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Diagnosing Dementia

What does it mean when someone is said to have dementia? For some people, the word conjures up scary images of “crazy” behavior and loss of control. In fact, the word dementia describes a group of symptoms that includes short-term memory loss, confusion, the inability to problem-solve, the inability to complete multi-step activities such as preparing a meal or balancing a checkbook, and, sometimes, personality changes or unusual behavior.

Saying that someone has dementia does not offer information about why that person has these symptoms. Compare it to someone who has a fever: the person is ill from the fever, but the high temperature does not explain the cause or why this person is ill.

Does any loss of memory signify dementia? Isn’t memory loss a normal part of aging? We often hear that because someone is old, memory problems are “just natural” and are to be expected. But we know that serious memory loss is not a normal part of aging, and should not be ignored.

On the other hand, families might assume that a loved one’s noticeable loss of memory must be caused by Alzheimer’s disease. In many instances, Alzheimer’s is, in fact, the problem. But other conditions also can cause memory and cognitive problems severe enough to interfere with daily activities. These conditions can affect younger as well as older people. A clear diagnosis is needed.

Certain conditions can cause reversible dementias. These include medication interactions, depression, vitamin deficiencies, or thyroid abnormalities. It is important that these conditions be identified early and treated appropriately so that symptoms can be improved.

The irreversible dementias are known as degenerative dementias, and Alzheimer’s disease is the most common. A number of other degenerative dementias, however, may look like Alzheimer’s, but have distinct or different features that need special attention and different treatment. Reversible and irreversible dementias are described in more detail below.

Importance of Obtaining a Diagnosis

The diagnosis of dementia requires a complete medical and neuropsychological evaluation. The process is first to determine whether the person has a cognitive problem and how severe it is. The next step is to determine the cause in order to accurately recommend treatment and allow patients and caregivers to plan for the future.

A medical evaluation for dementia usually includes the following:
  • Review of history or onset of symptoms
  • Medical history and medications
  • Neurological exam
  • Laboratory tests to rule out vitamin deficiencies or metabolic conditions
  • Brain imaging
  • Mental status testing (also called cognitive or neuropsychological testing)

The process of diagnosing dementia has become more accurate in recent years, and specialists are able to analyze the large amount of data collected and determine whether there is a problem, as well as the severity, and often the cause, of the dementia. Occasionally, there may be a combination of causes, or it may take time to monitor the individual to be sure of a diagnosis. Determining whether the cause is a reversible or irreversible condition guides the treatment and care for the affected person and family.

Reversible Dementias

Deteriorating intellectual capacity may be caused by a variety of diseases and disorders in older persons. An illness and/or a reaction to medication may cause a change in mental status. Such events are sometimes called “pseudodementias.” Detecting the underlying cause of changes through medical evaluation may lead to a determination that the cause is reversible or treatable. Examples of conditions that can cause reversible symptoms of dementia include:

  • Reactions to medications. Adverse drug reactions are one of  the most common reasons older persons experience symptoms that mimic dementia. All medications, prescriptions, over-the-counter pills, and herbal remedies should be monitored by a physician to reduce the possibility of side effects.
  • Endocrine abnormalities. The conditions of low or high thyroid levels, parathyroid disturbances, or adrenal abnormalities can cause confusion that mimics dementia.
  • Metabolic disturbances. General confusion, as well as appetite, sleep, and emotional changes, can be caused by medical conditions including renal and liver failure, electrolyte imbalances (blood chemistry levels), hypoglycemia (low blood sugar), hypercalcemia (high calcium), and diseases of the liver and pancreas.
  • Emotional distress. Depression or major life changes such as retirement, divorce, or loss of a loved one can affect one’s physical and mental health.  A physician should be informed about major stressful life events.
  • Vision and hearing. Undetected problems of vision or hearing may result in inappropriate responses and be misinterpreted. Hearing and eye exams should be performed.
  • Infections. Confusion can be a symptom of infection—such as a urinary tract infection (UTI)—and needs to be brought to the attention of the physician.
  • Nutritional deficiencies. Deficiencies of B vitamins (folate, niacin, riboflavin, and thiamine) can produce cognitive impairment.

Degenerative (Irreversible) Dementias

If reversible dementias are ruled out and it is determined that the person has a degenerative or irreversible dementia, it is important that families and medical personnel seek the cause of the problem. This will help ensure that the person affected receives proper medical care, and families can plan their caregiving and find appropriate support and resources.

The following are the most common degenerative dementias:

  • Alzheimer’s disease. Alzheimer’s disease is the most common cause of dementia in people over 65, although the disease also occurs in people much younger. Alzheimer’s affects approximately 50 percent of those over 85. Presently, researchers cannot definitely say what causes the disease, and there is no cure. Symptoms differ from person to person, but declines in memory, thinking, and ability to function gradually progress over of a period of years, ending in a severe loss of function.
  • Ischemic vascular dementia (IVD). IVD is the second most common dementia, characterized by an abrupt loss of function or general slowing of cognitive abilities that interferes with what are called “executive functions” such as planning and completing tasks. When symptoms appear suddenly, the person has usually experienced a stroke. For others, the condition develops slowly with a gradual loss of function and/or thinking.
  • Dementia with Lewy bodies (DLB). Dementia with Lewy bodies is a progressive degenerative disease that shares symptoms with Alzheimer’s and Parkinson’s. People affected by this disease have behavioral and memory symptoms that can fluctuate, as well as motor problems that are commonly seen with Parkinson’s disease.
  • Frontotemporal dementia (FTD). FTD is a degenerative condition of the front (anterior) part of the brain, which can sometimes be seen on brain scans. The frontal and anterior temporal lobes of the brain control reasoning, personality, movement, speech, language, social graces, and some aspects of memory. Symptoms may lead to misdiagnosis as a psychological or emotionally-based problem. FTD frequently occurs after age 40 and usually before age 65. Symptoms appear in two seemingly opposite ways: some individuals are overactive, restless, distracted, and disinhibited (showing poor social judgment), while others are apathetic, inert, and emotionally blunted.
  • Creutzfeldt-Jakob disease. Creutzfeldt-Jakob disease (CJD or Jakob-Creutzfeldt disease) is a rapidly progressive, fatal brain disease. It is part of a family of diseases called transmissible spongiform encephalopathies, caused by an agent known as a prion (“pree-on”). This condition can be very difficult to diagnose as it has many different symptoms, including behavioral changes, movement changes, cognitive changes, and general changes in well-being such as sleep problems, loss of appetite, and headaches.
  • Parkinson’s dementia. Parkinsonism is the name given to a collection of symptoms and signs consisting of tremor, stiffness, slowness of movement, and unsteady gait. Many neurological disorders have features of parkinsonism, including many of the dementias. When parkinsonism occurs without any other neurological abnormalities, and there is no recognizable cause, the disorder is termed Parkinson’s disease after the English physician who first described it fully in 1817.
  • Progressive supranuclear palsy (PSP). People with PSP usually show a group of three symptoms, including the gradual loss of balance and trouble walking, loss of control of voluntary eye movements, and dementia. Although these features are considered to be the hallmarks of PSP, patients with this disorder also experience other symptoms common to degenerative diseases of the brain, including difficulties with movement, changes in behavior, and difficulty with speech and swallowing. In part because it is relatively rare, PSP is frequently misdiagnosed as Parkinson’s disease. However, its treatment response and clinical symptoms are different, making an accurate diagnosis very important.
  • Normal pressure hydrocephalus (NPH). Gait instability, urinary incontinence, and dementia are the signs and symptoms typically found in patients who have NPH. Considered a rare cause of dementia, it primarily affects persons older than 60 years. The precise incidence of NPH is hard to determine because the condition does not have a formal, agreed-upon definition. Some physicians base the diagnosis strongly on radiographic evidence; another group of health care professionals relies more on clinical indications. Still others use a combination of signs and symptoms that they have found to be reliable. Traditionally, treatment is surgical implantation of a shunt to reduce the pressure caused by the build up of cerebrospinal fluid.
  • Huntington’s disease (HD). Huntington’s disease is a fatal disease typically characterized by involuntary movements (chorea) and cognitive decline (dementia). It is caused by a genetic mutation that can be passed down from generation to generation. HD is an illness with profound neurological and psychiatric features affecting certain structures deep within the brain, particularly the basal ganglia, responsible for such important functions as movement and coordination. Structures responsible for thought, perception, and memory are also affected, likely due to connections from the basal ganglia to the frontal lobe of the brain. As a result, patients may experience uncontrolled movements (such as twisting and turning), loss of intellectual abilities, and emotional and behavior disturbances.
  • Mixed dementias. At times, two of these conditions can overlap. This is commonly seen in Alzheimer’s disease and vascular dementia, and also in Alzheimer’s disease and Lewy body dementia.

There are no cures for degenerative or irreversible dementias, so medical treatments focus on maximizing the individual’s cognitive and functional abilities. Specific treatments for dementia vary depending on the cause of the dementia.

Good communication with the primary care provider affects the well-being of the person with dementia as well as the well-being of the  caregiver. Communicating your concerns clearly and describing the changes you may have observed will help guide the provider to investigate further. In some cases, you may find yourself “educating” medical staff about your loved one’s symptoms.

An accurate diagnosis begins a process of education for caregivers and families so that needs can be met and resources located and put to use. Irreversible dementia requires a level of care that increases as the disease progresses. Through education and the use of available resources, families can learn new skills to handle shifting care needs.

Research into the cause and treatments for dementia continues at a rapid pace. We all look forward to new developments that someday may postpone, cure or even prevent these debilitating disorders.
The above was excerpted from FCA’s fact sheet Is this Dementia and What Does It Mean?