Expert: Mary Gordon - 6/22/2005

Question
My mother in law seems to forget stuff every half an hour to 15 minutes. I suspect she has alzheimers, she has now started wondering arround all night and ocassionally forgets whos house she's at and a few faces. do you think she needs medication? What stage do you think she's at. does she need to see the doctor? How can I help her so she dosnt feel offended when I keep correcting her? Please reply thankyou.

Answer
Sam, I think you already know what you need to do. Get her to a doctor!!! The symptoms you are describing are extremely serious and alarming, and she absolutely needs proper medical attention pronto.

What you are describing could be the early stages of Alzheimer's but it just as easily could be a lot of other things. There are many, many illnesses that can affect the mind. Alzheimer's is only diagnosed by ruling out everything else it might be. Confusion and memory problems can stem from small strokes (so small the person may not show other signs of stroke), uncontrolled diabetes, drug interactions or side effects, thyroid problems, pernicious anemia, depression, Parkinson's disease - and a great big long list of other things. So, the first step is to make sure your mother in law isn't suffering from some other health problem that might affect her mind - especially if the "something" might be treatable.

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 to rule out strokes, tumors etc. Usually, you start with the family doctor, who will then refer her to a specialist such as a neurologist or a psychiatrist with a geriatric dementia specialty to make sure the evaluation covers all the bases.

A good assessment will also check out the extent of your mother in law's deficits. Alzheimer's doesn't just affect memory. Because it affects the entire brain, 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).

What is going on is NOT normal and you do need to find out what the cause is. Memory loss is always caused by something - it is never a normal part of aging, or something we should accept without proper exploration. You will never, never forgive yourself if she has something that could have been reversed if only she had seen a doctor early enough, so get on the phone today and make an appointment - and don't wait for her to agree she needs to see the doctor.

If she has an illness affecting her mind, she may never see what you can see. She may think she's fine, but you know she's not, so take action.

I'll keep my fingers crossed for you that it is something treatable. You need to know exactly what is causing the symptoms you are seeing so you can figure out what you can do about it. And if it IS Alzheimer's, you need to learn what you can about it so you can be ready for what may happen next, because Alzheimer's is a progressive disease that does get worse and worse, ultimately leading to the person's death.

The good news is that there are some new medications that can slow down the progress and improve quality of life, so the sooner you know what this is, the sooner you might be able to help her.

A very good book you will want to purchase is called The 36 Hour Day, by Mace and Rabin, published by Warner. It is full of insights into the behaviors that go with progressive brain damage, and tips for dealing with them.

One thing to keep in mind when dealing with her is that she really does have something wrong with her brain, so correcting her is not going to get you anywhere. Her logical thinker is broken, as well as her short term memory, so she will believe what she will believe, based on the best her brain can do. Her perceptions are damaged. All you get from arguing with her is to make her upset, as you've already discovered - its like trying to convince a 1 year old not to play in the knife drawer in the kitchen. Better to sooth, distract, redirect, divert, in a way that saves her dignity and feelings.  

Below my signature, I have pasted the most commonly used stages of Alzheimer's - but please don't assume this is what she has. You need some good medical involvement to help get whatever is going on diagnosed.

Just from your description, I would guess she's in Stage 4 or perhaps even early Stage 5, if this is indeed Alzheimer's you are looking at.

If she has any form of progressive dementia, you need to get her legal and financial house in order very quickly as she may not be legally competent to sign papers in very short order. Does she have a current will (including a living will)? Do you have durable powers of attorney for her for both financial and health care decisions? Do you know where all her assets are, where the keys to the safety deposit box are? Has any estate planning been done for her with respect to paying for long term care if she needs it (few families can manage the care of someone in late dementia).

A visit to a lawyer is a good plan (and worth every penny in real savings for most families) to review her situation, particularly if you are in the US and facing the convoluted rules for Medicare and Medicaid (which vary from state to state). Hope this helps.

Mary Gordon
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 referto 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 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