What is Dementia?

By Scott Halstead, PhD

Today, more than four million Americans suffer from Alzheimer's disease, the most common form of dementia. Millions more are affected by changes in blood circulation in the brain, known as vascular dementia. According to the U.S. Census data, the number of Americans over age 65 will double over the next 25 years as the baby boomers age, leading to a significant increase in the number of Americans affected by some form of dementia.

So, what is dementia? Dementia is a broad term that describes a pattern of memory and thinking problems which affects many areas of the brain. In dementia, memory loss is common, especially of recent events and detailed situations. People with a recent diagnosis of dementia will talk about the frustration of not remembering something that happened recently. Family members may notice that their loved one remembers events from long ago more easily than recent events.

In addition to memory loss, another aspect of dementia may be language difficulty (called "aphasia"). Persons with dementia may have a hard time expressing themselves (expressive aphasia) or struggle with finding the right word to say (word finding). They may have a hard time understanding what is being said to them or not clearly understand what someone is saying (receptive aphasia). These problems show up in written language, too.

In dementia, complex activities such as planning, organizing, and problem-solving can become more challenging. Sometimes doing even simple, routine things in the right order becomes more difficult, like putting on one layer of clothing over another in the wrong way, or preparing a meal. Sometimes, family members may notice times of confusion. And certainly driving is a complicated task, requiring many different abilities to be sharp at all times.

HOW DO YOU DIAGNOSE DEMENTIA?
Not surprisingly, the earliest form of assessment for individuals with dementia is not performed by the medical community but often by friends and family who notice early signs and symptoms. These may include forgetting scheduled appointments, uncharacteristic repeating of questions or statements, becoming lost or disoriented while driving, losing or misplacing items around the house, or word finding difficulties. Though we may all experience these symptoms to some degree from time to time, an ongoing pattern or an increasing number of symptoms could be signs of dementia that should be evaluated.

Once this question has been raised, the next step is to set up an appointment with your primary care physician who will conduct an examination and order the appropriate laboratory work to rule out a reversible dementia. The doctor may also conduct brief screening tests to measure certain cognitive functions, such as an awareness of time and place, learning and memory, language, and visual spatial skills. They will also collect a thorough history of the problems noticed. Primary care physicians may also order imaging of the brain (e.g. MRI or CT scans) and comprehensive testing of a broad range of cognitive abilities known as neuropsychological testing. All of this information will be used to help the doctor determine the correct diagnosis.

In some cases, the diagnosis will be easy for the doctor to determine. For example, blood tests can reveal clear evidence of thyroid problems or vitamin deficiencies, which can then be treated with the proper medication. Brain imaging studies can show evidence of strokes or small blood vessel disease. These studies could also reveal the presence of a tumor. In such cases, treatment could involve medications to reduce the risk of further stroke or blood vessel disease, or surgery to remove the tumor. However, in many cases the tests do not reveal an obvious cause for the cognitive changes. When this happens, a formal neuropsychological assessment may be requested.

Neuropsychological assessment is a detailed testing of multiple areas of brain function, and is conducted by a neuropsychologist. A neuropsychologist is a specialist with a doctoral degree in psychology, and the equivalent of at least two years of postdoctoral, supervised experience in the specialty field of neuropsychology. This specialist measures a broad range of brain functions, including intelligence, attention and concentration, higher order cognitive abilities (e.g., multitasking, problemsolving, planning and organizing), language skills, visual perception/ construction abilities, motor speed and dexterity, verbal and visual learning and memory, and mood. While the testing will take 3-4 hours, the tests are all painless to complete and are generally done in a question and answer format. The testing will look at tasks of writing, drawing, and also some simple muscle speed and dexterity tasks. Results of this comprehensive assessment can reveal a pattern of cognitive strengths and weaknesses that can help determine the correct diagnosis. For example, people with Alzheimer's disease show a certain pattern of memory problems whereas people with vascular dementia may show a different pattern.

Once diagnosis has been determined, the next step is to consider the most appropriate form of treatment. And, as stated already, if the condition is determined to be reversible, then the appropriate medication or other medical intervention can and should be started.

WHAT ARE SOME CAUSES OF DEMENTIA?
There are many types of dementia. Some forms of dementia are progressive, meaning they will continue to worsen over time, while other forms are stable. Still others, like those caused by low thyroid or certain vitamin deficiencies, are entirely reversible or treatable. Many other conditions can cause dementia, including head injury, HIV infection, brain tumor, normal pressure hydrocephalus (water on the brain), Parkinson's disease, and substance abuse. In some cases, untreated depression can mimic symptoms of dementia.

Knowing the cause of a person's dementia is critical for ensuring the most effective treatment. The earlier the problem is diagnosed, the more likely it is that treatment will be able to stop or reverse symptoms of cognitive decline (as in depression or normal pressure hydrocephalus) or to maximize the brain's ability to function over time (as in Alzheimer's disease). Effective management of dementia requires a thorough assessment, an accurate diagnosis, and prompt treatment.

WHAT DO I NEED TO KNOW?
The challenges to individuals and families who experience these symptoms can be reduced by careful planning ahead. All adults should give some thought to medical planning in case they become incapacitated. Decisions about whether a person desires to be resuscitated or kept on life-support should be discussed with loved ones and put in writing. This reduces the burden on family members who may not be aware of their loved ones wishes. Also, Alzheimer's disease and other types of dementias can require care and special living arrangements. Planning ahead through savings or long-term care insurance policies can also ease the burden on families if such services should be necessary.

Healthy living can help reduce the risk of developing a dementia. Knowledge of symptoms can lead to early diagnosis and treatment when it is most effective. Careful planning can help minimize the challenges associated with dementia care and maximize the quality of time spent with family and friends.

Until a cure for every type of nonreversible dementia is discovered, many, many people will live with some form of this condition. Dementia is a difficult illness with which to live, both for the person with the disease and their loved ones. However, even after a diagnosis is made, they may enjoy quality time for many years. Proper diagnosis and treatment coupled with careful planning can ease the stress and challenges associated with the various forms of dementia.