Expert: Mary Gordon - 12/21/2004

Question
Hi, I am in my mid thirties and living with my grandfather while I go to college. He and I have noticed an increase in his forgetfulnes; however, he states that his doctor says that it is normal in an 84 year old. I feel guilty for not noticing sooner, but i've been busy with finals, as recently as three or four weeks ago he regularly made blackberry jams every couple of months, pumpkin pies weekly, and he would have egg salad sandwhiches daily. He switched to peanut butter sandwhiches a couple of weeks ago and I thought nothing of it. He hasn't made any pies for a few weeks and again I thought nothing of it, because there are so many sweets in the house @ this time of year. He mentioned that he needed to buy some jam and I laughed. He has been making his own for years and years.  We had a conversation tonight about pie for Christmas and he said he'd like pumpkin pie, if I'd make it. we discused this further and he doesn't recall EVER making pumpkin pie. He gets a puzzeled look when I mention him making jams, and I didn't have the heart to talk about the change in his sandwich making. Finally my question: Can Alzhiemers effect one specific area of the brain so dramatically and leave the others relatively unaffected? His short term memory is admitedly worse lately, but he still handles all of his finances, goes to church, feeds his wife, who is in a nursing home three blocks away, three times day. I don't want to limit him and he seems to be in denial, but I am very concerned. Does this seem like alzhiemers or does it seem more like a mini stroke? I know your not a dr,. but your unbiased opinion would be helpful as I don't know what to do.  

Answer
If the alarm bells are going off in your gut, I'd listen to them.

The early stages of progressive dementias can be very subtle and deceptive, and when you read the descriptions of symptoms, it is easy to see how a person with Alzheimer's can function for years without others being aware that there is a problem. Some of us might even wonder if we're not in stage one or two ourselves. I've pasted a basic outline of the stages of Alzheimer's below my signature, based on the work of Dr. Reisberg, so you can get a feel for what may be happening. My immediate reaction to what you've described is that something is brewing, and I would gauge it to be equivalent to Stage 3 or even early Stage 4, so yes, absolutely, this needs proper assessment and diagnosis.

It is usually requires some expert screening and testing to spot early deficits because they rarely are overt. Many people are very good at hiding their problems, or finding ways to compensate. After all, if a family member's personality is intact, they seem like themselves, and we don't normally grill loved ones or test them on things like arithmatic, reading a calendar, telling time, copying stick figures etc. If you had met my mother in law in a social setting around the time of her diagnosis, you would never have thought there was a thing wrong with her (you would have thought WE were bonkers). However, we'd been alarmed about an accumulation of minor things for months. The family doctor did some screening tests in the office and a full physical to rule out various causes of confusion, and referred her to a specialist (usually a neurologist or geriatric psychiatrist with a dementia specialty), who arranged for cognitive testing with a psychometrist, among other work ups and tests. The results were shocking, since she was impaired in a number of areas...none of which were readily apparent to us (i.e. she was still doing just fine looking after herself - the only things we'd detected were what seemed like a series of very minor memory lapses, and some changes in habits that were a bit odd but no big deal).

What I'm trying to say is that you may only think he's okay in other areas, but proper testing might surprise you. He's your grandfather, an adult authority figure you respect, he has his independence and privacy, he's unlikely to admit he's finding routine things hard - I'm willing to bet things would really have to be falling apart in a major and obvious way before you'd find out he was having any challenges handling money, paying bills etc.

Don't expect your grandfather to believe he may have a problem. If he is in early dementia, whether from Alzheimer's or from some other cause like small strokes (called multi-infarct), he has global brain damage. What is frightenly apparent to you may not be visible to him at all.
You will try to use reason on a person whose "reasoner" is broken.

His doctor is off base if he has told your grandfather that cognitive impairment is normal for an 84 year old. We all get a little slower, but confusion and memory loss is always caused by something - its never just a function of age. It IS important to investigate and find out what is going on, since some causes of confusion are reversible with treatment, and even the incurable ones like Alzheimer's can be slowed down with current drugs, which translates into better quality of life and longer independence. It is also crucially important to know what is going on, so your family can make appropriate plans for the future based on what might happen next. There are quite a stack of things that can cause the kind of symptoms you are describing. Alzheimer's is just one of the more common.

The warning signs of Alzheimer's (from the Alzheimer's Association) include:
1. Memory loss.
2. Difficulty performing familiar tasks (they often start to avoid doing things they formerly enjoyed because they are having trouble and finding it upsetting).
3. Problems with language (i.e. word finding).
4. Disorientation to time and place (getting turned around even in familiar settings).
5. Poor or decreased judgment (they may not know what to do if something goes wrong).
6. Problems with abstract thinking and sequencing.
7. Misplacing things.
8. Changes in mood or behavior (becoming upset easier).
9. Changes in personality (i.e. becoming paranoid).
10. Loss of initiative.

Hope this helps. You aren't crazy. You love the guy and you are seeing something alarming. He needs to be properly assessed by the doctor, and if his own doctor isn't able and willing to take this seriously, its time to find someone who will.

Mary G. (stages below)


Stage 1 - "No cognitive decline." No memory deficit is evident any clinical interview used for testing the presence of Alzheimer's.

Stage 2 - "Very mild cognitive decline (Forgetfulness)." Some complaints of memory problems. Mostly the patient is forgetful in areas of where an item has been placed, such as car keys, and in forgetting people's names.

Stage 3 - "Mild cognitive decline (Early Confusional)." This is the stage at which there begins to be some memory loss evident in a clinical interview. The problem will affect the person in one or more of these areas: 1) getting lost while traveling, 2) lowered performance at work may be noticed, 3) increased difficulty in finding the needed words or remembering names, 4) reading retention lowered, 5) losing objects of value. The patient may experience both anxiety and denial along with these symptoms.

Stage 4 - "Moderate cognitive decline (Late Confusional)" At this stage there is clearly some memory loss evident in a clinical interview. The problem will be seen in one or more of the following areas: 1) Decreased knowledge of current events, 2) may begin to lose some personal history, 3) inability to concentrate, and 4) inability to travel, handle finances, etc. The person may also begin to be unable to recognize familiar people and may lose orientation to time or place as well as being unable to perform complex tasks. Denial is evidental, and withdrawal from challenging tasks becomes a defense mechanism.

Stage 5 - "Moderately severe cognitive decline (Early Dementia)" The patient needs assistance in daily living in order to survive. Though the person may require no assistance with toileting and eating, they may need help choosing clothes. They may not be able to recall in a clinical interview important information relavant to their lives as address or telephone number they've had for years, the names of family members, or the high school they attended.

Stage 6 - "Severe cognitive decline (Middle Dementia)." The patient may occasionally forget their spouse's name, and they may be largely unaware of much of their own history as well as of recent events. They may retain some knowledge of their past lives, but this is sketchy. During this stage personality changes may occur, and the person may become obscessive or delusional and may begin having hallucinations. They may begin to have some incontinence as well.

Stage 7 - "Very severe cognitive decline (Late Dementia)" All verbal ability is lost, the person is incontinent, and needs assistance with eating. The person may also lose the ability to walk, and eventually to sit and head control as well.