Expert: Mary Gordon - 4/5/2005

Question
My step mother, age 82, has always had a very sharp mind and excellent memory. There have been several instances lately where she either "remembered" something that did not happen, or she remembered it incorrectly. She got very angry when I tried to help her recall what really happened. The subjects we were talking about were minor, and not worth arguing about, so I let it go. But this is so out of character for her that I am worried. Is this a sign of dementia or is she just being old and cranky?

Answer
If the alarm bells are going off in your gut (and clearly they are), I'd listen to them. The early stages of brewing dementia are often quite subtle.

It can be deeply upsetting to the person experiencing the lapses - and often they can't recognize or acknowledge what is happening to them. They will do anything to deny a problem, cover it up, deflect your questions. My mother-in-law was a master at hiding deficits - if for example, she'd forgotten arrangements for a long planned dinner visit, she'd pretend it had just slipped her mind for minute (oh, how silly of me, of course we talked about that), even when the truth was, she had NO memory of the conversations about the subject.

Don't wait for her to agree there is a problem. That day may never come. Memory problems are never a normal part of aging.

As you probably know, there are many causes of confusion or memory loss in older people. Alzheimers is among the most common. It is diagnosed by ruling out everything else it might be. Cognitive impairments can stem from small strokes (so small the person may not show other signs of stroke), drug interactions or side effects, thyroid problems, pernicious anemia, depression - and a stack of other things.  So, it is always important to alert the doctor to what you are seeing, since it does matter what the cause is. Many of the causes are treatable - and even those that are not reversable can often be slowed down considerably if they are recognized early enough. A good assessment includes a full physical with assorted blood tests, some psychiatric evaluation to rule out depression, a review of history and medications, a neurological work up, usually including a CAT or other brain scan such as MRI to rule out strokes, tumors etc.

An assessment should be also be done to check out the extent of your step mother's deficits.  Dementias like Alzheimer's don't just affect memory. Because the entire brain can be impacted, reasoning, judgement and personality can be affected early in the disease. Things families notice first often include memory lapses, trouble with numbers or time, getting disoriented in familiar places (i.e. getting "turned around" on the way to the store), trouble thinking of words, asking the same question repeatedly,  getting upset easily or frustrated, changes in routine (i.e. they sometimes stop participating in things they previously loved), difficulty solving simple problems (i.e. not being able to figure out what to do when something goes wrong).

Beneath my signature, I have pasted the most commonly used description of the stages of Alzheimer's so you can see for yourself how subtle those early signs can be.

Hope this helps - don't leave it to her to talk to the doctor, since she may be unable or unwilling to do so. If you have to, write him/her a note, to make sure he/she knows what you are observing.

Mary G.
Toronto


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., paatients 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