Expert: Mary Gordon - 5/23/2006

Question
I was wondering if you could settle an argument.  The answer is probably 6 dozen one and half a dozen the other.  The dispute was with my mother-in-law (there s a shocker) about her mother who was 92 when she died and my grandmother whois 91.  They both suffer dementia but I know that my grandmother has great long-term memory.  I wasn t that familiar with my m-i-l s mom so I can t say.  I was under the impression that dementia is severe short term memory loss.  My grandmother seems fine w/ her long term memory.  Is this typical or does it vary?

Answer
Hi Jackee

I guess the source of the conflict is what is meant by the term dementia. If you are ever given a diagnosis of "dementia" for a loved one, its time for a new doctor. Dementia only describes a group of symptoms, and they are very variable. Essentially, it just means the person is confused enough to interfere with their daily life - usually from some kind of brain impairment, whether permanent or temporary. It doesn't tell you WHY they are showing the symptoms (i.e. what the underlying cause is).

Cognitive impairment can result in all kinds of issues depending on where and how the brain is affected, which in turn is the result of what the underlying cause is.

The range of problems can include confusion and disorientation, language problems, short or long term memory problems, hallucinations or delusions, personality changes, coordination and perceptual problems, loss of inhibitions, poor judgement, slowed reaction time, inability to reason - you name it.

So, saying a person has dementia is like saying they have a fever - it tells you a bit about the symptoms, but what the real problem is, or what might happen next. Its even worse when a doctor says "senility" since that just means an old person who is confused. The underlying cause is important to know since you need to know what the cause is before you can figure out if there is anything that can be done to help. Some causes are progressive and incurable, some can be slowed down, and some can even be treated and reversed.  Examples of illness that can cause cognitive impairment (i.e. dementia) include strokes (some so small that the person has no symptoms other than mental impairment), Alzheimer's, thyroid problems, nutritional issues like pernicious anemia, brain tumours, normal pressure hydrocephalus, kidney or liver failure, Parkinson's, Pick's, Bitzwanger's disease, Lewy body disease - and on and on.  Alzheimer's and strokes are the two biggies.  

Each of the underlying causes can result in a different pattern of symptoms - and many of the patterns can be so distinctive that it helps in diagnosis.  example, people with Pick's disease may start to exhibit really startling personality changes as a first symptom, such as a formerly shy reserved person becoming an very rude extrovert. So, even if a dementia can't be helped, knowing the cause can help families to understand why a person is acting in particular ways, prepare for what will come next, and make good plans for the future - the patterns caused by a particular disease are often predictable.

My mother in law had Alzheimer's and she was fairly typical in that she retained her longer term memories quite far into the illness. lf you had met her in mid disease in a social setting, you might not have known there was anything wrong with her (i.e. she could carry on a very good social conversation, and tell you all about her early life). You'd never guess she couldn't understand how a calendar worked, couldn't dress herself, and thought people on TV could talk to her.   

Below my signature, I've pasted a description of the stages of Alzheimer's so you can get a feel for how one common cause of cognitive impairment progresses.  Whether its from strokes or something else, if brain damage is accumulating, eventually, the person ends up in the same place - bedridden, unaware, helpless.

Given that your grandmother is very elderly, it is likely that if she does have a disease like Alzheimer's, she may not survive into the later stages - which is actually a mercy.

Hope this helps make the terminology easier to understand. It IS confusing.

Mary G.
Toronto

Stages of Alzheimers

In 1982 Dr. Barry Reisberg published what was to become the best and most widely accepted description of the stages of Alzheimer's disease. Even today, years later, when experts refer to a person being in stage 5 or stage 6, they are referring to Dr. Reisberg's scale of seven stages.

Adapted from Reisberg, B., Ferris, S.H., Leon, J.J. & Crook, T. The global deterioration scale for the assessment of primary degenerative dementia. American Journal of Psychiatry, 1982

Level 1

No cognitive decline - (or Normal Adult). No subjective complaints of memory deficit. No memory deficit evident on clinical interviews.

Level 2
Very mild cognitive decline (forgetfulness or normal older adult). Subjective complaints of memory deficit, most frequently in the following area:
(a) forgetting where one has placed familiar objects;
(b) forgetting names on formerly knew well.
No objective evidence of memory deficit on clinical interview. No objective deficits in employment or social situations. Appropriate concern regarding symptoms.

Level 3
Mild cognitive decline (early confusional or Early AD). Earliest clear-cut deficits. Manifestations in more than one of the following areas:
(a) patient may have gotten lost when traveling to an unfamiliar location;
(b) co-workers become aware of patient's relatively low performance;
(c) word and name finding deficit becomes evident to intimates;
(d) patient may read a passage of a book and retain relatively little material;
(e) patient may demonstrate decreased facility in remembering names upon introduction to new people;
(f) patient may have lost or misplaced an object of value;
(g) concentration deficit may be evident on clinical testing.
Objective evidence of memory deficit obtained only with an intensive interview. Denial begins to become manifest in patient. Mild to moderate anxiety accompanies symptoms. Deficits noticed in demanding employment situations.

Level 4
Moderate cognitive decline (Late Confusional or Mild AD). Clear-cut deficit on careful clinical interview. Deficit manifest in following areas:
(a) decreased knowledge of current and recent events;
(b) may exhibit some deficit in memory of one's personal history;
(c) concentration deficit elicited on serial subtractions;
(d) decreased ability to travel, handle finances, etc.

Frequently no deficit in the following areas:
(a) orientation to time and person;
(b) recognition of familiar persons and faces;
(c) ability to travel to familiar locations.
Inability to perform complex tasks. Denial is dominant defense mechanism. Flattening of affect and withdrawal from challenging situations occur.

Level 5
Moderately severe cognitive decline (Early Dementia or moderate AD). Patient can no longer survive without some assistance. Patient is unable during interview to recall a major relevant aspect of their current lives, e.g., an address or telephone number of many years, the names of close family members (such as grandchildren), the name of the high school or college from which they graduated. Frequently some disorientation to time (date, day of week, season, etc.) or to place. An educated person may have difficulty counting back from 40 by 4s or from 20 by 2s. Persons at this stage retain knowledge of many major facts regarding themselves and others. They invariably know their own names and generally know their spouse's and children's names. They require no assistance with toileting and eating, but may have some difficulty choosing the proper clothing to wear.

Level 6
Severe cognitive decline (Middle Dementia or Moderately Severe AD). May occasionally forget the name of the spouse upon whom they are entirely dependent for survival. Will be largely unaware of all recent events and experiences in their lives. Retain some knowledge of their past lives but this is very sketchy. Generally unaware of their surroundings, the year, the season, etc. May have difficulty counting from 10, both backward and sometimes forward. Will require some assistance with activities of daily living, e.g., may become incontinent, will require travel assistance but occasionally will display ability to orient in familiar locations. Diurnal rhythm frequently disturbed. Almost always recall their own name. Frequently continue to be able to distinguish familiar from unfamiliar persons in their environment. Personality and emotional changes occur. These are quite variable and include
(a) delusional behavior, e.g., patients may accuse their spouse of being an impostor, may talk to imaginary figures in the environment, or to their own reflection in the mirror;
(b) obsessive symptoms, e.g., person may continually repeat simple cleaning activities;
(c) anxiety symptoms, agitation, and even previously nonexistent violent behavior may occur;
(d) cognitive abulla, i.e., loss of willpower because an individual cannot carry a thought long enough to determine a purposeful course of action.

6a - Requires Assistance dressing
6b - Requires Assistance bathing properly
6c - Requires Assistance with mechanics of toileting
6d - Urinary incontinence
6e - Fecal incontinence

Level 7
Very severe cognitive decline (Late Dementia or Severe AD). All verbal abilities are lost. Frequently there is no speech at all - only grunting. Incontinent of urine, requires assistance toileting and feeding. Lose basic psychomotor skills, e.g., ability to walk, sitting and head control. The brain appears to no longer be able to tell the body what to do. Generalized and cortical neurologic signs and symptoms are frequently present.

7a - Speech ability limited to about a half-dozen intelligible words
7b - Intelligible vocabulary limited to a single word
7c - Ambulatory ability lost
7d - Ability to sit up lost
7e - Ability to smile lost
7f - Ability to hold up head lost