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How much dementia do you see as a neurologist? In a general neurology clinic, probably one in eight referrals I see are for problems with memory. Most people will start by seeing their GP. The GP will take a detailed history, perform a memory test, and look for potentially reversible or treatable causes of memory and thinking problems. Things like poor sleep, insomnia, undiagnosed obstructive sleep apnoea, depression and anxiety, chronic stress, thyroid disorders, certain medications, and excessive alcohol can make people forgetful or affect their ability to concentrate or think clearly, so an important part of the assessment is distinguishing between dementia and other conditions that can cause similar symptoms. If there is something unusual, or aspects of the history or physical examination that are concerning, the person may be referred to a memory clinic, geriatrician, or neurologist. How do you diagnose someone with dementia? The diagnosis often takes time. We look at how symptoms evolve, perform detailed cognitive testing, obtain brain scans and, increasingly, use biomarkers to help identify the underlying cause. In New Zealand, cerebrospinal fluid testing following a lumbar puncture is now available in specialist settings, which can give us a better idea of whether there is underlying Alzheimer’s pathology or something else going on. By the time we’ve completed all the investigations, we’ve usually been on a journey with patients and their families. Gradually, the different pieces of the puzzle come together, allowing us to make a diagnosis with greater confidence and explain whether the findings are most consistent with Alzheimer’s, frontotemporal dementia, vascular dementia, dementia with Lewy bodies, or another condition. The challenge is that the process can take months, and in some cases longer, and during that time neurodegenerative diseases continue to progress. Anything we can do to speed up the diagnostic process is incredibly important. What is the point of getting a diagnosis if there is no cure? For a lot of patients, there is relief in having an explanation for what is going on. The anxiety about what comes next can be a huge challenge. But when we give a diagnosis, we are always mindful of what happens next and what we can offer. What is your advice for someone who has just been diagnosed, and for their family? There are practical things people can do. We can wrap support around the person and their family by involving the community therapy team, including needs assessors, social workers, occupational therapists, and other members of the community rehabilitation team. We encourage people to plan ahead while they are still able to make decisions for themselves. This includes setting up an enduring power of attorney, ensuring that theirWill is up to date, and considering their financial and legal affairs. Just as importantly, we encourage people to think about what matters most to them. What gives you purpose? What would you like to do now? A diagnosis of dementia often changes people’s perspective on life and how they prioritise their time. Having open conversations with loved ones about future care preferences and documenting these wishes in an advance care plan can provide reassurance for both the person and their family. One of the most important things I encourage patients and their families to do is connect with organisations such as Dementia New Zealand or Alzheimer’s New Zealand. Many of these organisations are supported by people with lived experience, who can often provide practical advice and guidance that complements the medical care. They can help people understand what support services are available and connect themwith opportunities such as support groups and clinical trials. Finally, maintaining physical health and social connection is incredibly important. People are more likely to thrive if they remain physically active, socially engaged, and well supported in their own home. Having family and friends around, staying connected to the community, and continuing to do meaningful activities can make a real difference to quality of life. What do you think about the new drugs emerging that can treat Alzheimer’s? I think they are really exciting and represent a major step forward, but they also require a reality check. The benefits seen in clinical trials have been in people diagnosed at a very early stage of Alzheimer’s disease, before there has been substantial loss of brain function and independence. To maximise the benefit of these treatments, we need to be able to diagnose Alzheimer’s disease earlier and with greater confidence. This means improving access to specialist assessment and biomarkers so we can identify the right patients at the right time. If someone can begin treatment while they are still independent, working and functioning well, the potential impact on their quality of life and on their family could be substantial. It is also important to remember that these drugs are not a cure. They slow disease progression rather than stop or reverse it, and there will continue to be many people living with more advanced dementia who are unlikely to benefit from these therapies. Supporting those individuals and their families will remain just as important. Editor’s note: New drugs including lecanemab and donanemab have been shown to slow the progression of early Alzheimer’s disease. They work by targeting and removing amyloid, a protein that builds up in the brain. The drugs are not yet available in New Zealand. What else should we be doing about dementia? We need to place much greater emphasis on brain health and dementia prevention. That means things like eating a healthy diet, exercising regularly, minimising alcohol consumption, managing blood pressure and diabetes, getting enough sleep, staying socially connected, and remaining mentally active. Prevention is more than individual lifestyle choices. The social determinants of health have a profound influence on brain health across the lifespan. Ensuring people have warm, dry, safe housing, access to nutritious food, good education, meaningful social connections, and equitable healthcare, is likely to do as much for reducing the burden of dementia as any single medical intervention. If we create communities where people can live healthy, connected and fulfilling lives, we give them the best opportunity to maintain brain health as they age. The intersection of the eyes and the brain is a sub-speciality of Benson’s. He is currently researching optic neuritis, a condition where the immune system attacks the optic nerve. (Photo credit: University of Cambridge) You can hear more fromBenson by watching his talk, The eye as a window to the brain , on our website www.neurological.org.nz/events/lecture-library For guidance on enduring power of attorney, see our educational video www.neurological.org.nz/educational-resources/educational-videos 12 Headlines 13 Headlines