What is Dementia?
Everyone knows that we become forgetful as we grow older, right? Wrong. Memory problems are not a normal part of aging, but it isn’t always easy to know the difference between normal changes that affect us as we grow older and more serious symptoms that might be the sign of real memory problems that we normally associate with dementia.
Dementia is the descriptive term for any medical condition that causes memory problems and problems with at least one other brain function, such as speech, concentration, visual perception or more complex thinking involving problem solving, planning and organization.
Two of the most widespread forms of dementia are Alzheimer’s disease, which accounts for 60 to 80 percent of those with dementia, and vascular dementia, which accounts for 20 percent. Today, more than five million Americans suffer from Alzheimer’s disease, while millions more are affected by changes in blood circulation in the brain, known as vascular dementia.
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. Persons with dementia may have a hard time expressing themselves or struggle with finding the right word to say. They may have a hard time understanding what is being said to them or have difficulty tracking details in conversation. 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.
Alzheimer’s disease is the most common form of dementia and cannot be reversed. Nerve cells in the brain are damaged or die due to neurofibrillary tangles and amyloid plaques. Neurofibrillary tangles destroy the internal structure of the cell. Amyloid plaques disrupt the ability of brain cells to communicate with each other through the buildup of protein plaques in strategic areas outside the cells.
Although promising research is being done, currently we know of no way to stop or reverse these processes once they have begun. However, a class of medications known as cholinesterase inhibiting drugs (e.g. Aricept, Exelon, and Razadyne) can help brain cells work more efficiently and can help a person function at a higher level for a longer period of time.
Alzheimer’s Disease is present in as much as 10 percent of the population over age 65. In 2017, 5.5 million in the U.S. were estimated to have Alzheimer’s. Because the number of adults over age 65 is expected to nearly triple by 2050, this number is expected to rise to 16 million. Alzheimer’s is the fifth-leading cause of death for individuals over age 65 and a leading cause of disability and poor health.
Vascular dementia, caused by cerebrovascular disease or stroke, is another common form of dementia. The pattern of vascular dementia can be one of sudden onset of symptoms followed by a period of stable functioning over time, followed by another period of decline in stable functioning. This is sometimes referred to as a stepwise pattern of decline. But vascular changes can also come about gradually. It is also possible that people can have a combination of Alzheimer’s dementia and cerebrovascular disease, which can make diagnosis especially challenging.
In some cases, the same medication used for Alzheimer’s disease can be helpful for people with vascular dementia.
Decline can be minimized by decreasing “vascular risk factors” or health concerns that place someone at a higher risk for further damage to blood vessels in the brain. These include high blood pressure, elevated cholesterol, diabetes, untreated heart disease and smoking.
Reducing the Risk of Dementia
While some risk factors such as genetics or age cannot be changed, other lifestyle changes, including healthy eating habits, regular exercise and smoking cessation, can minimize risks. Taking prescription medications to reduce cholesterol levels and blood pressure is also important.
- Keep mentally active. Read, do puzzles or learn a new skill.
- Keep physically active.
- Maintain a heart healthy diet, like the Dietary Approaches to Stop Hypertension (DASH) or the Mediterranean diet.
- Get enough sleep. Seek treatment for insomnia and sleep apnea
- Develop new hobbies.
- Avoid excessive alcohol use.
- Quit smoking.
- Have an active social life.
- Practice good stress management.
- Manage your blood pressure.
- Protect your head. Wear a seatbelt in the car and a helmet when participating in sports.
- Seek treatment if you have depression, anxiety or other mental health condition.
Dementia is the result of damage to the brain cells, which affects communication within the brain cells. 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
- 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. Although there are many exciting treatment possibilities being studied, there is not currently any way to stop or reverse the symptoms in most types of dementia.
But because some dementias can be the result of reversible medical conditions, the first phone call should always be to one’s primary care physician to discuss the symptoms.
A thorough history of the recent problems described by family will be noted. The physician may also order imaging of the brain (e.g. MRI or CT scans).
In some cases, the diagnosis will be easy for the physician 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 or 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.
When these tests do not reveal an obvious cause for the cognitive changes, a formal neuropsychological assessment may be recommended.
Neuropsychological assessment is a detailed testing of multiple areas of brain function, conducted by a neuropsychologist. A broad range of brain functions are measured, including intelligence, attention and concentration, higher order cognitive abilities (e.g., multitasking, problem-solving, planning and organizing), language skills, visual perception/construction abilities, motor speed and dexterity, verbal and visual learning and memory and mood. While the testing may take several hours, the tests are all painless to complete and are generally done in a question and answer format.
Testing also looks at tasks of writing, drawing and 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.
Early Signs of Dementia
- Repeating questions or statements.
- Forgetting to pay bills or paying them twice.
- Missing scheduled appointments.
- Uncharacteristically misplacing items around the house.
- Changes in mood and personality.
- Decreased motivation.
- Uncharacteristically making rude or inappropriate comments.
- Having difficulty problem-solving.
- Having problems with complex activities (Example: driving).
- Becoming more easily confused.
Dementia Warning Signs
Scott Halstead, PhD, talks about the top 9 warning signs of dementia and how these differ from typical age-related changes. Dr. Halstead is clinical neuropsychologist and corporate director of Pine Rest’s outpatient services.
Once a diagnosis has been made, the next step is to consider the most appropriate form of treatment. If the condition is determined to be reversible, then the appropriate medication or other medical intervention can and should be started.
Though there is no cure for dementia, treatment with medication can help injured brain cells work more efficiently, while other medications administered later in the process can keep some healthy brain cells from dying. Because treatments are most effective when started early, it’s critical to get an early diagnosis.
Dementia is a complicated and chronic problem. Therefore, it is essential that health care providers communicate with each other and collaborate together in assessment and treatment over time. Since the continuum of care includes outpatient-to-inpatient settings, providers at each stage of the process need to be aware of the “big picture,” and how each member of the treatment team is contributing to care. Team members may include the primary care physician, a hospitalist and psychiatrists as well as multidisciplinary members of the outpatient and inpatient teams (physician, nursing, social work, occupational therapy, physical therapy and discharge planners). Good cooperation and communication among providers will help the person with dementia maintain the highest possible quality of life.
After the diagnosis: Steps for family members
Families are encouraged – early on – to be proactive in getting legal counsel for a loved one with dementia. This is especially important because of the irreversible and advancing nature of the illness. Early planning allows the person with dementia to be involved and express his or her wishes for future care and decisions, eliminating guesswork or disagreement among family members. It also empowers the person with dementia to designate decision makers on his or her behalf. Items to consider include Advanced Directives, Designated Power of Attorney for Healthcare and even guardianship if the loved one cannot give consent for power of attorney, all of which allow trusted family members to assist – and when advanced – to intervene on behalf of a loved one.
Finally, end of life conversations and decisions should take place while a loved one is able to state his or her preferences. This painful but vital aspect of the continuum of care is a real blessing if families know ahead of time how or what their loved one would want when they have a terminal illness and be able to honor those wishes with the help of a Palliative care or Hospice care team.
Need help for you or a loved one? We offer assessment and treatment for dementia as well as support for family caregivers.