- Short-term memory loss is a common part of aging; Dementia is not a common part of aging
- Dementia refers to symptoms that include memory loss, personality changes, confusion, and impaired thinking
- The earliest warning sign of dementia is usually memory loss, known as mild cognitive impairment (MCI)
- As MCI escalates to dementia, symptoms become more frequent and severe
- The intermediate phase of dementia brings significant changes in memory and cognitive function, making normal activities impossible
- The late stage of dementia impairs most of the patient’s functioning, both cognitive and physical
- There are different symptoms and brain changes specific to various types of dementia
- Although there is no cure for dementia, treatments are available to alleviate the symptoms
When you don’t seem to be remembering things as well as you did in the past, it can be extremely upsetting, even frightening. Facing up to the possibility of memory loss or dementia inevitably shifts your perceptions, relationships, and priorities. But experiencing symptoms of dementia doesn’t have to mean the end of normal life. Certain types of dementia can be slowed or even reversed if caught in time. The first step is to understand what distinguishes normal memory loss from dementia symptoms, and how to identify the different types of dementia. The more you understand about dementia, the more you can do to improve the outcome and preserve your sense of control.
It’s something we all have to face, but the inevitable changes of aging can still be both humbling and surprising. And while experiencing wrinkling skin, fading hair color, and mild, short-term memory loss is common as we age, severe and rapid memory loss is definitely not a part of normal aging. In fact, many people are able to preserve their brainpower as they get older by staying mentally and physically active and making other healthy lifestyle choices. Distinguishing between normal memory loss and dementia symptoms is not an exact science, although there are some clues to look for.
- Complain about memory loss but are able to provide detailed examples of forgetfulness
- Occasionally search for words
- May have to pause to remember directions, though you nevertheless don’t get lost in familiar places
- Remember recent important events, and conversations are not impaired
- Interpersonal social skills are at the same level as they’ve always been
- Frequently have word-finding pauses and word substitutions
- Complain of memory loss only when asked, and you are unable to recall specific instances
- Get lost in familiar places, and it takes you considerable time to return home
- Experience a notable decline in memory for recent events, and your ability to converse
- Experience a Loss of interest in social activities, and you may behave in socially inappropriate ways
Jake celebrated his seventieth birthday last month. His son and daughter threw a surprise party, attended by many close relatives and friends. Jake had lost his beloved wife to breast cancer five years earlier, and although this had been a great blow, he was resilient and was able to recover from grief and get on with his life. Jake was a clinical social worker who cared about his clients and had no wish to retire any time soon. He didn’t feel old.
Even so, turning seventy was scary. It sounded old. He knew that Alzheimer’s disease struck one in nine Americans age sixty-five and older. He began to worry about the possibility of having Alzheimer’s disease or some other form of dementia. He saw every glitch in memory as a warning sign. If he couldn’t remember a name, or where he put a client’s folder—and it seemed to him that this was happening more frequently than it used to— he would worry that this was “the beginning of the end,” as he said to himself. Was Jake torturing himself unnecessarily? Did Jake need to worry? Was he experiencing normal absent-mindedness, cognitive decline due to aging, or the beginnings of dementia that would develop into a diagnosed condition?
Jake didn’t have dementia. His memory and concentration might not have been as sharp as they once were, but he was not suffering a decline that impaired his functioning in any way. Normal changes in memory that are due to aging accounted for Jake’s having “senior moments,” which, in addition to occasional forgetfulness, included slower thinking and problem solving, decreased attention and concentration, and slower recall of information.
Dementia refers to symptoms that include memory loss, personality changes, confusion, and impaired thinking. Symptoms are sufficiently acute to interfere with daily life and normal functioning. Although the condition might be due to different ailments, including both disease and injury, they all involve physical changes in the brain that result in the death of brain cells.
The earliest warning sign of dementia is usually memory loss, known as mild cognitive impairment or early dementia. These are the symptoms:
- Frequently losing or misplacing things
- Frequently forgetting conversations
- Forgetting appointments, and when and where you are supposed to be
- Difficulty remembering the names of people you meet
- Difficulty following a conversation
Keep in mind however that these symptoms can accompany other conditions as well, such as Attention Deficit Disorder, and that normal aging brings some degree of cognitive decline for many people. In addition, some people remain at the level of mild cognitive impairment throughout their senior years, without developing dementia.
Ellen was a successful lawyer in her late sixties. She had always been extremely well-organized and efficient. One day, Ellen was supposed to meet a client for lunch and completely forgot about the appointment. This was the first time something like this had ever happened to her. She began to notice other changes as well, such as forgetting names and the details of conversations with clients. She had always kept a record of her professional activities, but this consisted of summarizing information at the end of the day. she now needed to write things down immediately or she would begin to forget them. She got really scared when she was speaking to a client, and when she had to ask him to repeat information several times because she kept forgetting details.
Ellen was worried about the possibility of dementia and sought medical attention. A neurologist diagnosed her with Mild Cognitive Impairment and asked to see her again in three months. Ellen realized she was no longer functioning well enough to remain in practice, so she retired. She now dedicates her time to volunteer work that does not make demands on her thinking, such as selling clothing at a local charity thrift shop. Her husband drives her to and from places, and other volunteers help if she has trouble with a task. Ellen goes back to her neurologist every three months to see if her impairment worsened. Fortunately, her condition remains stable.
In reality, Ellen was suffering from mild cognitive impairment. Her condition however was sufficiently benign, and her functioning sufficiently good, to allow for a satisfying life. She might not have been able to handle legal work, but she could still take care of herself, do housework, perform a job that made few cognitive demands, and interact socially with others.
As mild cognitive disorder escalates to dementia, symptoms become more frequent and severe. Changes take place in all of ordinary functioning. A person in the early stages of the condition might exhibit some or all the following early warning signs of dementia:
- Learning and Memory
Memory loss that affects day-to-day functioning and appears to be uncharacteristic of a person is usually the earliest sign of dementia. A person in the early stages of dementia has trouble recalling events and keeping track of appointments. He finds it difficult to follow characters in a book or film. He repeats himself, not remembering what he has already said. He loses things, forgetting where he put them. Short-term memory is definitely compromised.
- Cognition, Attention and Concentration
His everyday functioning declines because it’s hard to concentrate on ordinary tasks such as driving, cooking, running a household, and taking care of finances. Normal tasks take him longer to complete, and he makes frequent errors. For instance, he might not remember whether or not a bill has been paid. Thinking and accomplishing tasks are easier when there are no other distractions such as TV and other conversations. He has trouble completing multi-stage projects. Following conversations is challenging, especially where there are many claims on his attention, as in large social gatherings.
He has frequent trouble remembering ordinary words, often pausing during conversation to try to recall words and using synonyms for a “missing” word or name. He repeats himself, not remembering what he has already said. He makes uncharacteristic grammatical errors.
- Sense of place and space
He finds it difficult to follow directions in order to get to new places and gets lost easily, even in familiar surroundings, when not concentrating on his route. It also takes greater effort to accomplish spatial tasks such as carpentry or sewing.
He exhibits uncharacteristic behavior and traits. He is not himself. For instance, an introvert can suddenly become highly sociable. Mood swings might be a part of these changes, including brief episodes of anger or upset.
- Social Skills and Interaction
He shows a diminished ability to read facial expressions or pick up on social cues. Empathy might decrease as well.
Jon is a seventy-five-year-old sculptor, married to Imogen, a photographer who, at sixty, is considerably younger. Both are artists who had jobs to support their creative work; Jon taught at an art college, and Imogen still has a commercial business photographing weddings and other events.
Jon was always an absent-minded professor who left the details of daily living, from paying bills to cooking meals, to his more practical wife. But about two years ago, Jon began to be even more inattentive than usual. One night, Imogen arrived home late from a gig at a wedding to find him munching on candy and watching old movies at midnight; he hadn’t eaten dinner, but since Jon rarely prepared dinner, this lapse was not unusual enough to raise concern. Indeed, the changes were so subtle to begin with that Imogen didn’t notice the warning signs.
The first truly alarming sign was that Jon lost his sense of direction, which had always been impeccable. Even when driving to familiar places, he would suddenly get lost or forget where he was supposed to be going. A year and a half ago, Imogen and Jon had arranged to meet at a familiar coffee shop. Jon called her from another restaurant three blocks away to say he wasn’t sure he was at the right place.
The dementia became unmistakable last year at Christmas. Jon’s daughter and her boyfriend were going to Mexico for their winter break from college. Jon kissed his daughter good-bye and asked her to text him when they arrived. A few hours later, he turned to Imogen and said, “Where’s Jessie? Has she gone back to school?”
Because of these cognitive impairments, Jon had to retire from teaching. Imogen nevertheless says the condition is still very manageable. They took a fabulous three-week cruise to the Mediterranean, stopping at cities in Greece and Italy. Jon had a great time even though he didn’t always know where he was. He remembers the trip but thinks they went to the South of France, where he had vacationed as a young man.
One positive element of these changes is that Jon is now letting Imogen help him promote his work. Imogen was always far better at the publicity-networking aspect of being an artist, and Jon had been resistant to any interference on her part. But he has uncharacteristically agreed to let her manage publicity for him, and as a result, his work is being featured in a show at a very prestigious gallery.
Jon has enrolled in a clinical trial to test a new drug that might halt the progress of the disease. Jon is not worried because he doesn’t realize he has Alzheimer’s even though he’s been told. Whether this is a psychological mode of self-defense or a symptom of diminished cognitive ability, it might well be a blessing.
Jon’s cognitive deficits impair his normal functioning to a far greater extent than is seen in Mild Cognitive Impairment. Not only is he unable to teach, but his daily activities and his social interactions have also been affected. He might be able to have a conversation with someone, but he won’t necessarily remember what was said. He can’t go places alone, or accomplish even simple jobs such as cooking a familiar dish or going to the grocery store. Fundamental aspects of his personality have also changed, making him more agreeable to accepting help.
As dementia worsens and spreads through the brain, it gradually robs a person of function and identity. The intermediate phase of dementia brings some or all of the following changes for the afflicted:
- Learning and Memory
She has greater memory loss, especially short-term memory. She retains few recent experiences or conversations and has difficulty learning new information. As the disease progresses, she will become incapable of doing so. She repeats herself in conversation because she can’t remember what she has already said. She requires reminders and help to accomplish even simple tasks.
- Cognition, Attention and Concentration
She has increased difficulty in concentrating, especially where there are distractions such as the sound of a TV, or conversations in the background. All thinking takes longer, and she is unable to perform mental calculations, such as how long it might take to go to the grocery store. Indeed, she needs to rely on others to plan activities of daily living and to make decisions. She abandons complex projects, and even simple ones become difficult to accomplish. As the dementia worsens, she needs help with routine activities such as dressing, grooming, showering, and using the toilet. She sometimes loses her grip on reality. She might experience hallucinations, or fill in memory gaps with false information. She loses interest in the outside world and in activities she used to enjoy.
- Sense of Space and Place
She has difficulty finding her way around, even in familiar environments. This sense of disorientation might lead her to wander in an attempt to return to a place she knows. She is incapable of tasks demanding spatial awareness, such as driving or using tools. She is at greater risk of falls and accidents because of confusion about her surroundings. She might be disoriented in terms of time as well as space, and so sleep might be disrupted or follow a strange pattern (such as being up at night and taking naps in the daytime).
She demonstrates additional changes in personality. She experiences paranoid delusions, aggressiveness, agitation, and might even show inappropriate sexual behavior. She is anxious and depressed.
- Social Skills and Interaction
She is losing the ability to behave appropriately with individuals or groups. She is insensitive to social context, and so she might make statements that are unacceptable, e.g., explicit sexual information. Her concentration is poor and her inhibitions are crumbling. She is unable to participate in the give-and-take of speaking and listening that is a necessary part of social interaction.
Rachel, a homemaker, age seventy-eight, was diagnosed with Alzheimer’s disease seven years ago. She remained functional for several years, with the kinds of deficits characteristic of early dementia. But Eliot, her husband of fifty years, knows that her condition is getting worse. He can no longer make plans with her for the day because she can’t follow their conversation, not remembering that he said they need to go food shopping, or asking again and again to go to the craft store even when he told her it’s closed. Her wish to go to the craft store stems from habit, for she can no longer knit the gorgeous sweaters she used to make for friends and family.
Rachel used to be a highly social, extroverted person who enjoyed getting together with friends. But these days, when she and Eliot go to social gatherings, Rachel usually asks to leave after a few minutes. The multiple conversations confuse her, and she gets extremely anxious. The last time he attempted to take her to their weekly dinner out with good friends, an event Rachel always thoroughly enjoyed, she put her head down on the table and began to cry. From that time on, they’ve eaten dinner alone at home.
Eliot is a doctor in a family practice. He continues to work despite his age, only a few years younger than Rachel. He hires home health aides for the time he is at work, but the strain of caring for Rachel is so great that he began to ask for care for several hours during the weekend. He often catches up on sleep during this time because Rachel frequently wakes him in the middle of the night when she can’t sleep.
Rachel needs constant attention to ensure that she doesn’t get into trouble. A few months ago, she left the house to garden, and was found a half mile away wandering by the side of a busy road, trying to get home. Since then, Eliot has installed alarms to alert him when someone enters or leaves the house. Rachel can still do a lot for herself in terms of personal care and grooming, but she does need help getting dressed or she’s likely to choose clothes that are inappropriate for the weather or for a given occasion.
Recently, Eliot and Rachel watched the movie Four Weddings and a Funeral. Rachel liked the movie so much that Eliot now plays it every night. And each time, when the film is over, Rachel says, “That was a delightful movie. Thank you for showing it to me.” She has no idea that she watched this film the night before.
Rachel’s memory and cognitive function declined to such an extent that she is no longer the person she used to be, neither in terms of personality or capability. While a person with mild dementia can still participate in many pursuits, such as socializing and traveling with a companion, mid-stage dementia makes normal leisure activities, as well as work and accomplishing tasks, impossible. At this point, caring for a loved one with dementia begins to pose a significant challenge, because every aspect of her daily living needs to be supervised.
In the late stage of dementia, the signs and symptoms of intermediate dementia worsen to include the following:
- Learning and Memory
At this stage, a person with dementia loses all memory, short-term and long term. He might not be able to recognize friends and relatives.
- Cognition, Attention, and Concentration
He can no longer carry on even a simple conversation; he can’t focus sufficiently to follow or express a train of thought.
- Sense of Space and Place
He doesn’t know where he is. He lives in a timeless present.
The loved one you used to know is no longer there. He might have flashes of recognition, or of being himself, but these are rare. Many people with dementia (about 40%) also suffer from depression, which involves low mood, loss of interest in previously enjoyed activities, withdrawal from others, suicidal thoughts, and weight gain or loss.
- Social Skills and Interaction
He can no longer interact socially.
- Other Complications
The brain controls not only the mind, but the body as well. As the brain deteriorates, physical difficulties ensue. These can include impairment of movement; a person with severe dementia might be unable to walk alone. He might have trouble with physical functions such as bladder control. He will be vulnerable to dehydration, infections, seizures, and injuries from accidents or falls.
David, age eighty, is in the late stages of dementia. A widower, he lived alone for ten years after his wife’s death. He continued to work as a plumber until his cognitive decline, due to Alzheimer’s disease. He began to forget where he was supposed to go for jobs, and even when he remembered, he would often get lost on the way. David retired six years ago and appeared to be declining but still able to live at home with a few hours of help a day from home health aides to accomplish household tasks.
Three years ago, he nearly burnt his house down while boiling water for tea. Fortunately the smoke detectors functioned and a neighbor who was aware of his condition called 911. The firefighters found David in bed with a pillow over his head, trying to ignore the noise of the smoke alarms. At that point, his adult daughter, Jennifer, put him into an assisted living facility. She had to sell his house, the place where she grew up, in order to pay for his care. When all the money from the sale is gone, David will go on Medicaid in order to continue to get the care he needs.
Jennifer visits her father twice a week, but this seems to matter less and less to him. He often fails to recognize her, asking, “Do I know you?” Sometimes, however, he experiences flashes of recognition and gives Jennie the familiar warm smile she remembers so well. Most of the time, David sits there, staring into space. Sometimes he weeps. He had pneumonia twice, and Jennifer is bracing herself for the day when one of the infections he is prone to, or the disease itself, will take her father’s life. Most of that life is already gone however, and Jennifer mourns the fate of the living man as much as she will mourn his death.
Disease has impaired most of David’s functioning, both cognitive and physical. His is slowly losing his identity, and his sense of who he is. This is the tragic phase of dementia, the hardest to watch for loving friends and relatives. It is likely terrible for the afflicted as well, as the presence of depression in many sufferers indicates. Unfortunately, they cannot tell us what it is like for them. The disease robs them of the capacity to feel the love and empathy that would make this final journey less frightening and lonely.
The above descriptions of dementia reference a process in many different conditions. Jon, Rachel, and David were all afflicted with Alzheimer’s disease, and their dementia symptoms are characteristic of the disorder. There are other types of dementia that have characteristic symptoms in addition to memory loss, cognitive impairment, and loss of function. While all forms of dementia involve the death of brain cells, some of these conditions have distinctive signatures neurologically, and they manifest different symptoms, at least to begin with. As these conditions progress however, the differences between them appear less distinctive. All ultimately involve loss of the ability to think and function.
- Brain Changes
Plaque, which consist of abnormal amounts of a protein called beta-amyloid, builds up between brain cells, thereby impairing the connections between cells that are necessary for brain function. The plaques likely trigger an immune response that kills these disabled cells. Cells also begin to die as a result of twisted strands of another kind of protein, known as tau, which is normally neatly arranged in parallel lines within brain cells. When these strands begin to twist, they block the passage of vital nutrients to cells, which results in cell death. Plaques and tangles spread through the brain in a predictable pattern, another signature of the disease. In advanced Alzheimer’s, the cortex shrivels up, particularly in areas related to memory, and the fluid-filled spaces known as ventricles become larger. Alzheimer’s literally shrinks the brain through cell death.
With Alzheimer’s, memory loss is one of the first notable symptoms. There is also clear evidence of a decline in the ability to learn. If a genetic tendency is present, known from family history or genetic testing, clinicians are likely to make an early diagnosis.
- Brain Changes
This is the most common form of dementia after Alzheimer’s disease. Diseased blood vessels cause decreased blood flow to the brain, resulting in the death of brain cells.
Those with the disease are somewhat more prone to personality changes than those with Alzheimer’s disease; most commonly: increased irritability, aggression, and agitation. But such changes are also seen in those with other kinds of dementia.
- Brain Changes
Lewy bodies are abnormal clumps of protein known as alpha-synuclein protein that develop inside nerve cells, impeding function.
In addition to general symptoms of dementia, those with this condition are more likely to experience hallucinations and intense fear than those with Alzheimer’s disease or types of dementia.
- Brain Changes
Frontotemporal dementia can refer to a number of different disorders that cause degeneration in the frontal and temporal areas of the brain (the front and side areas of the brain). It used to be called Pick’s Disease, but this now refers to a specific form of the disorder. What is usually meant by frontotemporal disorder is the behavioral variant of the condition. As in may other forms of dementia, abnormal protein builds up in the brain, and this impairs cell function and results in cell death. Frontotemporal dementia can involve three different proteins, including the tau seen in other forms of dementia.
Behavior problems and personality changes are usually the first indicators of the behavioral variant of frontotemporal dementia. Most notably, people lose their ability to adjust or control their behavior to suit social context. Other signs include a lack of inhibition, apathy or inertia, the loss of the capacity for sympathy or empathy, compulsive behavior, and changes in patterns of eating. Memory and learning are not affected until later in the disease. Frontotemporal dementia usually strikes people in their fifties, although it can afflict those both younger and older.
- Brain Changes
Parkinson’s Disease is a disorder that begins in parts of the brain affecting movement. As it spreads, however, it leads to a form of dementia that affects all aspects of cognition including judgment, attention, memory, and concentration. As with other forms of dementia, protein buildup that interferes with cell function and leads to cell death is the culprit. In both Parkinson’s disease and Parkinson’s dementia, Lewy bodies, alpha-synuclein protein, form these deposits. These disorders and Lewy body dementia might all be due to the brain’s inability to properly process this protein.
Most of the symptoms of Parkinson’s disease involve the disruption of motor functions (muscle and movement). However, lack of energy, pain, and changes to mood and memory can also occur as part of the disease. And some people with Parkinson’s will eventually experience dementia as their disease progresses, including loss of memory and other cognitive functions. The National Parkinson Foundation estimates that fifty to eighty percent of people with Parkinson’s disease will eventually develop Parkinson’s dementia.
- Brain Changes
Pick’s Disease specifically affects the frontal lobes of the brain, i.e. the foremost part. Like Alzheimer’s disease, it involves a destructive buildup of proteins, tau proteins in this case. But this form of tau, called Pick bodies, is different from the tangles found in Alzheimer’s. Pick’s disease is also known as the “language variant” of frontotemporal disorder.
This condition usually begins with difficulties with language, especially aphasia, the inability to speak and think of or understand words. Other speech difficulties might include hesitant speech, stuttering, ungrammatical speech, and difficulty articulating words. This impairment distinguishes it from other frontotemporal dementias, in which behavioral symptoms and personality changes are often the first signs. However such symptoms usually develop as the disease progresses. Pick’s Disease is a rare form of dementia, accounting for only one to five percent of all dementia cases, but one that can strike people as young as twenty. Usual onset is between forty and sixty years of age.
Although there is no cure for dementia, treatments are available that alleviate symptoms, and the earlier the condition is diagnosed, the better such treatments work. For this reason, it’s important to be able to recognize the warning signs of dementia. Ignoring symptoms won’t make the condition go away.