“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.
Amie Tworzydlo says
My dad has hepatic encephalopathy due to end stage liver disease, he is currently listed for transplant. He also has diabetes. He has gone through several episodes that have hospitalized him over the course of the past year and a half. With each episode, he takes 3 steps down and recovers 2 steps in mental function. His daily life has been significantly impacted by this condition. He can no longer buckle a belt, work a faucet, he can’t reliably run phones, or electronics. He no longer manages his finances, and is now living with us as he is no longer safe to live alone. He left a bowl of oats on the gas stove and went to bed, and he has slept for 24hr at one point. He is now losing the ability to dress and toilet himself, he cannot administer his own medications or test his sugar. When Dr.’s talk to him, he can talk a good game, he can pull the date out of the air, and he can sound competent to them with the ability to laugh and joke around with them. But in the same day, he can get mixed up and pee in my clothes hamper, or walk into the pantry thinking it’s the bathroom.
We have reached a point where we will need to provide him with some kind of health aid care while we’re at work. It’s thousands per month and exceeds his monthly income. We are not able to pay this. He owns a house and has some savings, but is not willing to part with it. I don’t think he is capable of making the proper decisions to liquidate these assets to provide care. Would trying to obtain a dementia diagnosis be reasonable here?
Leslie Kernisan, MD MPH says
Sorry to hear of your father’s situation. It sounds to me like you are concerned about “self-neglect“, meaning he’s living in a way that you think puts his health and safety significantly at risk. Also sounds like the main reason he is impaired is his end-stage liver disease and hepatic encephalopathy, rather than a permanent and progressing neurodegenerative condition such as Alzheimer’s dementia.
Self-neglect is usually pretty challenging, as it’s often hard to determine at what point it’s justified for the local court to override an older person’s autonomy and enable someone else to make decisions. If you are worried about his decisions, I would recommend bringing it up with his usual health providers and also learning more about how self-neglect and guardianship is often handled in his jurisdiction (it tends to be extremely variable from place to place). You can report him to Adult Protective Services if you’re truly concerned; what they’ll do is quite variable.
You could also try contacting your local Area Agency on Aging to see what they recommend. Local geriatric care managers and/or elderlaw attorneys may also be good sources of information.
We have a podcast episode discussing self-neglect here: 066 – Interview: Addressing Potential Self-Neglect in Older Adults.
Basically, there is no easy way to intervene. I would recommend starting by learning more about what it would take for you — or someone else — to be able to override his choices, and that will be very dependent on how things are done in his area.
Last but not least, remember that you don’t necessarily have to hold yourself responsible for the outcomes in his life. You should try to help and you should try to be there for him, but it’s often not possible to control all the outcomes and sometimes we have to accept that people we love made choices that resulted in worse outcomes for themselves.
Good luck!
Denise Howe says
Hi,
I have been having a difficult time with my husband who is 62 years old now for the last two and half years. Our lives have changed drastically. His personality has flipped for the worst. In 2016, he accussed me of having an affair in 2013 again. We dealt with this problem, and I thought it was over. So, I was totally confused. All I could do was cry. During this time, he would say things then he would tell me that he never said them. By the time February 2017 rolled around, he forgot my girlfriend of 33 years. In the moment, he could not remember her and he was totally confused. That is when I realized that something might be going on. I started to notice changes in him. He would mix up names including our children, he would leave our garage door open and the house unsecured, he mixed up things in church, and he continued with accusing me of having an affair. He is delusion. The way he processes information is not normal. He has moved out of our home which is against our spirtual beliefs. He is a Pastor in our church, and he forgets the words when he is singing in church. His friends are starting to notice changes in him. He has shared with his friends that he writes notes to remember, but he cannot find the notes. To make matter even worse, my children are starting to realize that something is going on with him. He is constantly getting dates and conversations mixed up with them. I have been trying for a year in a half to get him to go to the neurologist. His internal medicine doctor ordered a CAT Scan in June 2017 and that came back normal. He was told to go to the neurologist after the CAT Scan. He went to the Neurologist and took the memory test and left. He never saw the neurologist. He scored a 27 on the test. In March 2018, he went back to the neurologist alone, and called me to say that nothing was wrong with him. I don’t know if he took another memory test. Then, April 2018, he was diagnosed with coronary heart disease. Last month, he loss consciousness in his place alone. Then, three days later, he had a severe headache. Both incidents sent him to the ER. After the second ER vist, they referred him to the Neurologist and for a CAT SCAN. He did not go to the appointments. My daughter had a talk with him about all the problems, but he assured her that he is going to the doctor and nothing is wrong with him. My question to you is how do you get someone to go to the neurologist who doesn’t think anything is wrong? He is so stubborn, and I am worried that something serious is going to happen to him. I just don’t know what to do. Any suggestions.
Leslie Kernisan, MD MPH says
Sorry to hear of your situation, it sounds very difficult. Well, given all the changes and problems you describe, it does sound very concerning and I can’t imagine that he’d be told “nothing is wrong” after a careful history and exam. (In fact, an appropriate evaluation should solicit information from family and others, because impaired older adults are notoriously poor reporters of their abilities.)
There is unfortunately no easy way to get someone to go to the neurologist when they are reluctant or convinced everything is fine. Some families still manage to coax the person to go. Some are able to get the doctor to ask the person to come in; whether the older person complies with the request is variable. Some resort to some deceptions and/or white lies to get their loved one to the doctor. Some hire a doctor to come to the house and do the assessment, but it’s not always easy to find a qualified health provider to do this.
It is usually easier to find a geriatric care manager to hire and come to the house; they are not physicians and cannot make the diagnosis, but they often do have ideas about what can be done to move the evaluation along and address safety issues.
I also recently heard of one man who was finally able to get his older father to the doctor because the father’s driving was reported to the DMV, and he had to get a medical exam in order to potentially keep driving.
In short, you have to keep trying various things. I generally recommend trying to connect with others who have been through this, which means either other family caregivers (there are online communities) or a geriatric care manager. You could also try contacting your local Alzheimer’s Association, they have a support line and may be able to give you suggestions. Good luck!
Denise Howe says
Thank you. I will keep trying and hopefully I will have a breakthrough soon.
Karen says
Is it possible a motorcycle accident 40 years ago has put my mother into an early (she’s 65) stage of multiple types of dementia? She’s functioning mostly ok she still works but she prefers to sleep most of the time when she is home or just watch TV or be on Facebook consuming herself with what is wrong in the world. She’s very hostile she only gets along with people if they have something to offer her and if that stops she accuses them of anything like being greedy or using her and stealing from her (she called me at work to accuse me of stealing a hope chest full of Target Christmas dishes (nothing fancy or expensive) because she couldn’t find them after not seeing them for almost a year). She has always trusted me with everything and I’m always there for her when she gets sick or has a surgery I’m her youngest of 4 kids and I care so I am her nurse if she needs it. I just don’t know what is going on if it’s because I still live with her (I pay most of the mortgage it benefits us both) we have opposite shifts so rarely see each other but when we do she is fast at yelling at me for something/anything. Or if she is truly showing signs of a mental health issue. Her doctor that we both shared was helpful to talk about things I notice with mom but she retired almost 5 years ago and her current doctor is retiring too so nobody is following up on how she is after having a mini stroke several years ago. Maybe she is fine and I’m just worried for nothing and just need to leave her alone and go off on my own life like the rest of my siblings have. But I worry because she wants to retire and sell the house we have struggled for so long to keep in the family and drive around the country just her and her dog like the free spirit she always wanted to be in the 70s before the motorcycle accident and before having kids. If you have any insight I would appreciate it and am open for anything even if it will hurt my feelings that’s ok I just need to hear a perspective different from family.
Leslie Kernisan, MD MPH says
Sorry if things are becoming more difficult with your mother. If she had a head injury years ago, that can make the brain more vulnerable and is associated with an increased risk of cognitive problems.
It’s not clear from what you describe that she has developed significant memory and thinking problems, but it sounds like her personality is becoming more difficult and perhaps she’s becoming more suspicious of you. This could be caused by mental health issues (some of which can be related to having very small strokes in the brain) or could be due to other changes in the brain or even other physical health problems.
Honestly, she needs more medical evaluation. I hope you can help her get it sooner rather than later, because if she becomes more suspicious, paranoid, or confused, it will be even harder to get her to see a health provider. I have more here:
6 Causes of Paranoia in Aging & What to Do
Cognitive Impairment in Aging: 10 Common Causes & 10 Things the Doctor Should Check
For help coping with your worry and with the stress of living with her, I would recommend seeking out an online support group. There is a very active forum at AgingCare.com, where you can get ideas and also encouragement on how to set reasonable boundaries and think of your own needs while still trying to help your mom. Good luck!
Maggie says
Is there a way you can reverse the posts so that the most recent is at the top?
Leslie Kernisan, MD MPH says
Unfortunately, the current software being used for the site does not allow us much flexibility in organizing comments. We will probably eventually move to a different system, but it’s expensive and time-consuming to do so.
Maggie says
Hello. My mother just turned 88 last month. She was widowed for the second time March 2017. Caregiving my step dad depleted her but she has “bounced back” so to speak. What concerns me are several changes I see: In July 2017 I found out she had a male friend staying at her house, not by her telling me, but by a neighbor. I have met this fellow, as well as my 2 grown daughters, and none of us feel comfortable around him, for many reasons and experiences. My mom says “the good outweighs the bad”, which concerns me. For the past 2 years she cries more easily. For example when her recipe wasn’t turning out, and over who is eliminated on Dancing With the Stars. She didn’t used to cry over things like that. She is forgetting words, can no longer give me directions if I ask her where to go, and sometimes just seems a little “blank”. We have always been close. Now I have found several times where she’s lying to me or keeping things from me. I have been doing a lot of reading, I have the book by Virginia Morris you suggest. I have met with a consultant, talked with her lawyer and taken care of other business. I can’t shake my uneasy feeling. I’m half way across the country, and an only child. It’s agony. Any suggestions, insights? Thank you for this blog!
Leslie Kernisan, MD MPH says
Well, what you describe does sound potentially concerning. The ideal would be for her cognition to be evaluated, and also for you to try to ensure she isn’t too vulnerable to financial exploitation. Both are easier said than done. Regarding her cognition, there’s a whole medical aspect to the evaluation but the health providers will also need information on what she is struggling with, and how it has changed over the past few years. I have more details here:
Cognitive Impairment in Aging: 10 Common Causes & 10 Things the Doctor Should Check.
I have more on financial exploitation here:
Financial Exploitation in Aging: What to Know & What to Do
To help with the agony and uneasy feeling:
– could you go stay with her for 1-2 weeks, and carefully observe the situation? It might help to see if you can get specific about what is off.
– Can you have the consultant — or someone else with suitable expertise — meet your mom and weigh in regarding how concerned you should be?
Good luck!
Sam Gibson says
My parents are worried that my grandmother might have early stages of dementia. You provided a lot of great tips. I loved your suggestion about writing down behaviors and issues that are worrisome. Bringing these documented problems or issues to a neurologist might help the doctor when it comes to diagnosing an issue.
Leslie Kernisan, MD MPH says
Thank you, glad you found this helpful.
M.B. LEBLANC says
You are an angel. Thanks for all your help to the world.
Nicole Didyk, MD says
I agree, Dr. K is a wonderful resource and has helped many people. Thanks for sharing your kind words!
Barbara Ivey says
Just recommended this page as the best first-place-to-go for everyone with a memory concern. Thank you for your commitment to helping us make better medical decisions for our family members and ourselves. Your thoroughness and compassion comes through in every one of your articles and podcasts. Thank you for sharing your gift with the world!
Leslie Kernisan, MD MPH says
Thank you, I’m so glad you find this article helpful.
Cindy McKay says
Hi, I have believed my Mom, who will be 84 in December, has been experiencing dementia for over two years. She had been under a lot of stress with caring for her husband due to Parkinson’s. He passed away in August 2017. We had hoped her memory issues were the result of stress but they continued to get worse. In late June 2018 she moved to a home closer to us (eight doors away). People who do not see her every day do not realize she has issues. Some of the examples are: she drove to an airport which should have taken no more than 1.5 hours. It took her over five hours to arrive and she never called any of us for help. She keeps calling things the wrong name i.e. calls the microwave a computer; calls the kitchen island a work bench; calls the bar (where you sit in a tavern) “the bench”. She forgets words and may or may not come up with the word(s). I call her every night on my way home from work. She can tell me the same thing three times in a 15 minute call. She has to write herself detailed notes, often, and still forgets. She has difficulty balancing her checkbook. Could take her hours to days to figure it out. She has problems comprehending what she reads. Recently prior to having surgery they provided her with things to do to enhance her recovery. She made four copies and read the material dozens of times; marked up the copies with highlights, underlining, circling, notes on the side and she still did not correctly follow what they wanted her to do. One of the things was if she was taking two types of specific medications she needed to stop taking them a few days prior to surgery. Instead she quit taking ALL of her medications cold turkey for six weeks, including the newly prescribed and filled medications to help enhance her recovery. Two days after surgery they gave her a little test. She answered everything correctly except for who is the president of the United States. She told the doctor it was Nixon. The doctor believes she has early onset Alzheimer’s dementia. Her older sister also has it. Her primary physician saw her today and said she has been under a lot of stress and will wait awhile and see how she does. Your thoughts? Thank you
Leslie Kernisan, MD MPH says
Sorry to hear about your mother’s situation. Her symptoms do sound concerning, especially since it sounds like they’ve been going on for quite some time. Stress will make her worse, but it sounds unlikely to me that only stress would be causing this.
Doctors do sometimes want to wait and see how things evolve, although that is often because we see people and we don’t have a knowledgeable informant available who can tell us how things have been going and changing for the past 2 years. Also possible the doctor wants to wait if her cognitive tests are borderline. But then again, the symptoms you describe sound pretty significant, and unfortunately pretty typical for dementia.
It’s still important that she have a careful medical evaluation for other causes of cognitive impairment; sometimes medications or other health issues are making people worse than they otherwise would be, and if the brain is damaged, every little thing you can do to improve the function is important. I describe the evaluation in more detail here: Cognitive Impairment in Aging: 10 Common Causes & 10 Things the Doctor Should Check.
This time while waiting for a diagnosis can be very stressful for everyone. Good luck to you and your mother.
Theresa says
Hello
I don’t even know where to begin..my 87 year old mother has always lived in denial for many things throughout her life. I believe that’s her defence mechanism for stressful things raising 6 kids. She has been active and healthy until complications from a femoral bypass 2years ago left her with a terrible infection that finally made it necessary to remove her leg. This woman fought colon cancer at 83 and came back stronger than ever after having all but 8 inches of her colon removed. My brother had colon cance at the same time as well as esophageal cancer (he was also in remission for non Hodgkins.
I say this because I want to show a picture of her stresses.
Last year, 2weeks after mom had her leg removed (was home from the hospital on day 4 because she did so well!) my alcoholic sister died suddenly. She mentioned to me a few days earlier that she thought my sister was coming in her house though a window and sleeping with my mom’s partner. When I went to tell her that my sister had passed, she s remedies to not hear me and said “b” her partner was in napping for a long time and I think “D” is in there with him. My husband and I couldn’t believe what we just heard, I had to be firm with her and explain that D was dead. The very next day, I had to break the news to this lovely woman that my brother had succumbed to cancer, right after we told him about our sister. (He was dying from oral cancer His 4th cancer..he was 62 and my sister was 61.
I’m sorr this is long. Mom has believed since all of this that someone is concerned Ming in her house and using her things, sleeping under the bed, eating her food. One tine she called me at work because half a banana wa gone and she asked if I ate it. Her partne4 is fed up and I believe helps to “feed” her paranoia by saying things like “ yes, my girlfriend can drive my car but you can’t”. I had a geriatric dr assess her when she was just n rehab for her leg. The social worker was shocked when I was old her this..she said she never would have guessed because she spent a lot of time with her and saw a youthful, vibrant go getter. The cat scan came back “normal for her age”. The said she doesn’t have hallucinations but delusions and seems to be in denial. They wanted to put her on risperadol but when she saw that it was written down “to stop hallucinations, she would not have anything to do with it and told me she would not be sharing anything with me again.
She was better for a while and is walking with a prosthetic..now the paranoia has returned and she is not holding back like she did…she is leaving notes in her drawers saying “keep out whore” and making notes of everything that is missing.
I should add that recent blood work shows decreased kidney function and liver problems. And her diabetes is out of control
She will not go back to the geriatric dr because she was “labelled”. I don’t know where to turn now…her family dr is retiring and gas neve4 been much help.
Leslie Kernisan, MD MPH says
Sorry to hear of your mother’s difficulties. I can certainly see why you are concerned. Given her age and the health problems you describe, her paranoia probably reflects her brain malfunctioning due to lots of reasons happening at the same time. It’s pretty common for people to have some small vessel changes to the brain by age 87, especially if they have diabetes, plus she might have some other health issues that are worsening this as well.
I explain the main causes for paranoia here: 6 Causes of Paranoia in Aging & What to Do.
Re how to behave with her, you might want to tell her partner that trying to reason with her or bring her back to reality generally doesn’t work. He doesn’t have to agree with every false thing she says, but it’s usually possible to diplomatically address the emotion and provide some type of validation and reassurance. That is what she needs the most, a reassuring emotional connection and also a stable routine and environment.
Antipsychotics such as risperidone sometimes help with florid delusions and paranoia, but they almost never make an older person “normal”; it’s more that they can take the edge off the worst of it.
It is definitely hard to get someone like your mom to the doctor. I offer some suggestions in the last part of the paranoia article linked to above. Good luck!
Michael Dale Sipes, Jr. Ph.D. says
Why diagnosing Alzheimer’s today is so difficult—and how we can do better
I can understand the current concern with glucose metabolism in the brain and possible damage, however, in a brain that is glucose deprived, astrocytes in the brain also generate ketones that can be used by neurons. I think a more precise if not accurate measurement would be to measure the rate of adenosine triphosphate (ATP) production. ATP levels fluctuate depending on brain activity. This may be beneficial in determining abnormal brain activity or neural activity at the molecular level. Calcium, sodium, and potassium ions continuously passed through the membranes of cells, so that neurons can recharge to fire. ATP supplies the energy required for these ions to traverse cell membranes. An imbalance of these ions can cause swelling, damaging cells leading to strokes and possible the disease process of Alzheimer’s.
This brings me back to the importance of measuring Calcium, sodium and potassium levels and their relationship to ATP levels and ultimately the development of amyloid plaques caused by astrocytes themselves. The amyloid plaques that accumulate and can cause neuronal loss and damage have been reversed to a degree in mice by reducing beta-secretase. I think this may be a promising treatment in the near future along with other advances in the progression of the disease process.
Leslie Kernisan, MD MPH says
Thanks for commenting. Yes there is a lot of interesting basic science research being done on the pathology of Alzheimer’s. The kinds of measurements you describe might be relevant for research purposes — or for clinically testing interventions applied during the early pre-symptomatic stage of Alzheimer’s — but right now are not applicable to the clinical evaluation of older adults with memory impairment or other cognitive complaints.