Dementia

The Healthy Aging Mind: Normal Changes versus Dementia

 

The number of seniors aged 65 and older is on the rise in Canada. By 2024, more than 1 in 5 Canadians will be a senior citizen.  Accordingly, the prevalence of dementia in our society is expected to rise significantly as the rate of dementia doubles every 5 years after the age of 65. As a result, it is important to identify what is a normal part of the aging process versus what the early symptoms of dementia are. Early identification of this condition helps patients and their family members and caregivers receive the information, guidance and support they need to prepare themselves for the progression of this condition and its complications.

What is dementia?

Dementia is a debilitating, progressive and fatal disorder characterized by a decline in cognition from a previous level of functioning in the following areas: language and memory, executive function, complex attention, perpetual-motor function and social cognition. The impairment must be severe enough to interfere with activities of daily living and independence. Further, the disturbance is not caused by another mental disorder or medical condition (i.e. major depression, schizophrenia, delirium). The progression of dementia varies from person to person, with the eventual progression to severe dementia occurring within a time span of 5-10 years for many. Most people do not die from dementia itself but rather secondary illnesses such as pneumonia, bladder infections and complications of fall.

What are signs of dementia?

The symptoms of dementia usually start off mild and slowly worsen over time. Early signs include:

  • Memory loss
  • Impaired judgment, concentration or reasoning
  • Difficulty with processing information and problem solving (ie paying bills or balancing checkbook)
  • Trouble with understanding or language (often being unable find the right words for things)
  • Problems with planning and execution
  • Getting lost in familiar places

As dementia gets worse, it can cause:

  • Changes in mood of behavior (i.e. anger or aggression)
  • A deterioration in the parts of the brain responsible for motor functions leading to an inability to feed oneself, bathe, dress and other everyday tasks.
  • Loss of bowel or bladder control
  • Hallucinations and delusions
  • Disorientation to person, place or time

 

What are the Signs of Normal Aging?

  • Temporary memory lapses (i.e. forgetting name of person but recalling it later or where the car is parked)
  • Able to complete daily activities independently(i.e. cooking, bathing, paying bills)
  • Occasional difficulty finding the right words but no trouble holding a conversation
  • May get distracted but still makes decisions appropriate to the situation
  • Able to correctly think in terms of general concepts and principles(i.e. knowing what numbers on a calculator mean)
  • Occasional moodiness
  • Personality traits remain relatively the same (i.e. occasionally inpatient, maintains humor)
  • Occasional loss of interest in activities once enjoyed but still maintains a regular social life and attends activities with family and friends.
  • May need to pause to recall directions but not getting lost in familiar places

What are the different types of dementia?

  • Alzheimer’s Disease- the most common cause of dementia, accounts for 60-70% of cases. It is a disorder in which brain cells die slowly over time and there are deposits of protein called beta amyloid plaques and protein fiber tangles in brain.
  • Vascular Dementia- the 2nd most common type, accounts for approximately 20% of cases, happens when parts of the brain are deprived of oxygen, usually with fatty deposits or blood clots which lead to strokes. This type of dementia often coexists with the Alzheimer’s type in people over the age of 85.
  • Parkinson Disease Dementia- Parkinson’s Disease is a brain disorder which causes stiffness, slowed movement and trembling. As the disease progresses, it can also cause dementia.
  • Lewy Body Dementia- form of dementia caused by abnormal protein structures called Lewy bodies forming in brain cells. This type often causes vivid hallucinations and “acting out of dreams”. Further, it may also have Parkinson like physical symptoms.
  • Frontotemporal Dementia (formerly called Pick’s Disease)- caused by loss of nerve cells in brain. Occurs at younger age than Alzheimer disease. It may cause personality changes, abnormal social behavior, impairment or loss of speech, and difficulty in understanding language.
  • Other less common causes- repeated head injuries (i.e. among boxers or football players), chronic alcoholism, |Huntinton’s Disease, Creutzfeldt-Jacob disease, Multiple Sclerosis, HIV, syphilis and other infectious diseases than can affect the brain, hydrocephalus (brain swelling).

Conditions which may cause “dementia like’ symptoms:

  • Environmental toxin exposure (i.e. lead)
  • Thyroid disorders
  • Vitamin deficiencies (i.e. Vitamin B12 deficiency)
  • Brain tumors.
  • Depression
  • Sleep disorders
  • Medication side effects or interactions
  • Acute head Injury (i.e. concussion)
  • Dehydration
  • Alcohol and drug abuse
  • Delirium (acute change in cognition often related to infection, medications)

Risk factors for Dementia

  • Age > 60
  • Family history of Alzheimer’s Disease (especially 1st degree relative diagnosed at age < 70)
  • High blood pressure
  • Smoking
  • Diabetes
  • Stroke
  • High cholesterol
  • Atherosclerosis
  • Down Syndrome
  • Heavy alcohol intake

How can you reduce your risk?

In addition to the risk factors above that are controllable, studies show people who stay physically active, mentally engaged in cognitively stimulating activities (i.e. doing puzzles or reading) and those who remain socially connected may avoid or postpone the development of dementia.

 

Dementia Diagnosis

Diagnosis of dementia and the type, your healthcare provider will interview you and your family members to gather information about cognitive changes. Further, memory and other cognitive tests may be given and repeated over time to assess a person’s ability to solve different types of problems. Blood tests may be ordered to rule out another cause such as a vitamin deficiency. A brain scan (CT or MRI) may be ordered to identify the type of dementia or rule out other causes (i.e. a tumor). A spinal tap ( lumbar puncture) may also be ordered  to help diagnose the type of dementia. Referral to geriatric specialist may also be indicated when the diagnosis of dementia is unclear or for treatment recommendations.

How is Dementia Treated?

Treatment depends on the type of dementia. Not all patients will show improvement with dementia medications and these treatments do not cure dementia but rather, the goal is to offer a people with dementia and their families an improved quality of life for a longer period of time. Further, these medications often include side effects. Treatment options include:

  • Blood pressure and cholesterol control for people with vascular dementia
  • Parkinson’s Disease medications for those with dementia with parkinsonism
  • For mild to moderate Alzheimer’s and other forms of dementia: Cholinesterase inhibitors (i.e. Aricept, Exelon or Reminyl) may cause small improvements in memory and activities of daily living but not all patient see benefits and long term impact unclear.
  • For severe Alzheimer’s and some other forms of dementia: Cholinesterase inhibitors in addition to a medication that may protect the brain from further damage called Memantine (Namenda).

 

Treatment of conditions which often occur with Dementia

  • Depression: antidepressants, behavioral therapy
  • Anxiety, aggression and delusions: behavioral therapy, medication management in severe aggression.
  • Sleep problems: behavioral therapy, sleep hygiene, medications

 

When should you see your health care provider?

You should see your health care provider if you think you or someone close to you is showing any worrisome signs of dementia. Your healthcare provider is the best resource for information regarding any questions or concerns about normal aging and abnormal changes.

Resources:

http://www.uptodate.com

http://www.alzheimer.ca/en

Ontario Medical Association (2016) Ontario physicians supporting patients with dementia: a call for an Ontario dementia strategy. Ontario Medical Review. 15-23