Mohan is a family physician and a Postgraduate Associate Dean working in the UK. He has a keen interest in self-regulated learning.
Read Chapter #1: Assessment
- Caring for a Person with Dementia : Top Tips for Car...
In the last chapter, we looked at the dilemma the caregivers, relatives or friends face when a person close to them starts to display symptoms of dementia. We talked about how to ensure we negotiate an early assessment.
Dementia is not a disease. It is, what we call in the medical parlance, a syndrome. A syndrome is a collection of symptoms and manifestations that can collectively represent a condition.
Dementia may be the presentation of many diseases and it may also be mimicked by many other diseases that are reversible.
It is, therefore, vitally important to get the right diagnosis so the physician can plan the right treatment and management plan. It is also important to exclude or confirm serious conditions that may present as dementia and to isolate those other diseases that are readily treatable.
Unlike many other conditions, diagnosing diseases that cause dementia is not easy. It needs a process of careful history taking, thorough evaluation, and accurate diagnostic tests. As many conditions start gradually, it is not unlikely that a person may get diagnosed more than 6-12 months after the onset of the condition. A period of observation is likely if the symptoms are very mild.
The Key Features of Dementia Syndrome
In the case of dementia, each person will experience the symptoms differently. This is based on their lifestyle, their pre-morbid personality, their surroundings, their employment and their family life. However, the main three features that denote a dementia syndrome are:
- A decline in memory, communication skills, and logical reasoning
- A gradual decline in skills required to function in daily life and activities
- Aspects of confusion and mood disturbance associated with this
This is the most common type of dementia affecting over 60-80 percent of people with dementia syndrome. This has an insidious onset with an early middle and late stage. Loss of memory of recent events, forgetting names, as well as apathy and low moods will be early symptoms. A brain scan typically shows deposition of plaques (beta-amyloid protein) and tangles (protein Tau) that cause brain degeneration
Second most common. Often a result of atheroscelrosis/aretrisclerosis , multiple 'mini-strokes' that affect the blood supply of the brain and cause mini- infarcts. It was previously called 'multi-infarct Dementia'.
This is characterized more by impairment of completing tasks and judgement as opposed to recent memory loss on Alzheimer's. Brain scan will show vascular changes and infarctions.
Lewy-Body and Mixed Dementia
Another presentation is a condition called Lewy-Body Dementia. But more often than not in the elderly you see a mixed picture with a combination of all of the above. This is called mixed Dementia.
While making these distinguishable is important for specialists in their academic curiosity and perhaps consideration of drug trials, for the lay person it does little to vary the actual management plan and treatment.
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Other Types of Dementia
Dementia can also be a part of the middle or late stages of Huntington's disease or Parkinson's disease, can be caused hydrocephalus, and can be a major presentation of vitamin B1 deficiency in chronic alcoholism (Wernicke-Korsakoff's).
Once they have done this and they have eliminated transient conditions that may cause memory problems and confusion, the primary care physician/GP will refer the patient to one of the following (depending on the healthcare network in your country and the local arrangements)
- Geriatrician/Gerontologist/Elderly Care Specialist
- Dedicated dementia/ memory assessment clinic
What Will the Physician Do?
The checklist in the previous chapter will help the affected patient and the caregiver to prepare for the doctor visit. A primary care physician is the best person to do the preliminary assessment of symptoms of memory loss. They will do the following during the visit/appointment:
- Record your medical history including previous illnesses and medications
- Record your personal history: work, home, lifestyle, habits
- Take a detailed list of symptoms presented objectively
- Assess your memory using a validated tool
- Physically examine you, including a basic neurological examination
- Order baseline tests: blood profile, urine analysis
One of the main problems in dementia is the person suffering from these symptoms may not always be the best person to make the appointment, give an accurate history and get the best out of a doctor's visit due to obvious reasons. Equally, we need to respect the dignity and confidentiality of the person attending the Doctors as they may want to do this on their own especially in the early stages.
It is very hard to be objective when it is memory related symptoms in giving history as you may overestimate or underplay the symptoms to the doctor. It is not uncommon in conditions of stress, busy life, tiredness that we all have memory lapses—as we said in the previous installment, it is important to triangulate facts and look for consistency, frequency, and periodicity.
Ideally, an accompanying family member is best placed to give accurate information, remember details of the plan for assessment and also make necessary appointments for follow-up and further tests. The person affected, if they attend on their own, may forget details and may even make false statements on their return from appointment to their family, hinting everything 'was ok'. We need to be wary of this.
While it is important to get as much an accurate diagnosis as possible, some of the more specialized diagnoses are merely academic exercises. The specialists may not always be able to narrow down to a specific, but they may be able to determine the following:
- Is this reversible or incurable?
- Will drug treatment help to slow down progress?
- Will drug treatment help with symptoms?
- Is the diagnosis sufficient to plan the future?
A quick test for memory assessment:
- Three objects are mentioned to the person. They have to remember and repeat back the three objects after a few minutes of talking about another topic.
- They have to draw the face of a clock indicating the times given by the examiner.
Medical Assessments to Diagnose Dementia
There may not always be time for the physician to explain all the tests they are ordering and what they are hoping to find from it. Here is a quick list of tests commonly done and the reasons for them to help you understand the sheer maze that is the medical assessment (no wonder we have to train for so many years!)
Note: A physician may not always perform all of these as based on the history given and other medical information they may go straight to specific tests.
- A Full Medical History: review of major diseases and medications
- A Physical Exam: BP, pulse, hearts and lungs overall appearance, Weight, BMI
- A Neurological Exam: Reflexes, coordination, muscle movements, sensations, and fundoscopy.
- Mental Status
- Memory Exam: One of the key tests in the initial diagnosis of Dementia is to perform an objective memory assessment using a validated tool (MMSE). After a series of questions they patient is scored out of 30. 20-24 will indicate possible mild dementia, 13-20 moderate, and under 12 severe dementia. Note, the test is validated but also needs corroborating with other tests/ exams.
- Mood: As assessment of mood is done using a series of questions about sleep, general mood, irritability, judgement, attitudes to things etc.
- Brain Imaging: An MRI (Magnetic Resonance Imaging) , a CT (Computerised Tomographic) scan or a PET (Positron Emission Tomography) may be performed to assess the brain structure.
Conditions that can be mistaken for Dementia
Medications: Certain medications or a combination of medications can affect memory and mood.
Metabolic syndromes: Hypoglycemia can cause confusion, memory problems and lack of judgment. Low thyroid hormone can cause apathy, memory problems, depression and sluggishness.
Dietary deficiency: Chronic deficiency of Thiamine (B1) can cause memory problems, as do B6 (a disease called pellagra), and B12. Even dehydration can cause confusion and metal impairment.
Brain Tumors: in very rare cases a slow growing tumor in the brain can affect memory, personality and mood. A scan will pick this out.
Hypoxia: Low levels of oxygen due to surgical accidents, poisoning, heart and lung diseases such as Emphysema, heart failure can also lead to this sometimes.
- Diagnosing dementia may be painstaking and sometimes long drawn out due to late presentation, patient not being motivated to go to the doctors, and carer/family hesitation to 'label' the person. This could prove a problem.
- Early consultation helps to eliminate other reversible conditions.
- Always be prepared for the doctor visit with full medical history, all the drugs or supplements you take, diet or other information
- The tests form a package and should not be taken out of context, a physician is best placed to interpret them. Don't try to do a test in isolation and start panicking. Each test adds to the final conclusion.
- The mental state examination is also limited by a person's literacy level, language skills, and vision. One has to careful in jumping to conclusions.
- An accompanying carer/ family member is a key resource in aiding the patient in their diagnosis.
In the next part, we will look at what to do after the diagnosis and how best to plan the future.
This content is for informational purposes only and does not substitute for formal and individualized diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed medical professional. Do not stop or alter your current course of treatment. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.
Nancy McClintock from Southeast USA on November 07, 2012:
Thank you for sharing. So many of my friends are dealing with this problem with their parents. I will be passing it along. Voted up.
Kim Kennedy from uk on September 21, 2012:
An important subject, raising awareness is great. The mother and daughter video was touching. Having a diagnosis at least makes it easier to understand the person's behavior. Thanks for your work here.
Ann-Christin from UK on August 10, 2012:
This is a really good article full of very useful information. My partners father is now in a care home he has Alzheimer's he doesn't recognise his sons any more. I'm now worried my mother may be showing the first signs of dementia as she seems to be confused sometimes and she also has Parkinson's disease.
Girish puri from NCR , INDIA on August 09, 2012:
very useful and informative article and clears many confusions as well, voted useful.
Bill Holland from Olympia, WA on August 07, 2012:
Fantastic article my friend and I agree, this is a must read. My best friend was diagnosed with Alzheimer's at the age of 46...he is now 51 and the progression is scary to say the least. I am saddened for him, as I am for anyone who suffers from any form of dementia. Thank you for this valuable piece of work.
Martie Coetser from South Africa on August 05, 2012:
Docmo, thank you so much for sharing this well-explained, important information about Dementia with us. This go straight away to my personal library in FB.
Christy Birmingham from British Columbia, Canada on July 18, 2012:
Useful indeed. I like that you include the side blue boxes that explain further if we we want to explore more, and the video is a good related tool as well. Thanks for putting together this quality hub.
Ruby Jean Richert from Southern Illinois on July 17, 2012:
Very informative Docmo. I had a Dear nurse friend who had alzheimer's disease. She taught LPN training, plus worked weekends in a nursing home. She was in her 50's. I wondered if perhaps she worked to much. Do you think too much stress can contribute to this disease? This series on dementia hits home with me. My sister Bea was diagnosed with dementia, finally an MRI was done and it showed an inoperable brain tumor. Thank you for sharing your expertise in the medical field.
Dana Strang from Ohio on July 17, 2012:
Very good information, clearly presented, and easy to follow. I know a fair bit about dementia yet found myself learning even more. This is an excellent resource.
drbj and sherry from south Florida on July 17, 2012:
Extremely informative hub, Docmo, and interesting graphics. The statistics are frightening to see. (Especially when you are older like me.)
Mary Craig from New York on July 17, 2012:
Beyond useful and interesting Mohan. So much we need to know for our parents, and in my case, for my aging self ;)
It is so hard to determine the difference between just forgetting things and dementia. My 85 yr. old mother-in-law appears to be in early stages of dementia but there is a lot of family logistics involved so no formal diagnosis has been made.
Thank you for this information and the wonderful picture, graphics and video. The poor lady in the video truly broke my heart at only 56!
Voted up, useful, awesome, and interesting.
iamaudraleigh on July 17, 2012:
I like how you broke down your material and outlined it for all of your readers. This is an exceptional piece Docmo! It is very important for many of us to hear!
Gabby McMahon from Ennis, Co Clare, Ireland on July 17, 2012:
wonderfully detailed hub, with bags of useful information. The opening pic is so captivating!
Audrey Hunt from Pahrump NV on July 17, 2012:
Excellent and most informative. I appreciate learning more about this subject. It not only gives me greater insight but I have more empathy and compassion for those suffering from this disease. Voted up and across (not funny) and will share with others.
Mohan Kumar (author) from UK on July 17, 2012:
I know, there is a danger people may think I am a Doctor ;-) . Sad to hear about your neighbor's mom. Hope the journey and end of life care wasn't too traumatic. The next in this series covers aspects of management and care after the Diagnosis.
Linda Bilyeu from Orlando, FL on July 17, 2012:
Very informative and useful. One might think you are a doctor or something!:)
My neighbor lost her mother on Sunday due to complications from dementia. Today is her viewing. Very sad day for them.
Thank you for creating this hub that others will find very helpful.
Mohan Kumar (author) from UK on July 17, 2012:
Thank you Daisy, glad you found these as useful resources. Appreciate your visit and comment.
Daisy Mariposa from Orange County (Southern California) on July 17, 2012:
Thanks for publishing the second article in this extremly informative series. I found it very helpful to know what the conditions are which can mimic dementia. I also found the chart "recognzing the signs and symptoms of dementia" to be a useful quick reference tool.
Mohan Kumar (author) from UK on July 17, 2012:
Thanks Michelle- I'm glad this is useful.
Michelle Liew from Singapore on July 17, 2012:
Docmo, thanks for this very informative hub and sharing your expertise with us. Will share this.
Mohan Kumar (author) from UK on July 17, 2012:
Thank you ananceleste: I am glad you found this useful. The previous section also deals with how much support caregivers need in terms of early assessment and difficulties around that. I am writing the next chapter that helps with day to day caring principles after the diagnosis. appreciate your visit.
Anan Celeste from California on July 17, 2012:
Magnificent article! A must read to all that in some way or another deal with this conditions. I am the sole caregiver of my grandmother, she is 85 and was diagnosed 2001 with Alzheimer. Most people know the symptoms, but don't know the process of diagnosing the condition. Very informative. voted up!