man x-ray; science, technology concept

So first let me say, “Well done, Paula Span!”  I like the NYT article on differentiating signs of dementia from other problems affecting cognition: http://newoldage.blogs.nytimes.com/2014/10/21/is-it-really-dementia/?_php=true&_type=blogs&_r=0

It’s reasoned, calm, and informative, which is pretty unusual for a piece on dementia.  The author’s personal experience with caregiving and her journalistic research have given depth to her understanding of the topic.

I thought I’d add to the article with a few brief comments.  In my clinic practice I routinely assess patients whose family and/or doctors suspect they may have dementia, often meaning a progressive condition like Alzheimer’s (which is the most common type of dementia). As a neuropsychologist, I use a combination of thorough medical record review, interview of patient and family, and paper and pencil testing to answer questions such as:

“Does this patient have objective, measurable impairment, or is this purely subjective?”

“Does this pattern of impairment look organic (meaning, neurologic) or psychiatric (meaning, depression or other mental illness)?”

“What type of dementia does this seem to reflect?”   (Alzheimer’s? Dementia with Lewy bodies? Vascular dementia? Frontal temporal dementia? etc.)

“Do you see any other factors coloring the picture?” (Such as medication effects, legal problems, pain, sleep disturbance, etc.)

When I am teaching medical and neuropsychological residents about assessment of dementia, I emphasize the importance of the clinical interview–including the questions I ask, below, which ANYONE can use, whether doctors, residents, or concerned family members.

“Looking back on it now, what was the very first thing you noticed that  made you think something was wrong?” Identifying whether the first sign was depression, or behavior change, or forgetfulness is really useful in diagnosis.

“Did it start gradually and you noticed it over time, or was it  sudden?”  This helps a great deal in determining whether a progressive condition is possible, or another process.

“Have you had to take over any things your loved one has always done on his/her own? Like paying bills, taking medicines, cooking, picking out clothes, driving, making appointments?” Many families will report their loved one is totally independent.  But then you ask carefully and turns out, they are doing everything for the patient. Sometimes this is just to be helpful, but sometimes it is because the patient can no longer do these activities alone. Along those lines, I also want to know if they do those activities correctly!  Some patients “manage their own medicines” but take them all in one week, or only once a week, or they lose pills.  Or they still drive, it’s just that no one will ride with them anymore!  Cooking is a big one in the South: some patients still cook but it just isn’t the same quality.

“Did anything else happen about the time all this began?”  I sometimes find that cognitive problems started after the patient took over parenting for a grandchild, or went into foreclosure on their home, changed medicine, had surgery, or lost a job due to layoffs.

“Is your loved one like this pretty much all the time, with good and bad days, or is it more off and on?”  Alzheimer’s, and sometimes Vascular dementia have an insidious, slow progression over time, whereas other problems may have a different course, much faster, or with fluctuations or episodes, or clearing totally for a time.

“Is there any change in personality or behavior?”  Even if there is no depression or anxiety, my patients with dementia may be more irritable, hostile, argumentative, disinhibited, or even more withdrawn, disinterested or quiet.

“Has he/she been doing anything just odd, or weird lately?”  My patients may start hoarding things or eating strangely (e.g. cereal for every meal). or touching strangers.

There are also some questions I ask my patients directly, and these can very quickly determine whether there is high risk for an “organic” or neurologic problem.

“Tell me what medicines you are taking.”  I look for my patient to just be able to tell me what the medicines are FOR, not names or doses.  Often persons with dementia fail to remember many medications or do not recall what they are for.

“Tell me what’s been going on in the news lately? What are people talking about?”  This is the great equalizer: everyone has something to say, whether it is a CEO who reads the Wall St. Journal, or a homemaker in a farming town who sees her friends at the local hairdresser.   My patients with dementia will often say, “I don’t watch the news,” or “I don’t know–it’s all bad.”  I look for them to be able to name a couple of recent events, and these can be local or national or international stories.

“Are you worried about these problems, or do you think everyone is making a mountain out of a molehill?”  Alzheimer’s dementia is commonly associated with a neurological (not psychological) lack of awareness of deficit: patients are convinced there is nothing wrong and strenuously deny cognitive problems.  Or they may admit to some minor problems but attribute it all to getting older.

A final comment is the adage that “normal aging is…..normal.”  There are some normal changes in thinking skills as we age, but things like rapid forgetting, loss of independence due to confusion, difficulty using appliances, and hallucinations, among other signs, are not at all part of normal aging and should be evaluated.