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Family Health Magazine - growing older

Diagnosing Dementia
Is there cause for concern?

As we watch parents and loved ones growing older, we expect to see wrinkles and gray hair. However, aging can also affect the mind. These changes can be subtle, getting worse over time. Health professionals use specific guidelines to determine how someone is managing mentally.

Changes to mental ability and memory are common in older adults. However, minor problems can evolve to become true dementia. This condition has become one of the most pressing problems in health care. The risk of dementia rises with age (see sidebar).

Risk of dementia rises with age
Age	Seniors with dementia
65	8%
75	16%
85	35%
90	50%

In primary care settings, more than half of dementia cases are missed. This means it may be worth mentioning concerns about cognitive function.

What are the symptoms of dementia?

Dementia can affect many areas (domains) of cognition. If you are concerned that someone might be cognitively impaired, ask yourself these questions.

• Is memory affected? Symptoms include having difficulty remembering new information, being repetitive, difficulty recalling names, losing items like keys and glasses, and forgetting details of events.
• Is speech the same? Impaired verbal ability (aphasia) appears as difficulty finding words, less fluency (ability to express oneself easily), and less spontaneous speech, reading, writing and comprehension.
• Are simple tasks a struggle? Difficulty in using devices like the TV remote or telephone can be a symptom.
• Is planning a problem? Executive function issues affect the ability to plan, initiate, correctly sequence, and monitor complex behaviour. This is the type of thinking needed to plan a vacation or prepare a big dinner.
• Does the person know you? Agnosia makes it harder to recognize people, familiar places and things.
• Does the person know where they are? Visuospatial impairment can appear as disorientation, such as recognizing day and night, getting lost, having trouble reading a map, and wandering.

Some forgetfulness is normal – isn’t it?

Yes, we normally experience changes in cognition and memory as we age. Loss of function, or being unable to carry out necessary tasks, is cause for concern. Basic activities of daily living (BADL) include washing, dressing, bathing, feeding, using the toilet, and mobility. Instrumental activities of daily living (IADL) are shopping, cooking, cleaning, yard work, managing transportation needs, doing the finances, and taking medications correctly.

Be concerned if memory issues are affecting the ability to function.

• Normal aging – Some short-term memory loss is a natural part of growing older.
• Mild cognitive impairment – Symptoms are present but there is no loss of function.
• Dementia – Both domains are affected (memory, speech, praxis, recognition, executive function, or visuospatial), along with loss of function.

The effects of delirium, depression, and drugs always must be considered, as they can also impact cognition. A diagnosis of dementia always involves loss of function. At this point, it is time to get help.

Comparing delirium and dementia
	Delirium	Dementia
Onset	sudden onset over hours or days	slow onset over months or years
Course	fluctuating	progressive
Speech	rambling	normal
Attention	inattentive, easily distracted	normal
Memory	variable	gradual and progressive memory loss
Hallucinations	common, especially visual	possible
Level of consciousness	impaired	normal
General health	signs of illness or drug side effects	usual

Talking to your loved one about getting help

It is never easy to bring up cognitive issues with a loved one. When symptoms first appear, the person may have good insight. However, as the condition progresses this understanding may be lost. Consider gathering all significant family members for a meeting, especially whoever is most influential. Try to frame your suggestions in a positive light, for example - 'We want to make sure you’re safe, and help you to make your own choices. If the assessment does find dementia, the doctors can look for a reversible cause. If none is found, certain treatments might help to keep you stable. We would have a better idea of how you are functioning, and can find ways to fill any gaps. We want to keep you independent for as long as possible, and this could help you to stay at home longer. We can also go over what you want to have happen with advance planning, and consider alternative living options and respite if you need them.'

Could it be something else?

Confusion can be caused by many conditions. While certain conditions mimic dementia, they can be treated and reversed. They include:

• hypothyroidism
• a low level of vitamin B12 or folate
• a high level of calcium in the blood
• fluid accumulating in the brain
• medication effects.

Depression and delirium can sometimes masquerade as dementia.

How do I tell the difference between delirium and dementia?

Delirium and dementia share some common features. It is very important to tell them apart. Delirium comes on quickly, and warns of a serious underlying medical condition. In comparison, dementia is chronic. As time passes, the ability to remember and function keep getting worse.

Are there different kinds of dementia?

Yes, cognitive impairment takes more than one form, and has different causes (see chart on next page).

With Alzheimer disease, change is gradual. It happens over months and more often years. Memory, particularly short-term memory, is affected first. Next, speech, abstract thinking and the ability to use numbers and judgment falter. This condition often runs in families.

Vascular dementia was once called multi-infarct dementia. It was thought to be caused by a series of strokes. Now, researchers believe that a lack of blood supply to the brain damages it over the long term and no actual strokes occur.

Mixed dementia is Alzheimer combined with a loss of blood supply to the brain (cerebrovascular disease). This is thought to affect a significant number of people with dementia. Those with dementia are more likely to have other disease conditions apart from dementia.

Frontotemporal dementia was once called Pick’s Disease. It affects areas of the brain associated with personality, behaviour and language. Changes in behaviour appear early. Signs include inappropriate behaviour, loss of social awareness, neglecting personal hygiene, inertia, and acting on impulse. The person is unaware of these changes. This dementia tends to appear at a younger age than Alzheimer disease.

Lewy body dementia involves unpredictable levels of cognition and ability to concentrate. Visual hallucinations may occur, often involving children or animals. Features of Parkinson’s disease are also common. These people may also be sensitive to various medications including antipsychotics.

Assessing dementia

Certain medical professionals can help decide whether or not someone has dementia. They include:

• family doctors
• geriatricians (doctors specially educated in the health care needs of older adults)
• and medical specialists such as neurologists or psychiatrists.

A physical examination is the first step. The doctor assesses symptoms, function, and possible changes in behaviour due to brain issues. Cognitive tests are performed. As well, blood tests check red blood cell count, hemoglobin (which carries oxygen), electrolytes, glucose and calcium levels, and thyroid function.

Certain factors will cue the doctor to order a CT scan. They include:

• a sudden appearance of symptoms
• memory function problems in a relatively young person
• certain findings on a physical exam
• a recent head injury
• symptoms in somebody who takes blood thinners
• or a history of cancer.

If it is dementia, what comes next?

Your health care provider or team may make a referral to the Alzheimer Society. It is a great source of information and support for people with Alzheimer and those who care for them.

Although current medications cannot cure or improve dementia, they can help stabilize symptoms. Your doctor may explore using acetylcholinesterase inhibitors like Aricept, Reminyl, and Exelon, as well as Memantine.

Your health care provider should also consider any functional loss, and look at ways to support your loved one. For instance, services like Meals on Wheels can help provide good nutrition. It may be wise to move to a more supportive environment where meals are offered. Home care can help with bathing, dressing and taking medications.

The review should include an assessment of mood, behaviour, and possible psychosis. Practical solutions may exist for safety issues that concern you. For instance, a driving assessment or road test can evaluate driving ability. The Alzheimer Society’s registry and GPS trackers can help locate those who wander. If you worry about the stove being left on, it can be unplugged, turned off at the breaker, or put on a timer.

Finally, ask for recommendations on advance planning. If you have not already done so, set up a personal directive and power of attorney. Your doctor can explain available options if your loved one needs a higher level of care. Explore ways to ease the burden of caregiving, including day programs and respite care.

If you have concerns about cognitive ability, help is out there. Approach your family doctor, or call the resources in the sidebar for additional support.

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While effort is made to reflect accepted medical knowledge and practice, articles in Family Health Online should not be relied upon for the treatment or management of any specified medical problem or concern and Family Health accepts no liability for reliance on the articles. For proper diagnosis and care, you should always consult your family physician promptly. © Copyright 2019, Family Health Magazine, a special publication of the Edmonton Journal, a division of Postmedia Network Inc., 10006 - 101 Street, Edmonton, AB T5J 0S1    [GO_FHab17]