“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.
MWS says
What is another option for when the very long term family physician – seemingly – does not want to do a dementia test/evaluation? My mother is almost 90, has been exhibiting memory loss, mood changes, forgetting/seeing things, paranoia, has had strokes in the past 10 years and other family/friends are saying, she is not right and needs help. I went to her doctor – he said he did not see it, her ‘tests’ were normal and grudgingly scheduled a MRI which showed she had just had a small stroke…and he did not want to do anything else further with her.
Nicole Didyk, MD says
This must be a very frustrating situation for you and your family. The symptoms you’re describing could be related to dementia, but other conditions like depression, infection, or medication side effects should be ruled out as well. And “just” a small stroke can warrant steps to prevent further stroke change, like reviewing blood pressure, cholesterol levels, the need for aspirin or other medications, and so on.
There can be many reasons why a primary care provider is reluctant to address a cognitive issue: not wanting to deal with driving or other thorny issues, a desire to preserve a long-term patient-physician relationship by avoiding the delivery of a painful diagnosis, projecting their own fear of dementia onto a familiar patient, therapeutic nihilism (a belief that nothing could be done even if the diagnosis was made), or other reasons.
Clarifying the degree of cognitive impairment is an important step in planning for an older parent’s future care, so persistence may be needed. In the meantime though, seeking help to accommodate a parent’s functional gaps, whether they’re due to dementia or some other cause, doesn’t have to wait for a diagnosis. I advise family members who are worried about an older parent’s cognition to get in touch with the Alzheimer Society or other social agencies to explore local resources.
Very concerned family members says
I found your post and I am writing this comment to you right now in hopes to receive a response. I have a 76 year old cousin who has nowhere to live has been living with different church members for the last year. She was a teacher for a long time and also took care of young children. She was laid off during the pandemic. The various families she’s been living with had her watching their kids in return for room and board. I don’t know what has happened recently that caused the family she’s with right now to take her to the doctor but myself and other family members have certainly noticed changes in her behavior over the past 2 years. The doctor these people took her to recently did diagnosed her with early onset dementia. My cousin has one child who is 30 years old. Unfortunately he is not the most capable of making the good choices or capable of even knowing where to go to look for help with his mother. He is an alcoholic with a long history of substance abuse issues as well as a long history with anxiety disorder which he is in treatment for. Hence the reason why I am attempting to start doing some research on his behalf. In an effort to attempt to assist and guide him with his mother’s best interest in mind. My cousin’s son is in San Diego. He has recently found a job, but his past work history is spotty at best. He has essentially relied upon his mother for financial assistance his whole life and this has resulted in my cousin to be broke. She could no longer afford rent, which again is why she has been taken in by different families from her church. Myself, immediate family, as well as extended family are all in the Bay Area and unfortunately nobody is able to take my cousin in. If I could i would myself, but I am not in any type of position to take this on. The only thing I can do, is do as much of the research and phone calls as possible to help my younger cousin with his mother. I am looking for resources, such as an advocate, Medi-cal or Medicaid information (ie. What assistance can be provided during early onset dementia). This article was incredibly informative and it’s clear that you genuinely care. I am going to pray to receive a response from you. as it stands right now the family that has currently allowed my cousin to stay with them wishes to drop her off at her son’s house in San Diego in 2 weeks. The son, lives in a studio apartment, in what sounds like a college dorm like apartment complex where the residents have all tested positive for coronavirus, and have already “recovered “. In speaking to him,
He, himself, nor the residents of his apartment complex are taking the current pandemic seriously at all. (Not social distancing, not wearing masks or gloves, partying at the pool daily with 50 or 60 other idiots.) In speaking to him last night, it is clear to me that the only plan he has thus far is to do nothing to prepare for his mother’s arrival. He literally told me that when the church family gets to his apartment complex with his mother, he is going to parade them through the complex, past the raging party by the pool, to his pigsty studio apartment with his cat and dog and his hope is that the church family will be so horrified by all this, they simply cannot leave her there with her son!! I have already told him that no matter what, they are leaving her with him. These people are not related to us in any way. They have 3 small children of their own. I am truly afraid that my older cousin is going to die as a result of her son’s complete lack of concern about the pandemic with respect to his mother’s arrival. It is clear to me that he doesn’t want to change his own lifestyle in any way, no does he want to take on this responsibility. I will do anything and everything I can in regards to leading the horse to water. Please, any direction or resources you could possibly provide me with would be greatly appreciated. Please help me.
Nicole Didyk, MD says
Sounds like a very complex situation.
The first thing I do when I am faced with such a dilemma in my practice (which is in Ontario, Canada), is find out:
1.What the older person’s wishes are.
2.Whether the older person is capable of making a decision about where to live.
It may be that a person like your cousin is capable of making a decision to live with their son, and is able to appreciate the risks of doing so, even if the person is living with dementia.
This may be the case, especially if a person has gotten themselves into financial difficulties in order to support an irresponsible child. Capable people are allowed to make bad decisions.
Determination of capacity is usually done by a doctor or by a specially trained capacity assessor. Family members can apply for a capacity assessment, and it probably depends on the state or province that they live in as to how to go about that.
If a person isn’t capable of a shelter decision, then their substitute decision maker would make that decision for them.
A social worker can usually help to navigate these services and point families in the right direction.
Tim says
My mom’s 73, and since the middle of 2015 I noticed her starting to have memory issues, wild mood issues, emotional outbursts over things that never used to bother her, her style of speaking has changed some, she’ll forget things she did two hours ago, she sometimes stumbles over her own feet and will bumps into walls, things that were always familiar she now sometimes says has changed, despite those things not changing, she’s gotten lost driving around her home down, she once drove in the opposite direction of where she lived and was convinced she was going the right way, etc, etc.
With the urging of us kids, she went to get evaluated, and apparetly the doctor said she’d fine. Needless to sayt, we’re stunned. In our estimation, she has lost about 25% of her short-, mid- and long-term memory. She’s reguarly forgets how to use the e-mail program she’s been using for nearly 20 years. She forgot how to open files in Wordperfect and ended up over-writing some of her writings that she saved over the years (Luckily, I had made backups for her) she’ll fill bird feeders at noon, return home at 2PM and thank whoever is home for filling them. She claims someone keeps changing the angle of the flagpole holder outside the frontdoor because she said that position doesn’t look right, she become irate and starts yelling and pounding her fists on her legs if we take a road that has a lot of traffic (traffic had never bothered her prior to 2015. Then, weeks later, we’ll take a different route and mention to her that we made sure to avoid traffic, to which she’ll respond “I don’t mind traffic at all.”
She is a pathological liar, drama queen, and something of a hypochondriac. She also used to be very good at Scrabble until 2017, at which point even trying to let her win she couldn’t win. There are too many examples. She had issues balancing her checkbook, she sometimes has problems following any kind of story in a casual setting of 3-4 people. Often her response to something you’ve mentioned to her doesn’t remotely fit what was said; it’s as if she’s just saying something to say something. We’ve lost track of the number of times we’ve responded to her with “We’ve never said anything about what you’re talking about. Where are you coming up with this stuff?” She has said a few times over the past five years that she hears voices in her head and talks to them. Her mother and father had dementia and died from it via Hospice intervention at home. She claims she had two mini-strokes around May 2015. She twice said she had memory issues and that’s why she uses Post-Its and a daily planner for everything she does. She has Post-Its all over the place for daily things she has to do. If you ask her what she has planned for the day, most times she can’t tell you without looking at her daily planner. She developed OCD about eight years ago. She was hooked on NyQuil for at last four years because she said it helps her sleep. She also takes Tylenol PM pills. Recently, we found she’s been putting Baileys in her iced coffee during the day and going through a large jug every week. We’ve repeatedly urged her to stop with the medicine and alcohol because it will only had to her memory problems, and she agreed to stop using them.
I’ve heard that even people with onset-Dementia can be fine outside of their “safe” environment because they’re more guarded than around their own home or family. I find it impossible to believe a thorough evaluation of her memory was done if it only took 30 minutes and since none of her children were involved to provide insight into what’s been happening with her. She has a bi-polar personaility and gets depressed very easily. She’s still able to function fine despite the known issues, but we were hoping the doctor would find something to possibly help, in case it’s not dementia but something else that’s actually treatable. Not sure what steps to take now. Thank you.
Nicole Didyk, MD says
Thanks for sharing your story, and what a story it is! In my work as a Geriatrician, I often hear about changes in memory performance, function, mood and behaviour, and even personality changes, such as the ones you describe.
There are so many complicating factors here including the pre-existing personality issues, substance use (alcohol and over-the-counter sedatives), and potential strokes. As Dr Kernisan indicates in the article, memory testing is just one part of diagnosing dementia, a thorough assessment would look at all of those other issues as well. This is often more than can be done in a primary care provider’s office so a referral to a Geriatrician would be a great idea. You’re right that input from collateral information sources, like adult children is invaluable in an assessment for dementia.
It can be frustrating but when there are all of those issues in the mix, we often have to try to clean the slate and re-evaluate when the alcohol and OTC’s are gone.
Ginta Gorbane says
Hi my partner who is 81,had a lobotomy at age of 26,since then he had been on diazepam 30mg a day up till 10 years ago he went down to 10mg a day,a recent visit to the doctor to get a note to change his will because of the arguments in the family,stressed he didn,t pass the memory test,the doctor did the blood test and a brain scan,which showed of being atrophy of hippocampi,so he was referred to memory clinic and on the day of the long test he scored 54 out of 100,the thing is al the tests we have done at home he passed,he said during the test which was too long he was nervous because he didn,t like the nurse as she was pushing him,didn,t hear most of questions as she woudn,t repeat them,we were present during the test and I agree,I can,t see anything wrong with him,maybe I live with him,do you think that long use of diazepam can be mistaken for dimentia,thank you
Nicole Didyk, MD says
Sorry to hear about what sounds like a pretty stressful experience. The diagnosis of dementia is not just based on a test score or a scan, but also the story about how a person’s brain performance has changed from a previous level of function, and how that change affects day to day life. The tests that we do in an office aren’t supposed to be used as a “pass” or “fail” scenario, but add data to the overall assessment of a person’s brain health.
You are correct that testing conditions can affect a person’s score on a test, and stress can definitely impair test performance. Ideally, memory tests should be given under the most standardized conditions possible.
And it may be that long term use of medications like diazepam does increase the risk of developing dementia, and that current use of diazepam could also make a person seem more impaired than they are.
All of this to illustrate that dementia diagnosis is not straightforward and it’s reasonable to ask questions about whether the tests were done in the best way they could have been, and what information was used to arrive at the diagnosis. And remember that just because a person has a dementia diagnosis doesn’t always mean that they are not capable of making decisions, even important ones.
SL says
Hi
My dad had what appeared as sudden onset of Anomic Aphasia ( both expression and some issues with reading / writing ) . He also experienced some autobiographical memory losses , although this was fragmented . There does not appear to be any ST memory issues and his level of functioning does appear ok in terms of ADLs and he can still manage bills , although does need some assistance . He is also physically fit , no imbalance or weakness
He attended a Neurology Appointment (TIA emergency clinic) to rule out a TIA / CVA which resulted in a MRI scan and a very brief MME ( 10 questions )
The scan should moderate SVD – the Neurol list was vague and informed that she thought the issue was vascular , although did not mention bleeds infarcts etc .
I requested a referral to the memory clinic as in view of symptoms thought it was important not to rule out Alzheimer’s, as medication may help , although she said it wouldn’t as the problems was vascular. She increased his statins and added a different aspirin
My dad is 84 and my understanding is that Alzheimer’s is difficult to diagnose or in this case discuss on the results of a scan .
Would it be prudent to Perdue more vigorous testing via the memory clinic ?
Many Thanks
Nicole Didyk, MD says
Hi SL. Looks from your IP that you are in England, so I am not sure what a memory clinic looks like there. It must be frustrating to be wondering about the type of dementia and whether treatment would help, but it can be very difficult to sort this out short of a brain biopsy, which we don’t really do.
In Canada, neurologists are very experienced in stroke care, but less so in dementia diagnosis, so seeing a specialist in dementia would probably offer the opportunity to ask questions about what is going on and how to move forward. They have Alzheimer Society in England as well, which can be an excellent resource.
Sharon says
Thanks for your article. Very informative.
Our problem is our mom probably has dementia but refuses to acknowledge it or get any help. She is 78 and has always been negative and sticks her head in the sand when there is a problem. She has had a knee problem since 2013 and refuses to get it checked out because she is afraid of the prognosis (she probably needs a knee replacement). She still lives alone but since she was let go from her job a few years back (probably because she was making mistakes because she was forgetting things), she’s been depressed and stays in her apartment alone all day just reading. She still drives though. My sisters and I have tried to help her but she refuses help and will stop talking to us for weeks if we bring up the subject.
My sister and I just saw her the other night and she’s markedly worse than the last time I saw her. Asking the same questions, not being able to hold a train of thought and just not being involved in the conversation. Not her old self. She might have anosognosia. She was telling us about her cousin and how she is developing dementia (she told us the same story twice in the span of the evening) but seemed to not have any clue that her own memory was so impaired.
My sister texted my mom the next day and asked her if she would be willing to go to the UCLA geriatric center to get evaluated. My mom never texted her back, which means she is mad at my sister for insinuating that she has a problem.
What can you do for a parent who refuses to admit (or know) that they have dementia and refuses to go see a doctor?
Leslie Kernisan, MD MPH says
Hi, I’m sorry for the delayed reply, we had a glitch in our system and we stopped getting comment notifications for a while there.
I’m sorry to hear of your mom’s situation. Unfortunately it’s fairly common, and it can be hard to work through it because there are usually no easy solutions. I cover approaches to try in this article: 6 Causes of Paranoia in Aging & What to Do
You should esp read the section “Tips on following up on safety issues and memory problems”, which includes suggestions on agencies you can call for help.
We also have a special membership program to provide families with ongoing support and guidance as they work through these situations: the Helping Older Parents Membership Program.
Your mom is very fortunate to have you looking out for her, even though it sounds like she’s unable to appreciate it right now. Good luck!
Paul says
Hello! Thank you so much for taking the time to comment on all of these posts.
I am concerned for my Dad, he is 79. He had a broken neck from a car accident about 10 years ago, and he’s never really been the same. I think part of it is just general depression at his decline in abilities. He still gets around and is reasonably active, but he is a family practice MD that is no longer able to practice. He drives, he golfs, and putzes around in the yard. We moved him and my mother into a single level townhome 5 years ago, to be closer to us.
He is diagnosed bipolar and takes lithium, and drinks too much, and has a bit of that doctor syndrome where he knows everything (no offense) and has been difficult to convince to get an evaluation. I don’t think he tells the truth when he talks to his doctor anyway, that’s according to my Mom. I have said I will take him for a mental health evaluation but she just says there is no point. Can he really trick a doctor?
Anyway, I don’t know if it’s just getting old, at 79 should he remember everything? He will sometimes tell me the same thing 2-3 times in a visit, and he’ll often tell old stories, which are charming, but he doesn’t seem to remember that he told the same 3-4 stories last time I saw him. But at the same time, he remembers names and dates, he remembers all of his grandchildren’s names even though he doesn’t see most of them very often. He still drives but not well, he still golfs but not well, and he doesn’t eat very much anymore and has gotten thin. He’s crankier than he ever has been and he can’t hear very well, and isn’t great about wearing his hearing aids. My mom cares for him and has noticed his decline more than I have, but as previously stated, she doesn’t think he’ll go see a neurologist. If he isn’t going to see a doctor for an evaluation, what can we really do? I read some of these other posts and I think he is pretty good shape compared to some of the stories, but he just isn’t what he once was. Any advice?
Leslie Kernisan, MD MPH says
Thanks for posting the question and no offense taken re “know it all” doctors, there’s something to it!
So…he may well be cognitively declining. Repeating the same story over again is potentially a symptom, but usually people who are declining will also manifest other symptoms that are on the “8 behaviors” list.
It’s possible that his hearing loss is a factor; if he won’t wear the hearing aids, you could look into using a Pocket Talker for some conversations. We’ve just recently posted an article on hearing loss, it’s here and explains the Pocket Talker: 4 Key Things to Know About Age-Related Hearing Loss.
Drinking “too much”, as you also know, is probably not helping matters, but it can be very difficult to persuade an older person to stop, especially if they are cranky or cognitively deteriorating. And, people with a history of mental illness can be harder to evaluate.
He could fool a doctor in that many of them can’t or won’t go in-depth and really make an effort to assess what is going on cognitively. This is why I recommend families prepare for the visit.
I’m afraid that the situation you describe is pretty common, and generally has no easy fixes. In principle, he should be medically evaluated, since you’re concerned. In practice, it can be hard to get an older person to the doctor and then the doctor may not do the evaluation that we’d recommend.
For these situations, I generally recommend trying to get the person evaluated. It can help to frame the evaluation as a way to help him get something he wants out of his medical care, like a check up to help him stay independent for longer.
Otherwise…since these situations are difficult and tend to drag on for months (or years), we have started a Helping Older Parents Membership community, to support people like you in working through these situations. To learn more, see here.
Good luck!
Becky Eidson says
Dr. Kernisan, I have an elderly (88 yeas old) Aunt who has lived alone since her mom died in 2005. My Aunt has never married and no children so I am her next of kin.
She lives a state away from me so I’m on the road an average of once a month and sometimes twice to check on her. She has been on the dementia journey for a couple of years. Her friends and I have been working together to keep the “train on the tracks” so to speak , but it is getting increasingly more difficult. My main problem is that I can’t get her to the doctor for a diagnosis. She is physically healthy and sees no need to go. The only medication that she takes is synthroid. She recently changed doctors within the practice so they refilled her prescription for 90 days as a courtesy but she doesn’t take them regularly and they are lasting longer than the 90 days! She is convinced that all she has to do is call the pharmacist .
I honestly don’t know how to get her to the doctor. I’ve set up an appt. in the past and drove her there only to have her refuse to get out of the car, even after the doctor went to the car and tried to coax her out!
I am her POA but that means nothing unless she is compliant, which she isn’t. In fact she can be quite combative and easily agitated. I’ve been keeping records of her behavior with input from other close to her as well as my and my family’s observations.
Do you have any suggestions on how to get her evaluated? And IF I can get her to the doctor what happens if she refuses to take any of the cognitive tests that we’ve requested??
Any suggestions are welcomed. Thank you
Leslie Kernisan, MD MPH says
Wow, your aunt is so lucky to have a devoted niece like you! What you’re describing is pretty common, and unfortunately, there are no easy solutions. If you have enough documentation of the problems she’s been having over the years and is having now, she could probably get a diagnosis of “likely dementia” just based on the health provider talking to her and some labs demonstrating that it’s not an obvious metabolic disturbance or thyroid issue.
Could you get her to go if you tell her it’s absolutely necessary for her to get her synthroid refilled?
If she won’t go to the doctor, you could try to see if there are any health providers in her area who will come to the house and do an assessment. This is sometimes available if you pay out of pocket; some of these providers are physicians and others are psychologists. A local geriatric care manager often knows which health providers provide this service.
Otherwise, I would recommend starting to plan ahead for what you’ll do when she needs more care and supervision. In some states, a POA is not sufficient to place an older person in a supervised living situation; you should find out what is required in your aunt’s state. If she is refusing to address her health, you could also try calling Adult Protective Services in her state. Sometimes they are able to request or organize further evaluation of an older person’s mental condition.
I’m sorry that it can be such an uphill battle to get an older person the help they need. Good luck!
Paula Whitman says
My husband is 63, retired from Public Safety x 3 years. In the last 6-9 months I have noticed changes, now both our Adult children that don’t live with us have separately expressed concern about things they have noticed. Struggling for the right words, sometimes never finding them..so we end up almost playing charades trying to help him with the word. Long term memory is so accurate back like 40 years ago and beyond. Short term memory is horrid, sometimes no recollection of conversations we had an hour prior. If it is a conversation from the day before, very common for him to not remember any of it…. We went to a neurologist, he asked him 7 questions, literally who is the president, what city are you in etc….I get it that can reveal issues in someone much more elderly. Of course he got the answers correct. I brought along notes of some examples of what we as a family have observed. Calling street names here in our development street names from a City we lived in 30 years ago, calling our dogs by the name of dogs we had 20 years ago…Dr. said he answered the questions correctly and he is fine!!! I left feeling like a fool, yet the bizarre behavior continues, and my husband now tells me I am the “crazy one”. If something is going on with him, my gut tells me it is, I wanted to catch it early. During the visit with the Dr. he handed my husband a piece of paper said fold it in fours, and hand it back to me with your right hand. He folded it in half and handed it back with his left hand…. ugh. I guess now I just wait for something more significant to happen, before getting help in addressing it. The “kids” are so concerned and feel I should take him to another Dr.
Leslie Kernisan, MD MPH says
Sorry to hear of these issues coming up. Honestly, I think it sounds concerning and worthy of adequate evaluation, and what you are describing does not sound like adequate evaluation. You may want to try seeing a different doctor. The alternative is to ask the current doctor some extra questions, or ask him specifically to go through what I list in this article: Cognitive Impairment in Aging: 10 Common Causes & 10 Things the Doctor Should Check.
Developing a new poor short-term memory at 63 is not “normal aging”.
I will say, however, that when memory is affected, it’s almost always short-term memory, so maintaining a good memory for what happened 40 years ago is not surprising, and does not mean he’s ok. Good luck!
Joyce Swain says
My father will be 82. He doesn’t remember what he eats from day to day. He still takes care of his personal hygiene , he still manages his finances. He tells me when he doesn’t remember who I am then take him to the dr. Is almost as the previous day is wiped out. I”m worried , he’s not. I moved back home the first of the year. Am I correct in worrying ?
Leslie Kernisan, MD MPH says
If he sometimes does not remember who you are, that does sound worrisome. I would recommend evaluating him specifically for the 8 behaviors that indicate memory and thinking problems. I also have more information on what a cognitive assessment should include here: Cognitive Impairment in Aging: 10 Common Causes & 10 Things the Doctor Should Check. good luck!