Ask the Geriatrician: Dementia

Maryjo Cleveland

Maryjo L. Cleveland, MD
Associate Professor of Internal Medicine
Program Director, Geriatric Medicine Fellowship
Director, Geriatric Clinic, Section of Gerontology and Geriatric Medicine
Wake Forest Baptist Hospital

As we grow older, we may have minor problems with our memory. We may forget the name of someone we recently met or misplace our car keys. We may be slow to find a well-known word. So, how do we know when we — or someone we care for — should worry about memory changes as a sign of developing dementia? 

Q:   What is dementia?

A:   Dementia is a word used to describe a group of different brain diseases and simply means a memory impairment significant enough to affect daily function. Symptoms include memory loss, confusion, and problems with speech and understanding. There are many different causes of memory loss. Some of these, like thyroid disease or certain medication side effects. can cause symptoms that seem like dementia.  These are treatable conditions and should be screened for and eliminated before a diagnosis of dementia is made.

Q:   Isn't dementia just old age or senility?

A:   Aging alone does not cause significant memory problems or stop us from taking care of ourselves. As we get older, it might take longer to remember names or find the right word to say. This is different from the loss of memory and other mental problems associated with conditions like Alzheimer's disease. Those suffering from Alzheimer's can get lost in familiar places like home or close to home, fail to recognize family members, fail to recognize familiar objects such as a pen or a watch, and cannot make up for these problems. 

While the risk for various kinds of dementia increases with age, dementia is not part of normal aging. All memory changes should be thoroughly evaluated. 

Q:   What are the different kinds of dementia?

A:   The most common dementias are Alzheimer's disease, vascular dementia, Lewy body dementia, and FTD. But there are many other causes of impaired brain function such as repeated injuries to the head, low vitamin B12 levels, thyroid conditions, depression, AIDS, sleep apnea, and other infections and illnesses. In addition, medicines, either prescription or non-prescription, or alternative and herbal remedies, can affect memory and cause confusion in older people. 

Q. What is mild cognitive impairment (MCI)?

A:    MCI is a diagnosis made when an older adult has memory loss noticed by patients and their families and is evident in cognitive testing, but is not severe enough to affect everyday activities. Just like dementia, MCI can have many causes. People with MCI are more likely to develop dementia over time, but it is not inevitable.

Q:   What is Alzheimer's disease?

A:   In this condition, certain cells in the brain stop working and eventually die. These cells produce important chemicals [acetylcholine, serotonin, dopamine, and others] needed for memory, language, and other thinking functions. As the chemicals decrease, so do the person's abilities to remember and think clearly. Alzheimer’s disease usually sneaks up on the person and family. It can get worse slowly over several years before changes are noticed. Over time (usually 2-12 years), it gets to a point where the person can no longer handle simple tasks such as eating or bathing. 

Q:   How do you get Alzheimer's disease?

A:   As we get older our chances of getting Alzheimer’s disease increase. Between the ages of 65 and 70, about one in 20 people has the disease. By the age of 85 and older, between 1 in 3 people has this disease. We also know that some families pass along genes that increase the risk of developing Alzheimer’s disease. Some factors in our environment can increase the risk also, such as head injury with unconsciousness. When we say “increases the risk” of getting Alzheimer’s, this does not mean we will get it for sure. It just means the chances of our getting it are higher. 

Q:   Is there any point to seeing my healthcare provider?

A:   It is very important for a person with mental and thinking changes to get a good checkup. First, the changes could be a result of a treatable condition such as thyroid disease, or medication related. Second, there are now treatments available for Alzheimer’s disease and other dementias that may improve the symptoms and slow the progress of the disease. Third, your healthcare provider should be able to assist you in finding community resources for information, support groups, and help at home. Finally, if diagnosed early, the person with dementia can participate in planning for the future and may be able to say "what matters most" to her or him. 

Q:   What can we expect from the healthcare provider?

A:   Your healthcare provider should take your concerns seriously. They should carry out a careful medical checkup and medication review. There should be tests of memory, mood, daily function, lab tests, and sometimes a scan of the brain. A referral for detailed mental testing may be made. Treatment and support should be started. 

Q:   What treatments are there for Alzheimer's disease?

A:   Medications approved for treating Alzheimer's disease are donepezil [Aricept], galantamine [Razadyne, formerly Reminyl] and rivastigmine [Exelon]. They work by raising the levels of acetylcholine in the brain and are called cholinesterase inhibitors. If you begin one of these medications, your healthcare provider should check every so often to see if these drugs are helping your thinking and memory, and to manage any negative gastrointestinal effects. These medications seem to provide the most benefit when started early. 

Memantine (Namenda) regulates glutamate, another brain chemical, and might help symptoms of Alzheimer’s disease. This medication is generally added to a cholinesterase inhibitor in a more moderate stage. None of these medications cures or stops the disease but they might slow how quickly the disease gets worse. 

Several herbal remedies and other dietary supplements are promoted as effective treatments for Alzheimer’s disease and other dementias, especially on television and in health magazines. However good scientific evidence of this is still lacking. 

Q:   How can I convince my family member to go to the healthcare provider?

A:   Often, your family member already knows there is something wrong and is frightened. It is helpful to remind your family member that early detection allows decisions to be made about treatment, and help to make sure that patients and families have support as they manage this disease.

Q.   How do I know when the person I care for should stop working, banking, driving, or living alone?

A:   These are difficult questions that your healthcare provider should assist you in answering. In general, if there is potential for harm to your family member or to others, it is time to consider stopping certain activities. Healthcare providers rely on your reports as well as cognitive testing when making recommendations about major life changes. They can be supportive in reinforcing your concerns. 

Q:   What else can I do as a caregiver?

A:   Above all else, the person with dementia needs your care and support. You can't provide that care if you don't look after your own health. Caregiving can be rewarding, but can also be exhausting, sad, and depressing. You can become sick if you ignore your own health needs. You need breaks from caregiving; you need help at home; you need to eat, sleep and exercise regularly; you need to forgive yourself for feelings of anger and guilt. A support group can help you through some tough times you may face. 

Q:   Is a nursing home really necessary?

A:   Often, as dementia progresses, the person affected requires 24/7 care and supervision. Some caregivers may be able to provide this level of support in the home, especially when they take advantage of help such as adult day programs and/or hired help. For many caregivers, however, this becomes an impossible task and placement in either a memory care assisted living or nursing home is necessary. When this happens, it is important for families to realize that they still an important role in their relative's life. While caregiving tasks, such as giving medications or bathing, can be handed over to a caregiver, the role of daughter, spouse, sibling, or friend can never be replaced.

Last Updated June 2019