“Doctor, do you diagnose dementia? Because I need someone who can diagnose dementia.”
A man asked me this question recently. He explained that his 86 year-old father, who lived in the Bay Area, had recently been widowed. Since then the father had sold his long-time home rather quickly, and was hardly returning his son’s calls.
The son wanted to know if I could make a housecall. Specifically, he wanted to know if his father has dementia, such as Alzheimer’s disease.
This is a reasonable concern to have, given the circumstances.
However, it’s not very likely that I — or any clinician — will be able to definitely diagnose dementia based a single in-person visit.
But I get this kind of request fairly frequently. So in this post I want to share what I often find myself explaining to families: the basics of clinical dementia diagnosis, what kind of information I’ll need to obtain, and how long the process can take.
Now, note that this post is not about the comprehensive approach used in multi-disciplinary memory clinics. Those clinics have extra time and staff, and are designed to provide an extra-detailed evaluation. This is especially useful for unusual cases, such as cognitive problems in people who are relatively young.
Instead, in this post I’ll be describing the pragmatic approach that I use in my clinical practice. It is adapted to real-world constraints, meaning it can be used in a primary care setting. (Although like many aspects of geriatrics, it’s challenging to fit this into a 15 minute visit.)
Does this older person have dementia, such as Alzheimer’s disease? To understand how I go about answering the question, let’s start by reviewing the basics of what it means to have dementia.
5 Key Features of Dementia
A person having dementia means that all five of the following statements are true:
- A person is having difficulty with one or more types of mental function. Although it’s common for memory to be affected, other parts of thinking function can be impaired. The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) lists these six types of cognitive function to consider: learning and memory, language, executive function, complex attention, perceptual-motor function, social cognition.
- The difficulties are a decline from the person’s prior level of ability. These can’t be lifelong problems with reading or math or even social graces. These problems should represent a change, compared to the person’s usual abilities as an adult.
- The problems are bad enough to impair daily life function. It’s not enough for a person to have an abnormal result on an office-based cognitive test. The problems also have to be substantial enough to affect how the person manages usual life, such as work and family responsibilities.
- The problems are not due to a reversible condition, such as delirium, or another reversible illness. Common conditions that can cause — or worsen — dementia-like symptoms include hypothyroidism, depression, and medication side-effects.
- The problems aren’t better accounted for by another mental disorder, such as depression or schizophrenia.
Dementia — now technically known as “major neurocognitive disorder” — is a syndrome, or “umbrella” term; it’s not considered a specific disease. Rather, the term dementia refers to this collection of features, which is caused by some form of underlying damage or deterioration of the brain.
Alzheimer’s disease is the most common underlying cause of dementia. Vascular dementia (damage from strokes, which can be quite small) is also common, as is having two or more underlying causes for dementia. For more on conditions that can cause dementia, see here.
What Doctors Need to Do To Diagnose Dementia
Now that we reviewed the five key features of dementia, let’s talk about how I — or another doctor — might go about checking for these.
Basically, for each feature, the doctor needs to evaluate, and document what she finds.
1. Difficulty with mental functions. To evaluate this, it’s best to combine an office-based cognitive test with documentation of real-world problems, as reported by the patient and by knowledgeable observers (e.g family, friends, assisted-living facility staff, etc.)
For cognitive testing, I generally use the Mini-Cog, or the MOCA. The MOCA provides more information but it takes more time, and many older adults are either unwilling or unable to go through the whole test.
Completing office-based tests is important because it’s a standardized way to document cognitive abilities. But the results don’t tell the doctor much about what’s going on in the person’s actual life.
So I always ask patients to tell me if they’ve noticed any trouble with memory or thinking. I also try to get information from family members about any of the eight behaviors that are common in Alzheimer’s. Lastly, I make note of whether there seem to be any problems managing activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
2. Decline from previous level of ability. This feature can be hard for me to detect on my own during a single visit. To document a decline in abilities, a doctor can interview other people, and/or document that she’s reviewed previous cognitive assessments. I have also occasionally documented that a patient is currently unable to correctly perform a cognitive task that is related to her career or education history. For instance, if a former accountant can no longer manage basic arithmetic, it’s reasonable to assume this reflects a decline from previous abilities.
3. Impairment of daily life function. This is another feature that can be tricky to detect during a single visit, unless the patient is very impaired. I usually start by finding out what kinds of ADLs and IADLs help the person is getting, and what kinds of problems have been noted. This often means talking to at least a few people who know the patient.
Driving and managing finances require a lot of mental coordination, so as dementia develops, these are often the life tasks that people struggle with first.
In some cases — usually very early dementia — it can be quite hard to decide whether a person’s struggles have become enough to qualify as “impairment of daily life function.” If someone isn’t taking his medication, is that just regular forgetfulness? Ambivalent feelings about the medication? Or actual impairment due to brain changes? If I’m not sure, then I may document that the situation seems to be borderline, when it comes to impairment of daily life function.
4. Checking for reversible causes of cognitive impairment. I mentally divide this step into two parts. First, I consider the possibility of delirium, a very common state of worse-than-usual mental function that’s often brought on by illness. For instance, I’ve noticed that older people are often mentally assessed during or after a hospitalization. But that’s not a good time to try to definitely diagnose dementia, because many elders develop delirium when they are sick, and it can take weeks or even months to return to their previous level of mental function.
(My approach to considering dementia in older adults who are confused during or after hospitalization: Make a note that they may have underlying dementia, and plan to follow-up once the brain has had a chance to recover.)
After considering delirium, I check to see if the patient might have another medical problem that interferes with thinking skills. Common medical disorders that can affect thinking include depression, thyroid problems, electrolyte imbalances, B12 deficiency, and medication side-effects. I also consider the possibility of substance abuse.
Checking for many of these causes of cognitive impairment requires laboratory testing, and sometimes additional evaluation. It may even involve doing an MRI of the brain. I’ve written an article with more details about this here: Cognitive Impairment in Aging: 10 Common Causes & 10 Things the Doctor Should Check.
If I do suspect delirium or another problem that might cause cognitive impairment, I don’t rule out dementia. That’s because it’s very common to have dementia along with another problem that’s making the thinking worse. But I do plan to reassess the person’s thinking at a later date.
5. Checking for other mental disorders. This step can be a challenge. Depression is the most common mental health problem that makes dementia diagnosis difficult. This is because depression is not uncommon in older adults, and it can cause symptoms similar to those of dementia (such as apathy, and poor attention). We also know that it’s quite common for people to have both dementia and depression at the same time.
In many cases, there may be no easy way to determine whether an older person’s symptoms are depression, early dementia, or both. So sometimes we end up trying a course of depression treatment, and seeing how the symptoms evolve over time.
It’s also important to consider the older person’s mental health history. Paranoia and delusions are quite common in early dementia, but could be related to a mental health condition associated with psychosis, such as schizophrenia.
Is it Alzheimer’s Disease or another form of Dementia?
Families often want to know just what type of dementia their loved one has. Is the underlying condition Alzheimer’s disease? Lewy-body disease? Vascular dementia? Or frontotemporal?
The truth is that as people get into their 80s, the answer is that usually it’s “mixed dementia,” meaning that if we were to look inside the brain, we would find two or more causes of damage to brain cells.
This has been a consistent finding in brain studies of older adults with dementia, with one autopsy study finding that 78% of participants had 2+ causes, and a whopping 58% had 3+ causes. This study found that Alzheimer’s disease was very common (present in 65% of participants), but was rarely the only underlying cause of dementia.
In other words, especially in people aged 85+, the symptoms that families observe are probably a mix of two or more dementia causes.
Furthermore, in geriatrics, we find that the likely type of dementia does not help us manage symptoms and care. Most medications that are FDA-approved for dementia can be used for the various types (and none works very well). Generally, the best way to provide care is to focus specifically on whatever symptoms or difficulties the person with dementia is experiencing.
That said, it’s true that in recent years, researchers have been able to identify “biomarkers” to help identify certain dementia causes in the brain.
This is especially true for Alzheimer’s disease, which starts affecting the brain an estimated 15 years prior to obvious symptoms. Signs of “pre-clinical” and very early Alzheimer’s disease can be detected through special brain scans, and through analysis of the cerebral spinal fluid.
However, this type of biomarker assessment is mostly used in special research studies, and is not yet available for routine clinical care. It’s also mostly used in research evaluations of middle-aged adults and the “young-old” (e.g. people under age 75).
Is it Dementia or Mild Cognitive Impairment?
Sometimes, when an older person is having memory problems or other cognitive issues, they end up diagnosed with “mild cognitive impairment.”
Mild cognitive impairment (MCI) means that a person’s memory or thinking abilities are worse than expected for their age (this should be confirmed through office-based cognitive testing), but are not bad enough to impair daily life function.
The initial evaluations for MCI and dementia are basically the same: doctors need to do a preliminary office-based cognitive evaluation, ask about ADLs and IADLs, look for potential medical and psychiatric problems that might be affecting brain function, check for medications that affect cognition, and so forth.
I explain more about MCI in this article: How to Diagnose & Treat Mild Cognitive Impairment.
But remember: in practical terms, if an older person’s memory problems have gotten bad enough that he can’t grocery shop the way he used to, or she can no longer manage her finances on her own…those qualify as impairment in daily life function. And so, a diagnosis of “mild cognitive impairment” is probably not appropriate for those cases.
To learn more about the difference between mild cognitive impairment, Alzheimers and dementia, watch this video:
Can Dementia Be Diagnosed During a Single Visit?
So can dementia be diagnosed during a single visit? As you can see from above, it depends on how much information is easily available at that visit. It also depends on the symptoms and circumstances of the older adult being evaluated.
Memory clinics are more likely to provide a diagnosis during the visit, or shortly afterwards. That’s because they usually request a lot of relevant medical information ahead of time, send the patient for tests if needed, and interview the patient and a family member (or other knowledgeable “informant”) extensively during the visit.
But in the primary care setting, and in my own geriatric consultations, I find that clinicians need more than one visit to diagnose dementia or probable dementia. That’s because we usually need to order tests, request past medical records for review, and gather more information from the people who know the older person being evaluated. It’s a bit like a detective’s investigation!
Can Dementia be Inappropriately Diagnosed in a Single Visit?
Sadly, yes. Although it’s common for doctors to never diagnose dementia at all in people who have it, I have also come across several instances of busy doctors rattling off a dementia diagnosis, without adequately documenting how they reached this conclusion. (It’s also common for them to hardly document anything in terms of the older peron’s cognitive state, other than “confused, didn’t know date.”)
Now, often these doctors are right. Dementia becomes common as people age, so if a family complains of memory problems and paranoia in an 89 year old, chances are quite high (at least 60%, according to UpToDate) that the older person has dementia.
But sometimes it’s not. Sometimes it’s slowly resolving delirium along with a brain-clouding medication. Sometimes it’s depression.
It is a major thing to diagnose someone with dementia. So although it’s not possible for an average doctor to evaluate as thoroughly as the memory clinic does, it’s important to document consideration of the five essential features of dementia that I listed above.
If You’re Worried About Possible Alzheimer’s or Dementia
Let’s say you’re like the man I spoke to recently, and you’re worried that an older parent might have dementia. (Remember, most dementia is due to Alzheimer’s or a similar underlying brain condition.) You’re planning to have a doctor assess your parent. Here’s how you can help the process along:
- Obtain copies of your parent’s medical information, so you can bring them to the dementia evaluation visit. The most useful information to bring is laboratory results and any imaging of the brain, such as CAT scans or MRIs. See this post for a longer list of medical information that is very helpful to bring to a new doctor.
- Write down worrisome behaviors and problems, and bring this documentation to the visit. You can start with this list of 8 behaviors to track if you’re concerned about Alzheimer’s.
- Consider who else might know how your parent has been doing and behaving recently: other family members? Close friends? Staff at the assisted-living facility? Ask them to share their observations with you and jot down what they tell you. Share these notes, along with the names of the informants, with your parent’s doctor.
- Be prepared to explain how your parent’s abilities have changed from before.
- Be prepared to explain how your parent is struggling to manage daily life tasks, such as work, house chores, shopping, driving, or any other ADLs and IADLs.
- Bring information about any recent hospitalizations or illnesses.
- Bring information about any history of depression, depressive symptoms, or other mental illness history.
By understanding what it takes to diagnose dementia, and by doing a little advance preparation when possible, you will improve your chances of getting the evaluation you need, in a timely fashion.
Watch this Youtube video to learn six ways getting evaluated for memory loss benefits an older person and their family:
And if you have an aging parent who is refusing to get evaluated for memory loss or other concerning symptoms: my free online training for families (see below) covers how to get past this, and includes a nifty PDF summarizing what to say and not say to your parent who may have dementia.
This article was first published in 2015, and was last updated by Dr. K in September 2023.
Maxine Gold says
My father will be turning 83 this year and we have noticed changes including not remembering to take his medication (cholesterol, diabetic, aspirin as well as glaucoma eye drops). Thought we worked on a good system but noticed that he was either not taking at all or maybe more than once in a day. Here is some notes I took with me to the neurologist appt. Phone conversation with Dad when he was in Florida (lived part year in Florida) mentioning that he had been driving around a lot and had been in Texas and Alabama, but I knew he never left Florida. Was told by close friend in Florida – he tried twice to pack up his Ford F250 and leave Florida to drive to New Jersey. Thinking New Jersey was 4 hours away (Dad is a retired truck driver). The friend took keys from him after taking ride to Walmart shopping center with him and Dad not knowing how to get back to trailer park. Flew from Florida to New Jersey on May 5th, friend took him to airport and then got a security pass to take him to gate. Arrived in New Jersey and I met him at security desk. He had called my brother on cell phone to tell him he arrived as he thought he was picking him up. Didn’t recognize my car. Have had the car since 2011. Talked to me in the car about coming up through Virginia as they had to take a different path because his boss had spies watching them. At my house brought in his luggage and about 3 hours later he asked if we needed to bring in luggage. Unpacked his luggage and found that he did bring the Metformin with him but not Lisinopril, baby aspirin or Simvastatin nor Cosopt or Latanprost, or his shaving gear or deodorant but packaged bath towels, curtains, and rags. I did have back up of medication since it seemed he wasn’t taking the correct dosage. Had hoped I had him back on schedule when he left the end of February to go to Florida. Sunday morning, I saw he took his medication and eye drops but I ran to CVS later that evening and when I came back he told me he took his medication. Don’t know if he took it twice or not. For Mother’s Day went to Harrah’s Chester to the steak house and did some gambling afterwards. His sister-in-law came up to me about 10 minutes after we arrived to say that instead of using player’s card for the machine he asked her if he could use this card, which happened to be his debit card. She had him put it away in his wallet and retrieved his player’s card instead. I spent the rest of the evening with him. He also left me to go to cashier to cash in ticket. Was supposed to come back to me but ended up in an entirely different area but found his other sister-in-law and she called me to say he was with her. Saw a neurologist and the memory test scoring was a 13 out of 30. Mentioned Alzheimer’s. Ordered a MRI and blood work. MRI conclusion: No acute intracranial abnormality on non-contrast MRI of the brain. There is advanced chronic small vessel ischemic disease of the white matter. There is advanced atrophy and venticulomegaly. Have a follow-up appointment coming. Can you give me feedback and direction of questions to talk to neurologist about?
Leslie Kernisan, MD MPH says
Sorry for delayed reply. His symptoms sound concerning and consistent with dementia. The MRI is suggestive of a vascular dementia component. Mixed dementia is very common in older adults so he may have a combination of Alzheimer’s and vascular dementia.
You could ask the neurologist to clarify if there is any signs of Lewy-Body dementia. This matters in that people with LBD tend to be quite sensitive to certain types of antipsychotics (should they ever become necessary to manage behavior, which hopefully won’t be the case as they are supposed to be used as a last resort).
Otherwise, I would recommend connecting with the Alzheimer’s association or some form of dementia support group. You will need to process the diagnosis, figure out how to support your father, and especially start planning to manage his care now and in the future. Good luck!
Ariel says
Hello, if I may, I need to ask for advice. I apologize in advance if I’m not clear enough. I’ll try to tell as much as I can without repeating myself.
For about a year now, my mother has been displaying a lot of erratic and uncharacteristic behavior. She’s talking to herself (not in a “thinking out loud” way, but more like a whole conversation), occasionally sees things that aren’t there, has reported hearing noises, such as birds chirping or running water, when at the time there are no such sounds occurring, or at least aren’t heard by others. She’s also been accusatory and agitated. She accuses people (myself included) of theft, of controlling her, forcing her to do things, or wanting her dead. I don’t want her dead, nor does anyone else in the family, nor her friends. Mom is also confused a lot. She has forgotten things like the date, my age, my weight (that’s another topic though), the date, and whether I’m married with children (I’ve never been married and don’t have any children.) and is swearing rather frequently, including inside stores and even around children. “Swearing like a sailor” as the saying goes. I know that a lot of people do swear, and she has sworn before, but never to this extent, if that makes sense. Mom has also been saying that people are doing x, y, or z, when said thing has either never happened, didn’t happen the way she said it did, or involved other people instead of her.
Mom never set up legal aid, like power of attorney or anything. She believes that “it would give someone else control over her life.”
I would speak to her doctor, but she retired a little over two years ago, and that was before all of this began. She refuses to get another doctor, and believes that she’s okay. Mom also gets mad anytime someone even mentions doctors, and has also said things like “You can’t control me!”, or “You just want me dead!”, or “You’re after my money!”
If you ask her about one of her “moments” (for want of a better word), she thinks that nothing happened; she didn’t say ____, didn’t do ___, etc.).
I know that I cannot force her to see a doctor, and I don’t plan on trying, but I feel that I’m getting to my wits’ end. I don’t want to jump to conclusions, but I worry that she has some form of dementia.
Is there any way I can get her to see a doctor, and find out what’s going on?
Thank you in advance.
Leslie Kernisan, MD MPH says
Well, you don’t say how old she is, but I agree it sounds worrisome. The things you’re describing are not uncommon in the earliest stages of dementia. But, they can also sometimes be caused — or worsened — by other health issues, such as medication side-effects, or electrolyte imbalances.
Some of the false beliefs, hallucinations, and suspicious thinking you describe fall into the category of “late-life psychosis”, and I explain the most common causes here: 6 Causes of Paranoia in Aging & What to Do.
In the article on paranoia, I also cover some of the ways you can try to get help, when the older person is refusing to see a doctor. Sometimes it’s possible to persuade a person by bringing up some other aspect of their health, you would have to see what kind of reason might seem persuasive to her. Otherwise, if things get very bad in terms of how an older person manages their home, family sometimes calls Adult Protective Services.
It is a difficult situation. Try to avoid arguing and reasoning with her and instead try to be reassuring. Good luck!
Ariel says
Oh, I’m sorry. I didn’t mean to leave that out. My mother is 66.
Unfortunately she refuses even if the visit would be about something else, so I’ll have to see what else I can try. I’ll read that article you’ve shared as well.
Thank you for your reply. I apologize for this taking me a while to get back to.
Leslie Kernisan, MD MPH says
Another possibility would be to see if you can get a health professional to visit and assess her at home. You would have to see if that type of service is available in your area, and you might have to pay out of pocket for it.
Although she doesn’t have a diagnosis, since her symptoms are concerning, you could try calling your local Alzheimer’s association for advice on how to get a reluctant older person assessed. Good luck, it is a difficult situation.
Dan says
Hi
My wife (age 62) was asked about 4 months ago to obtain a medical evaluation for problems with her memory at work. There are several things that are making an evaluation of the cause of her symptoms difficult. She is a computer programmer and seemed overwhelmed. Her employer sent a letter written by a non-medical person that said she was exhibiting signs of early Alzheimers because she sometimes forgot her password and asked a lot of questions. We feel that may have biased the primary care MD and neurologist not to fully investigate other causes. Just before this happened, she was starting to finally get treatment for untreated, severe generalized anxiety disorder and just started a small dose of Lexapro. The psychiatrist that interviewed her also said that she also had untreated PTSD stemming from witnessing a fatal shooting at close range. She has had symptoms of anxiety for over 30 years. Sometimes it is better, sometimes it is worse but it has been there as long as I have known her. (We have been married for over 30 years) The incident with PTSD happened over 30 years as well. She also has untreated sleep apnea first diagnosed over 30 years ago as well. She says that the CPAP mask makes her claustrophic and she won’t wear it consistently. She started the assessment for memory loss with the primary care doctor and a referring neurologist. Based upon one MMSE (25/30) , a CT Scan (which was normal) and a MRI that showed some atrophy (we are not sure where) she was believed to have early onset Alzheimers and he was prescribed Namenda. He does not have trouble with grooming, driving, getting lost, knowing the season or date or any of the other symptoms usually associated with Alzheimers. If she is nervous he searches for words but again but can usually remember things minutes later. She has always had severe test anxiety. She almost did not graduate from college because she was afraid of a required test. So these symptoms have gone on for years. Because we wanted a more thorough evaluation, she is now being evaluated through a university memory clinic. She was extremely nervous during the Mini-Cog (given by a medical student) and didn’t score well. For example, she stumbled over the serial 7s but did it perfectly when we left the clinic. We also have a 22 year old son with schizophrenia that has caused upheaval at home. He is now in a treatment facility but is still a handful to deal with. The university has ordered a sleep study, PET scan, and blood work. I know that she could have age related dementia (which I know is not reversible) on top of cognitive difficulties with anxiety, PTSD and untreated sleep apnea (which may be reversible). But before she is labelled as having cognitive deficits due to Alzheimers, do you think she should have these other conditions treated ? What would be a suitable length of time to tell whether the memory loss is really from these other factors ?
Leslie Kernisan, MD MPH says
62 is young for dementia. I think it’s good that your wife is now being seen at a university memory clinic, they should be able to do a more in-depth investigation. Normally such clinics will also perform (or refer for) in-depth neuropsychological testing.
It is really common for people to do cognitively worse when they are anxious, and evaluating people like her can be tricky.
Whether or not she might have an underlying problem such as Alzheimer’s, it’s important to treat everything to the extent that you can, because you want her to be able to think her best. I would especially recommend you look into non-drug treatment for anxiety, as many of the anxiety drugs (especially benzodiazepines) tend to make cognitive function worse.
Regarding Namenda: studies have not shown that it’s effective for people with mild/early dementia. I have more information on dementia drugs here:
4 Medications to Treat Alzheimer’s & Other Dementias: How They Work & FAQs.
In people your wife’s age, whether or not they have Alzheimer’s often becomes clearer over time…people with Alzheimer’s will tend to get worse over the coming year, whereas cognitive impairment that is not due to neurodegeneration often remains stable or even improves.
I would recommend you request and keep copies of all lab results, radiology results, and so forth. This will make it easier to get a second opinion or do your own research.
Good luck sorting it out. I especially hope your wife will find ways to alleviate her anxiety and feel ok despite all the health and life challenges she is facing.
Dan says
Thank you so much. Your response makes sense. I will come back to this posting to let you know the results
Kris says
My 73 year old mother has thought (feared) she’s had Alzheimer’s for about 6 years. Just last week she saw a psychologist to take screening tests to check cognitive function and memory. She scored below (mildly) normal aging memory problems. She is also had ADD, anxiety and lately had suffered some depression (as she’s lost all three of her brothers and her mother in the span of 5 years, two of them died 3 days apart, also a close sister was diagnosed with Parkinson’s and best friend with cancer, also was dealing with her mothers Health issues) she had gone off her anti anxiety medication for about a year all on her own. We got her back on it in April and she said she has been feeling a lot better. We’ve all noticed improvement but still memory issues and also confusion at times. We know when she took that test she was super nervous, and as my dad said, “crumbled” while being asked questions. He knows that she could answer some of them while not under the pressure and fear of taking the test to semi diagnose for Alzheimer’s or dementia. We will be getting full blood tests done, checking for thyroid issues and b12 Deficiencies, also I think it’s so important she checks in with a psychiatrist to adjust or check her prescription for anxiety medication to see if it’s still the correct Dosage and/or medication. I believe it has been MANY years since she’s seen a psychiatrist for medication.
So, my question(s) are…. is it possible for someone to show many symptoms of early Demetria/Alzheimer’s and the cause be solely depression and/or side effects of medication? She has trouble with numbers (although math was NEVER her strong suit) and remembering dates, etc. she gets a little confused at times, forgetful (but not horribly), she had forgotten how old I am …just knew general age. I’m just wondering if these signs could be a cause of a lingering depression that’s been undiagnosed for years? Her symptoms have gotten worse, but mildly worse. And like I said, she got really bad last fall after two family deaths back to back and then improved after getting back on anti anxiety meds. Although I’m still not sure this is correct dose for her now, or even best medication as I think her needs and other things may have changed with age?)
Would depression or side effects to meds mimic THAT closely Dementia?
Thank you.
Leslie Kernisan, MD MPH says
Depression and/or medication side-effects can certainly cause cognitive symptoms that can mimic dementia.
For people your mother’s age, I have found that it’s very common for depression or stress or grief to make brain function worse.
That said, I’ve also found that it’s rare that people with such symptoms (and of this age) are otherwise entirely cognitively normal. Usually further evaluation suggests that they either have underlying mild cognitive impairment, or underlying dementia (often very early/mild stage).
There is a concept related to brain function that is called “cognitive reserve.” Basically, a younger or healthier brain has extra processing power, so even if it’s impaired by stress/grief/medications, thinking and memory will remain pretty good. Whereas a brain that has developed damage due to very early Alzheimer’s (or a variety of other problems) will have less reserve. So it takes less stress for the person to become noticeably worse in their thinking.
In short, I think you are right to suspect that the other factors are playing a role in your mother’s symptoms, but there’s still a good chance that her brain is not entirely normal and healthy for her age.
Regarding anxiety and anti-anxiety medications: anxiety certainly makes a person’s thinking worse, so it’s important to help her find ways to manage that anxiety. However, one of the most common classes of medication used for anxiety is benzodiazepine drugs, such as Xanax and Ativan. Those do help with anxiety but they also impair mental function. So I generally recommend that older adults be very careful about relying on those long-term, especially if they’ve had any memory concerns. I have more information here:
4 Types of Medication to Avoid if You’re Worried About Memory
Kris says
Thank you so much for your response and this info. I appreciate it.
Kris says
She is taking celexa, which is classified as an anti depressant (I read it’s sometimes used to treat anxiety as well…although I feel those two often go hand in hand) I didn’t see any side effects listed that would cause confusion or memory loss though. Do you know anything about Celexa ever causing those symptoms?
Leslie Kernisan, MD MPH says
Citalopram (brand name celexa) is indeed an antidepressant, of the SSRI class (selective serotonin receptor inhibitor). SSRIs do have anti-anxiety effects.
Citalopram and sertraline are actually a top choice for geriatricians, if we need to treat depression or anxiety in an older person. SSRIs are generally “well-tolerated” and studies have found citalopram and sertraline, in particular, have fewer drug interactions than the other SSRIs, and also tend to have fewer side-effects.
I would not expect citalopram to cause any significant confusion or cognitive worsening.
However, you should know that pretty much all antidepressants — including SSRIs — are associated with an increase in fall risk. In many cases, it still is reasonable to continue with the SSRI, especially if anxiety treatment with cognitive behavioral therapy isn’t a feasible option. (Psychotherapy works when people stick with it and have a decent therapist.) That’s because the benefits of helping the person with their anxiety — esp if the med seems to be working — often outweigh the concern about fall risk.
I think it’s good that you’re planning to have a clinician re-assess your mother’s medications. Good luck!
Monica Boler says
I didn’t read anywhere that you ultimately refer the patient to a neurologist specializing in dementia. My father had Lewy Bodies dementia. Is a primary care physician qualified to solely diagnose dementia. I would argue that they are not. My father died prematurely because he was not properly diagnosed and was prescribed medications that adversely affected him. Had he been referred to a neurologist specializing in dementia, he would not have been prescribed this medication, and he would have died from a natural progression of the disease. He was a victim of a primary care physician, who was too arrogant to admit that they were not qualified to solely diagnose dementia thoroughly. Do you not see this as an obstacle to adequate care?
Leslie Kernisan, MD MPH says
In many cases, a primary care clinicians should be able to make a preliminary diagnosis of dementia. Now, in this article, I don’t go into the additional issues that PCPs — or any clinician — should check for once they conclude an older person likely has dementia. But actually, checking for hallucinations and signs of Parkinsonism would be among them. Such features are common in Lewy-Body dementia, and do indeed mean one should avoid medications that interfere with dopamine in the brain.
Whether to refer to a neurologist or specialist depends on many factors. If a patient or family has any concerns, it’s certainly reasonable to ask for a second opinion or a specialty consultation. But specialists don’t always get things right. There is probably no substitute for doing a bit of one’s own research, as this helps one prepare to ask better questions.
A separate but related question is, to what extent is it important to have the underlying cause of dementia identified? I think PCPs should be able to diagnose dementia, but determining the underlying cause is indeed much harder. In people who are older than, say, 80, I don’t particularly try to identify the sub-type of dementia. That’s because mixed dementia becomes very common as people get older, and I don’t find that it’s useful (meaning helps me better care for the person) if we get specialty consults to try to identify the underlying cause.
Instead, I think it’s important to check for certain features that will affect care, such as visual hallucinations, parkinsonism, or other signs of Lewy-Body dementia. Again, this is because such features means it’s more important to be careful about certain types of medications.
It is also important to inquire about what types of difficulties a patient or family is encountering, and then create a care plan that addresses those. There can be a lot of variation in symptoms within a type of dementia. Now are PCPs equipped to deal with this? Probably not, but they need to get better. In the meantime, it’s multidisciplinary dementia clinics that are best, because they usually have nurses and social workers who are trained to help families with common challenges.
In terms of obstacles to adequate care…there are so so many of them, when it comes to the care of older adults. People with dementia are routinely given medications that are suboptimal or not recommended by best practice guidelines, often by PCPs, but also often by neurologists! I describe issues related to medications in dementia in these posts:
4 Medications to Treat Alzheimer’s & Other Dementias: How They Work & FAQs
5 Types of Medication Used to Treat Difficult Dementia Behaviors
In short: I agree that it’s risky to solely depend on PCPs for adequate dementia evaluation and care. But referring everyone to a neurologist is probably not the answer. Instead, we need for PCPs to be better trained, families need to be ready to ask a lot of questions, and most of all, we need more dementia clinics that are equipped to help families with the many common challenges they will encounter.
Derek Mcdoogle says
My mother just celebrated her 75th birthday but had a lot of trouble remembering how old she was. You stated that although it’s common for memory to be affected, other parts of thinking function can be impaired. Do most nursing homes offer memory care or options for patients with dementia?
Leslie Kernisan, MD MPH says
Memory care is common in assisted-living. There are a number of sites online offering help in choosing a suitable facility.
I would recommend your mother be carefully evaluated before you look for a facility.
Pat says
My mother fell two months ago and fractured six ribs and hit her head. She is 93. The hospital took X-rays, told me to take her home and give her some Advil. I was flabbergasted. Shouldn’t they have kept her overnight at least because of her head injury? Now she has started scratching her head saying there is some kind of cradle cap on it. She has dug sores in her head and is losing her hair. We took her to her Dr. he ask her if it itches and she says no. He prescribed Zanex .5 for her nerves. She is still scratching. Could this be caused by something else????
Leslie Kernisan, MD MPH says
Digging sores in her head sounds concerning. She says it’s not itching: what reason does she give for her scratching? It sounds like she might benefit from a little more investigation from a clinician, to figure out what is driving her head-scratching behavior.
Xanax is a benzodiazepine sedative/tranquilizer drug. Like all benzos, it’s on the Beer’s list of medications that older adults should avoid or use with caution, because benzos tend to worsen thinking and increase fall risk in people your mother’s age. As a geriatrician, I only use benzodiazepines as a very last resort, when all other options have been considered and if we decide the likely benefits outweigh the risks.
So I would recommend you follow-up with her doctor and ask more questions. You may also want to consider a second opinion from a geriatrics clinic, a dermatologist, a geriatric psychiatrist, or just another generalist physician (preferably one who is careful and thoughtful).
Last but not least: Advil is also on the Beer’s list of medications to use with caution. Unfortunately, it remains common for doctors to prescribe risky medications to seniors, without having discussed risks and alternatives with patients and families. So keep asking questions and doing your own research, as you are doing. Good luck!
Keeping myna secret says
There is so much I could write about this article. It’s really interesting to see what is termed dementia, vs delirium. My mother is a very complex case. But what is especially interesting about her case is she has a pattern of having seemingly mental anxiety which is related to an untreated illness. She often has the mental anxiety go away when the cause of the illness goes away. Dad often would side with doctors who would say, it’s all in your mind and she’s get nerve pills to treat anxiety over real symptoms. This happened a few times but she also had some episodes where she was treated for mental illness likely depression and bad thoughts many years ago after pregnancy. So she had a few cognitive problems, like being bad with math since an accident as a child.
Later in life she was addicted that is took nerve pills for many years, also tied to resolvable illness that was undiscovered. In getting off those drugs she took a drug that gave her a debilitating illness that stopped her ability to walk. Hardly at all. So my father and I have to wait on her and get her everything. My dad is very old and my mom is old as well. 90 for dad and 76 for mom.
Without going into to many details. There was known diagnostics and hidden diagnostics made by a psychiatrist. Those hidden things were kept from me by the will of my parents and covered up, or the psychiatrist put diagnosis opinions in his notes without telling my parents. This remained hidden in her record.
Now over the years my mom has seen well over 30 doctors for her physical debilitating illness and she has basically the same results, her nerves are damaged and she will never walk without pain that is extreme. She has burning foot syndrome, likely caused by a side effect from a drug that destroyed not only her life but ours as we are stuck wrung for her. She takes a lot of drugs, some off label to treat the effects of the disease/syndrome. Two drugs she takes are Ativan and also Cymbalta. Cymbalta is being taken at 30mg dose per day. She also typically gets 3 hours sleep per night, and naps at times during the day. Without Ativan she cannot fall asleep if stressed and she’s used to taking the equivalent of four 1mg doses per day. She takes heavy pain mess each day. We are talking Norco and a duregesic pain patch. The pain patch is fentanyl 50mg every three days but was 75 mg every three days before the hospital visit. She also takes lisinopril 10mg a day for blood pressure. The blood pressure is will rise due to pain. Level 7 normally up to level ten during a pain flare. She also has environmental chilling of her feet.
She also is very demanding, but of course a part of this is due to being immobilized in a lazy boy and has a strange setup that took 3 hours to get in and out of to go to the restroom. She has home care givers come to the house. She can’t be in a warm environment for long. She basically has a ton of problems and some come from adapting to the foot peoblem, a result of adapting and doing behaviors to compensate for foot pain or reduce it. For example when you don’t want to spend more than two or three times going to the bathroom because it’s a three hour ordeal you limit your fluid intact. Sitting long hours can cause more problems with your body. The cold air for the feet which burning foot sufferers end up using chills the rest of the body, so you’ll have to bundle up and experience aches and pains. Chilling the room makes our family a bubble house family because the cold air leads to isolation. We have had to feed her special diets and meals because her pain is related to diet as well. Salty and sweet or spices or even hot foods can cause pain flares. She lost her teeth and has to have chopped and chilled food. Some foods set her off.
She had some minor problems she wanted to get taken care of and went into the hospital for those. She can be very demanding. If her Cymbalta is increased to 60mg a day, her requests that are always demanding with Cymbalta added go to 30 requests per minute, even a staff of four people could not keep up with those demands.
She has suffered a mania from lack of sleep before. Sleep deprived for three or four days when overdosed on Neurontin given off label to try to cure her foot problem. She experience sleep deprived delirium and was hearing things. I’m aware of this and saw it. I’ve had a kind of rem sleep delirium myself a kind of sleep deprived rem state where the mind races without sleep or when fatigued a lot. It’s like sleepwalking while your awake. Mixing dreams with reality forming an alternate reality. I have my own theory but just as a normal person, and that is sleep deprivation can drive the mind I to a rem state while awake. Maybe that’s delirium. If you are alert enough you might take notes and even have interesting dream like thoughts that are like a kind of cognitive drawing.
In the last hospital episode she was interested and demanded to go to the hospital for a non emergency, that could be handled by ER but didn’t have to be. I found out relatives who don’t live with us we’re hearing complaints from mom about our not meeting her every wish and filling APS social worker complaints against us as some kind of abuse or neglect charges. Didn’t know who that was. Didn’t know the exact charge as they would arrive, take notes and leave and say the charges would be dropped.
When we got to the hospital mom was dropped off her medication for procedures and some required things like colonoscopy tests. These won’t work with someone who takes three hours to go to the bathroom. Mom was not getting much sleep. And she only got 10 to 12 hours over a week. Her medications were changed and without Ativan her sleep deprived delirium like symptoms and racing mind were happening. And I saw this decline before so I was worried about it.
They were not feeding her enough and she was complaining about everything and not on any one topic, like rem state dreaming while awake. Every complaint was accurate and made sense to me but the topic of context was absent as she would switch topics constantly. I found out that she wasn’t getting Ativan because they were afraid of side effects and could not sleep until she got that. Drugs used for common recovery caused her burning foot flares to move around the other parts of her body, as evidenced by skin temperature readings. The family had to do the medical chilling and I ended up bringing food I made from home in coolers to feed her.
I caught a social worker lying to me, covering up something. I didn’t trust her from that point on. My dad and I were left for a week trying to stay in my moms room and support her care and we were losing sleep.
The hospital made a few mistakes and when my. I’m complained and I started to complain, well we became problems in their eyes. I’m sure of that. They abused her feet when I left her alone and then covered it up in the records. Then they tried to railroad us to a nursing home quickly. And we said we can’t trust the nursing home unless we check it out because you guys aren’t taking good enough care and we can’t trust you. So they gave us a chance to stay one more day for a mental health evaluation. That night I realized mom wasn’t going to ever pass it. Because she had not been getting enough rest and there was no point in testing her mental state she would fail. We decided to leave in the morning and reject care. I talked it over with mom and dad. But we were held against our will with a threat of hospital guards. I didn’t understand why. Mom failed the test and the staff who promised that we could decide if she didn’t pass the test pressed us for a placement into the nursing home because she had dementia and families will not see it and choose to deny it. We agreed. Once in I found that relatives filed for guardianship. Because we had no living will or poa that we could recall and none was signed during admission.
Mom was put in a room that was 84 to 90 degrees hot when she normally is in a 60 degree room with air conditioners and fans blowing over her burning feet.
Dad and I and mom were out of the frying pan and into the fire.
The transport van lady didn’t fasten down her wheelchair and had the heat on High during the entire ride to the nursing home. We had to pay for transport, because they didn’t trust us or that’s the common way things are done. Moms blood pressure was 193/83 from the transport to the nursing home.
We were stuck in legal limbo and the state had guardianship rights over her care and my relative drove up to file for guardianship to take car of mom and later admitted to “save us from ourselves”. Mom was losing more sleep in there and I was as well. My heart felt like it was going to fail. I found that my relative filed for control of 50 percent of our finances, by virtue of the wording.
I ended up asking the nurse to retest mom to find out if she had dementia, stating I didn’t think she had it and that it was a false diagnosis. It she passed the evaluation and was able to sign herself out. I wanted to see the hospital and all medical records to figure out what was going on. What did I find. I found out that my father and I were charged with neglect by my relatives. They were treating us as part of the problem and there were two plans. A public plan and a secret private plan apparently. This private plan was determined to diagnose my mother as having dementia in order to get her out of our care/neglect. The problem was the hospital and nursing home actually cares less, abused her and covered it up. I have absolute proof of this. Everyone in the hospital was lying about this. But the record didn’t lie. The measure,mets didn’t lie. And the evidence and facts I uncovered didn’t lie. What happened was selective half truths were used to frame my father and I as neglecting my mom when medical professionals have said we are the best caregivers they have ever seen. Yer we were being accused behind HIPPA privacy and didn’t see that. We didn’t know but were being tried behind e scenes without any chance of defense. Relatives trying to help us were setting us up and twisting us into a series of catch 22 scenarios. They even lied when making excuses after the facts and never apologized.
I found out the hospital entered a diagnosis into the system before my mom was tested which stated dementia as the diagnosis. A letter was written to the nursing home and signed with lies that mom had dementia as a diagnosis and was treated for It in the past 24 months which is a lie. That she was diagnosed with it, five days before the psychiatrist saw her. She was on three times more blood pressure medication than she normally gets and was losing sleep. Basically dementia was used as an excuse to kidnap my mother from our care. Now I do admit we neglect some of her requests because there are many of them. She has a complex case with many ailments and many drugs being taken. A discussion with a neuro psych clinic person in the phone resulted in them admitting if we went to get her tested we’d never get a proper diagnosis with all the drugs she has to take for her burning foot syndrome. In the backstory of this my relatives decided to make my dad and I villains as we reacted we were attacked through emails and texts saying my dad had dementia as well. That’s just another way to get him in a nursing home as well. Dementia can be used to get guardianship and steal assets from the person. It’s a rising trend by those who have no respect for the elderly or their care.
It’s important to have care givers keep an eye on seniors who might be easily exploited by those seeking to take advantage of them. How did the hospital get involved with this. One of the accusers was a social worker and set us up with the medical workers behind the scenes. So we were tried by a kangaroo jury behind the scenes. And the lies are evident in the records and flaws point not only to neglect and mistakes by the medical system, but a plot and purposeful use of a false diagnosis to take control.
Now I understand is someone is really abusing someone then something has to be done. My point is subjective emotions were manipulated behind e scenes and once the ball started rolling there was virtually no way we could stop it.
This makes me so mad, I’d like to sue the heck out of everyone involved. I even wouldn’t mind going around that and going directly to the criminal court system and file because the conspiracy was so wide ranging end full of lies and bs. The biggest problem I have is my relatives even though they did this would be implicated and it’s difficult to say how far the courts would go. This kind of stuff happens all the time But people don’t have time to figure this out, and would rather move on with their life. The problem I have now is the past medical records could harm her future care. Things written that are false may show up in future records. Everyone has a right to their opinion. I’ve had eight medical professionals say my mom doesn’t have dementia and some claim the doctors and relatives who did this have dementia instead. It becomes a thing that is so difficult to unravel.
I’m ready to write a book about this and almost feel like going for the publishing of the true story in all its details without revealing the actual names. I almost feel new laws like laws to allow patients to have a recording via video and audio of their entire stay which are secured for future evidence needs to be allowed. After all a police officer may have to wear a body cam to document life and death decisions. If a police officer needs body cams to protect him and the citizens, why should a medical professional not wear one. They can be judge and jury and harm or kill you and hide it and hide the evidence.
I feel like we got a taste of socket healthcare instead of US healthcare. Supposedly the patient and his loved ones are supposed to be given truthful information during their care. We got a lot of lies and stonewalling. My advice is beware and get good references before going to Mickey Mouse hospitals.
Leslie Kernisan, MD MPH says
Wow, sounds like you have been through a lot.
I would agree that your mother is a “complex case.” In particular, it can be hard to diagnose dementia in people who take a lot of potentially mind-altering medications. Also true that sometimes there isn’t a lot of transparency when it comes to diagnoses or medical information. I hope things get sorted out — or at least improve a bit — soon.
Another secret says
Once the elderly start with unmanageable mental problems, real life of the law and greed of medical insurance is mind blowing.
Best advice? Give all money and property to the youngest heirs in the family. Way ahead of time. Otherwise….. you lose.
Ccat says
Ooohhh, you are telling my story!! I have a suspicion that there is alot of money being made within the adult protective services, care home, conservatorship triangle. If they think you have a nickel, as a caregiver, you will get targeted!
Watch out! The system is not your friend. They almost killed my husband. I could write a book also.
Nicole Didyk, MD says
I’m sorry that you had a difficult time with “the system”. I sincerely hope and believe that most people who work with and care for vulnerable older adults do so in good faith and with the intention of helping and supporting the person.
Carol Marak says
Sounds like my Dad and Therese’s Mom had many of the same symptoms. It took many months for Dad’s doctor to diagnose his Alzheimer’s, It wasn’t until after my Mom’s passing – I guess they were able to hide it (unknowingly) from the world.
Good information on dementia.
Therese Sibon says
thank you. My 86 year old mom has been having erratic behavior all of a sudden – after a series of traumatic incidents, such as my dad going into hospice, her caring for him relentlessly, then being hospitalized herself with vertigo, etc. My concern over her meds as well as possible neurotoxins affect from fumigating their house this past fall (ants infestation) has me checking into possible external causes. A very clear and insightful post.
Leslie Kernisan, MD MPH says
Yes, quite possible that the things you mention are contributing to your mother’s mental worsening. Dementia usually does not come on “suddenly.” Good luck investigating those contributors, and helping your mother get the rest and support that will allow her brain to recover to its best capabilities.
Amanda says
is it possible to be suffering from dementia if your in your 30’s? I have been having alot of trouble with my memory, at work and at home. I get turned around, lost , and im struggling to multi task. Forgetting dates, times . I feel like my brain is literally dying. I have been to doctors they tell me its anxiety and just try to put me on a pill. NO MRI no scans nothing
Nicole Didyk, MD says
Dementia is unusual before the age of 65, and very rare below the age of 40 or 50. Alzheimer’s disease is the most common cause of dementia, and only 5% of all cases are in those under 65, although it can happen.
We usually refer to dementia that comes on before the age of 65 as Young-Onset Dementia.
Other factors can have a big impact on cognitive performance, such as anxiety, medications, recreational drugs, stress, learning differences and other brain conditions (like ADHD or Autism Spectrum Disorder for example). I’m sorry to hear that you’ve been frustrated by the response of your medical providers, and I would encourage you to keep advocating for yourself.
Susan says
Also check for Urinary Tract Infection. This can send seniors off the rails extremely quickly, especially if they’re not staying hydrated.
Nicole Didyk, MD says
A urinary tract infection can definitely be a cause if sudden onset confusion in an older adult, and if there are any other symptoms like a change in the frequency of going to the toilet, pain or burning with urination, or new incontinence, we would check a urine sample.
We always want to make sure it’s an actual infection and not asymptomatic bacteriuria, as Dr. Kernisan discusses in this article: /urine-bacteria-without-uti-in-elderly/