical Coordinator; Joseph Hirsch, PhD, PsyD, Consulting Neuropsychologist; Dr. Fonzetti; Dr. Jordan; Rosanna Cirio, MA, Program Coordinator, Alzheimer’s Disease Assistance Center; Mark Herceg, PhD, Director of Rehabilitation Psychology and Neuropsychology

It is important to recognize that some memory loss is reversible, through stopping a problematic medication, remedying a dietary imbalance or even removing a benign brain tumor. Other times, patients have a progressive dementia. The most common is Alzheimer’s disease. Other, less common types of dementia are vascular dementia, Lewy body disease, frontotemporal dementia and Parkinson’s disease dementia. It is not uncommon for signs and symptoms among different types of dementia to overlap. While these are difficult diagnoses for patients and families to accept, accurate knowledge is necessary to plan the best course of action.

According to Dr. Fonzetti, newer brain imaging techniques, such as brain PET scan or the Florbetapir plaque imaging test, assist in detecting Alzheimer’s disease at a very early stage.

“However, these more recent diagnostic tools can be used only in complex cases, when the probable diagnosis of a specific type of dementia is unclear,” he says.

Family Involvement, Community Support

Upon diagnosing a patient’s memory loss, METS physicians arrange a family conference. During this meeting, the physicians tell the family about the patient’s disease, its treatment and its natural course of progression. Families frequently have questions, which METS providers are well-equipped to handle.

It is not uncommon for patients with dementia, such as Alzheimer’s disease, to experience behavioral and emotional problems as the disease progresses. Burke providers can help families navigate these difficulties. In addition to cognitive remediation therapy, providers offer medical management and counseling to ameliorate some of the emotional and behavioral dysfunctions associated with Alzheimer’s disease.

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METS staff, who include (L-R) Cirio, Dr. Fonzetti, Dr. Jordan and Hirsch, offer a variety of options for patients, including a family conference, the possibility of participating in research trials and more.

“We can offer interventions to alleviate symptoms of dementia,” Dr. Fonzetti says. “We also help families learn how to deal with these problems. We connect them with local support centers, such as the Alzheimer’s Association Caregiver Support service, Visiting Nurse Services in Westchester, agencies for home care, adult daycare centers and community recreational groups.”

The METS program at Burke Rehabilitation Hospital is a participating member of the Hudson Valley Alzheimer’s Disease Assistance Center (ADAC). The ADAC program, with the cooperation of the Hudson Valley/ Rockland/Westchester, NY Chapter Alzheimer’s Association, provides assistance to patients with dementia and their families. Continued care and support services are coordinated through community organizations.

Research in a Continuum of Care

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The METS program, under the direction of Dr. Jordan (left, with Byrnes and Dr. Fonzetti), provides patients with a detailed exam that focuses on the possible causes of memory problems, as well as diagnosis and treatment.

Patients at Burke Rehabilitation Hospital receive cutting-edge therapeutic interventions and may choose to participate in leading clinical research in the field of neurological recovery and rehabilitation. They become part of a continuum of rehabilitative care designed to help them enjoy their lives at the highest level of functionality.

Burke Works with Physicians

Family medicine providers understand their patients’ needs well, having developed long-term relationships in many cases. They know when these patients will not welcome advice to leave home for assisted living or make other life changes. METS can help primary care providers and patients meet their goals, keeping patients living functionally at home or with their families as long as possible.

Normal Aging or Something More?

Patients may complain they are forgetting names, dates or daily tasks. As you consider making a referral to a cognitive rehabilitation service, such as Burke Rehabilitation Hospital’s Memory Evaluation and Treatment Service (METS), consider these clues from the Alzheimer’s Association:

  • Are your patient’s memory lapses disrupting her daily life? For instance, many people may forget the location of their car at a shopping center — but a person with Alzheimer’s may forget she has a car and catch a bus home instead.
  • Does your patient forget how to do essential tasks he could once perform easily?
  • Does your patient forget where she is in familiar settings, such as her hometown?
  • Does he become lost in his home or office?
  • Has your patient developed speech or writing problems?
  • Is your patient unable to find things she has lost? Many people misplace keys, for example, but a person with dementia may not realize she should search in her purse, car or house to find the keys.
  • Has your patient’s judgment declined lately? Family members may have insight into this question.
  • Has your patient recently quit activities he previously enjoyed?
  • Does your patient appear excessively suspicious, depressed or anxious?

If your patient exhibits any of these symptoms, contact METS to arrange an evaluation.

To learn more, visit burke.org.