Ian Neel, MD, didn’t realize that volunteering in an assisted living facility as an eighth-grade student would shape the trajectory of his career. Yet he quickly became fascinated by dementia while planning activities for people dealing with cognitive decline as a teen.
"My volunteer work fostered an interest in the disease process and how we could work to help patients with dementia," Neel said of his years of volunteering at Alvarado Hospital, which is now East Campus Medical Center at UC San Diego Health. "That early exposure sparked a lifelong interest in memory care, which I pursued through philosophy studies and medical training. Despite the challenges, I find the field filled with hope and opportunities to improve lives."
Neel, associate professor of medicine at University of California San Diego School of Medicine and geriatrician and clinical lead of geriatric medicine consult services at UC San Diego Health, was recently appointed co-chair of the local chapter of the Champions for Health Alzheimer’s Project. The project, launched in 2014, has become a model for collaborative, community-based dementia care. Neel shares his passion for improving outcomes of those affected by dementia with a county-wide team of experts working to empower primary care physicians with the tools and training needed to detect and manage cognitive decline early.
In this Q&A, Neel reflects on his journey to cognitive care for older adults, the urgent need for dementia early detection and awareness, and how collaboration is key to transforming memory care for patients and their families.
You are now co-chair of the San Diego Alzheimer’s Project and have played a crucial role in it for eight years. What is the goal of this project and what drives your passion for this work?
The San Diego County Alzheimer's Project is an initiative created by former San Diego County supervisor Dianne Jacob in 2014, who saw the importance of caring for people with dementia. Over the past decade, the project has attracted a roundtable of experts in the field of memory care with local representation from San Diego’s major health systems and community care organizations. Our goal is to educate physicians on the screening, diagnosis and treatment of people with dementia.
While those of us who care for dementia patients in specialty practices are blessed by training in this domain through fellowships, there is not sufficient time for memory care training during a traditional medical school and residency education. The Alzheimer's Project has created clinical guidelines and routinely gives trainings to help fill this need. With so few specialists in dementia care, it is imperative that we help educate our colleagues so they can perform evaluations with confidence. Doing so will increase early detection of dementia in San Diego, and thereby facilitate earlier treatment and interventions to help improve the lives of those with dementia and their families — I view this as one of the most important aspects of my career. As an educator, doing what I can to bring this vital information to others can help improve care not just for the individual patient, but for the community as a whole.
As a geriatrician with specialization in caring for seniors with dementia, what drew you to this work and what improvements have you seen in this area?
I became fascinated by dementia early in my career and even long before that through my volunteer work. When I tell people I work predominantly in the field of memory care, they often comment that it sounds like "such a sad field." While there is indeed a sadness to the disease, I find it’s one with a lot of hope that can be uplifting both to those caring for people with dementia as well as the patients themselves. I witness this firsthand through my work with patients at UC San Diego Health.
I was fortunate to be a part of the UC San Diego HALT-AD trial, which is a study to systematically address interventions for dementia to improve quality of life and functional abilities without the use of medications. Well beyond the limited effect of the use of medications for cognitive care, educating families on core elements, such as mental and physical activity, can make drastic improvements in a patient’s overall function. This can have downstream effects of delayed entry into nursing facilities, lessening behavioral agitation and even reducing the use of multiple medications — all of which can lead to better quality of life for our patients.
Early on in medical school, you thought your path was leading to neurology. What changed your trajectory to geriatrics and what do you love about the field?
Given my interest in the mind, I initially thought that neurology was my calling, but UC San Diego expanded my vision to realize that geriatrics was another avenue toward dementia care. In medical school at UC San Diego School of Medicine, I discovered that I gained the most joy by sitting down with patients, explaining the hospital system to them, helping them understand why subspecialists were making certain recommendations, and partnering with the patient in informed decision making about those recommendations. My interests coalesced when I took a selective rotation in geriatric medicine. On my first day of that rotation, I thought, "Whatever I do, I want to work here."
Ian Neel, MD, is helping to shape county-wide efforts to help primary care physicians improve early detection of dementia. Photo courtesy of Ian Neel
I fell in love with the co-management model of psychiatry and geriatric medicine, partnering to care for a highly frail patient population while working to better their lives. I saw through the rotation that geriatricians could care for those with dementia, challenging perspectives that it was a disorder primarily cared for by neurology. I additionally found I enjoyed stopping medications more than prescribing them for patients — the emphasis in geriatrics on reducing the use of polypharmacy (the simultaneous use of multiple drugs to treat a single condition) was a huge allure to me. From that point I set up the rest of medical school and residency in internal medicine to do as much geriatric medicine as I could.
Mentors, including physicians John Daly, Victor Legner, Daniel Sewell, Arnold Gass, and Khai Nguyen, further propelled me toward a career in geriatrics. This ultimately led to a decision to undertake a fellowship in geriatric medicine at UC San Diego.
How do geriatricians play a critical role in dementia care and how can education on this important topic benefit primary care physicians?
Geriatric medicine is all about preserving and improving a patient’s function. This can become particularly difficult when aging-related diseases accumulate, including cognitive impairment, polypharmacy and frailty syndromes.
In patients with dementia, we find that treating certain medical issues can inadvertently worsen function, such as deconditioning and delirium risk from hospitalization or from sedating medications. Geriatrics focuses on these syndromes, attempting to lessen the burden they place on the patients, and, when successful, can lead to better health outcomes for those with dementia. The problem is, there are not enough of us. Geriatric medicine nationwide often does not fill its fellowship positions. As senior health care needs continue to grow, cognitive care is falling increasingly upon primary care physicians to deliver the bulk of dementia care. This is why I’m committed to volunteering with the Alzheimer’s Project — it is a way to empower primary care physicians to do this important work with the support they need.
How can early detection of dementia and Alzheimer’s play a crucial role in interventions that can improve the lives of patients and their families?
Early detection is crucial for Alzheimer’s disease and other related dementias. Many will cite the advent of new drugs as the reason for this, since the new medications are only approved for mild cognitive impairment. While true, this is by no means the most important reason for early detection. Lifestyle modifications, and the impact of physical and mental exercise, can have long-term ramifications for a person’s functional status and be associated with a slower rate of decline. The earlier these modifications start, the more effective the interventions can be.
Additionally, as dementia is a long-term condition that can affect patients and their families for up to a decade or more, knowing early about the condition can help with advanced care planning. Important decisions about finances, such as determining when or if memory care is needed, is best done early when the patient can be part of the decision. An early diagnosis can help patients ensure they are doing what they want with the time they have to enjoy life and preserve a legacy. Waiting until more moderate to severe stages of the disease surface could mean that patients no longer have the capacity to make decisions, which could leave medical care specifics and end-of-life planning to their families without having a voice in those decisions. The earlier we detect, the more time patients and their loved ones have to live their lives to the fullest and protect their future.
What are the warning signs of dementia and when should patients and their families talk with their doctor about concerns? How can early screening and diagnosis be beneficial?
Warning signs for dementia include any change in memory, cognition, or function. We all can have memory lapses from time to time — such as misplacing keys — but when these lapses begin to disrupt day-to-day life, such as missing an appointment because the keys were missing, this can be cause for concern. Sometimes we find patients begin having difficulty with problem solving or completing what once were familiar tasks. Changes in judgement with decision making, such as increased frequency of fender benders or neglecting to get household tasks done, can be another sign. Often changes in mood or late-life depression can be signs of cognitive impairment as well.
Increasingly, we observe that a decline in functional abilities (such as managing medications, finances, shopping, etc.) can also be a sign of possible cognitive impairment. If these warning signs begin to surface, it’s important to discuss them with your doctor. We are recognizing the importance of early detection from a systems level as well, with Medicare recipients now receiving annual wellness visits with their primary care providers. These visits are specifically geared toward identifying issues that could become problems for patients in the future, and one element included is a requirement for cognitive screening. So an avenue to start the discussion of cognition beyond asking your doctor for an evaluation would be to ensure you are having an annual wellness visit each year.
Tell us about the San Diego Alzheimer’s Project team and the unique tools they have developed to help patients and their families experiencing cognitive decline?
We have a phenomenal committee of clinicians from health systems across San Diego that contribute to this important work, including UC San Diego physicians in the departments of neurology, geriatrics, geriatric psychiatry, family medicine and internal medicine. Physicians James Brewer, Joseph Diaz, Douglas Galasko, Omar Ghosn, Gene Kallenberg, Gabriel Leger, William Mobley, Daniel Sewell and Lindsey Yourman have all have been essential in the work we perform. Doctors Sewell and Kallenberg deserve specific recognition for their work in a study of our guidelines’ effectiveness in increasing provider confidence in Alzheimer’s screening. The study has been conducted at several UC San Diego Health family medicine clinics, the results of which are pending journal acceptance.
From Scripps Health, we have been fortunate to have contributions from Dr. Peter Kim, who is an additional co-chair of the project, as well as Dr. Michael Lobatz, the former chair of the Alzheimer’s Project, and Dr. Greg Sahagian, who also represents The Neurology Center. From Kaiser Permanente we have physicians Ricky Ochoa, Lisa Heikoff and Liz Spier, who have been essential in the formation of our guidelines and implementation discussions. We also have benefited from the work of Dr. Abraham Chyung, who despite moving to Hawaii, has maintained his work on the education committee.
Representing the County of San Diego, we have been fortunate to have leadership from Kristen Smith, MPH, as well as her team at the County of San Diego Aging & Independence Services, which has continued to recognize and support the work of this project. We further have representation from the Alzheimer’s Association, Alzheimer’s San Diego, Glenner Alzheimer’s Family Centers, and Southern Caregiver Resource Center.
Our organization has also been part of the UC San Diego Geriatric Workforce Enhancement Project (GWEP), coordinated by Jennifer Reichstadt. Through this partnership, our educational materials have been integrated into several community health centers and nursing schools throughout San Diego. We have also added these important educational materials as a part of the core educational curriculum for the UC San Diego Geriatric Medicine Fellowship, furthering our educational reach.
Most importantly, none of the work of our project could be accomplished without the incredible effort from our coordinator, Barbara Mandel, with Champions for Health. She has been a true champion for this important work.
Our current focus is to continue expanding and augmenting our educational materials as new medications and research evolve, and to work with health systems to integrate best-practices workflows and tools into their electronic medical records (EMR) to make the practitioner’s job easier and patient visits more efficient. The Department of Family Medicine at UC San Diego School of Medicine has already taken the lead in integrating the project’s workflows into Epic to streamline screening. Family Health Centers of San Diego and True Care, both Federally Qualified Health Centers, have also accomplished screening and evaluation workflow and EMR integration. Additional health systems will soon also be achieving these goals.
Senior Medicine | Geriatrics
UC San Diego Health geriatricians specialize in keeping older adults healthy.
Ian C. Neel, MD
- Geriatrician
- Clinical Lead, Geriatric Medicine Consult Services at Senior Behavioral Health
- Associate Professor of Medicine
