Forward with Dementia

UNSW experts say it’s never too late, nor too early, to adopt healthy habits that can delay the onset of dementia.

Forgetting names and misplacing items happen to us all, more so as we age.

But when should you be concerned that these small acts of forgetfulness are part of a larger cognitive decline that may indicate dementia?

Scientia Professor Henry Brodaty, co-director of UNSW Sydney’s Centre of Healthy Brain Ageing, says there’s no single test that can say conclusively whether someone has the beginnings of dementia – but diagnosis begins with a visit to a GP. There the GP might test the patient’s short-term memory with some word, number and drawing exercises, after which they may then refer the patient on to a specialist.

But Prof. Brodaty says sometimes the most reliable indicator is to ask someone who lives with the patient.

“The diagnosis is usually a combination of getting a history from the patient and a history from someone who lives with them,” he says.

“That’s probably the most useful thing – someone who lives with you 24/7 is a much more accurate rapporteur than someone like me doing a one hour assessment in a clinic.”

Major changes in memory

We all have our forgetful moments. But when major memory lapses start becoming consistent and start impacting one’s day-to-day life, it could be an indicator of cognitive decline.

“We have to distinguish between what is cognitive decline and what’s physical decline,” says Associate Professor Simone Reppermund, with the Centre for Healthy Brain Ageing.

“As we age, we get more frail, and it may be difficult to walk longer distances or to have the range of motion to drive a car.

“But that’s unrelated to cognitive decline, and this is where dementia or cognitive impairment comes in. A person with dementia at some point will not be able to do the things they once could do without thinking, such as drive a car, because they get confused and are no longer able to process the sensory information required to do this.”

Prof. Brodaty says some cognitive decline is part of normal ageing.

“As we age, we become slower in our processing speed. We’re not as good at remembering things, particularly when they’re not able to be logically sorted and connected.

“There’s a test called the Rey Auditory Verbal Learning test where you’re given a list of 15 words five times in a different order, and we normally see a learning curve as people remember more and more. A 20-year-old will do better than a 40-year-old, who’ll do better than a 60-year-old, who’ll do better than an 80-year-old.”

But it’s not all bad for older folk; some things improve with age.

“As we age our vocabulary improves, our judgment improves, our ability to organise things improves. In tests where we can sort, say, 10 grocery items into different categories, we do just as well as the younger person because we can use those strategies to compensate. There is also evidence that we become wiser as we get older.”

According to Dementia Australia, it’s when people encounter difficulties with the following on a regular basis that there could be some underlying cognitive cause worth investigating:

  • Trouble remembering recent events
  • Trouble finding the right word
  • Trouble remembering the day and date
  • Forgetting where things are usually kept
  • Difficulty adjusting to changes in routine
  • Trouble understanding written content or a story on television
  • Difficulty following conversations in groups
  • Problems handling finances
  • Difficulty with everyday activities
  • Losing interest in activities that were previously enjoyable

It may not be dementia

One strong reason it’s worth seeking advice about problems with memory is that some conditions can cause similar symptoms and are reversible if caught early enough.

“Vitamin B12 deficiency, low thyroid, some infections and some sorts of cancer can present as dementia. As a psychogeriatrician, I always check for these, but they occur very rarely in my practice because they’ve usually been screened for by blood tests by the time the patient sees me,” Prof. Brodaty says.

Other conditions with similar symptoms that may be reversible dementia include normal pressure hydrocephalus (a build-up of cerebrospinal fluid in the brain) and infections such as syphilis. Urinary tract infection, certain medications, stress, and depression can mimic dementia and need to be ruled out.

A/Prof. Reppermund says depression in an older person can sometimes look like dementia at first glance.

“There is the term pseudodementia, which refers to major depression in older people that may interfere significantly with their cognitive function, for example their concentration and their memory. And that’s treatable,” she says.

Convincing someone to get assessed

The fact that some conditions appear to look like dementia could be a strong reason to urge someone close to you to visit the GP. But as Prof. Brodaty points out, no-one can be forced to get assessed for dementia.

“If a person refuses to get assessed, and they’ve gone downhill, and they’re no longer able to look after themselves, then you can make an application for an intervention order with what used to be called the Guardianship Tribunal and is now called NCAT in New South Wales,” he says.

The NSW Civil and Administrative Tribunal consists of a legal representative, a presiding member, a health professional and a community member. They hear cases to determine whether or not somebody has decision-making capacity, whether it’s caused by a disability such as dementia, and whether there’s a need for intervention.

“But unless somebody is in danger, or is not able to care for themselves properly, you can’t force someone to do anything different,” says Prof. Brodaty.

A/Prof Reppermund agrees that it may be difficult to convince someone to be assessed, but you can certainly put forward a case for it in a positive and respectful way.

“You can approach them and say, ‘I’ve noticed that your memory may not be working as well as it used to be for you, and I’m a bit worried. Have you noticed that as well?’ So just make them aware and think about whether there is a problem or not. Most of the time they would have seen their own warning signs already. But they may not be open yet to go to a doctor, because it’s scary.”

Life goes on

And even if the diagnosis is dementia, there’s no reason for them to think they’ve moved through a one-way door.

“It is really important for people to see that once you have a diagnosis of dementia, you’re still the same person,” A/Prof. Reppermund says.

“You have a diagnosis so you can plan for it. But that doesn’t mean that from yesterday to today, you are a different person. I think stigma still exists today, that somehow your life ends as soon as you get a diagnosis of dementia.”

In fact, A/Prof. Reppermund says, a diagnosis – which could be for one of more than 100 different types of dementia – can actually come as a relief.

“It’s not necessarily a loss,” she says, “to know what you finally have a name for your symptoms. You can now understand and learn more about the particular type of dementia you have, what to expect and what are the next steps, how to plan for the future, for your finances, and be more confident to tackle the next years of your life.”

People can live positively with dementia for many years, adds Prof. Brodaty, who helped set up a website for people recently diagnosed with dementia that offers advice on how to take their lives forward.

Can dementia be prevented?

Prof. Brodaty says while there is no cure for most types of dementia and no known way to prevent it, we can certainly delay the onset of it, hopefully to the day we die.

“We just ran a large trial online with over 6000 people aged 55 to 77. And we showed that by doing exercise, observing good nutrition such as the Mediterranean diet, being socially connected, and doing brain training exercises as well as treating depression and anxiety – we improved cognition in people, over three years, compared to a control group.”

A/Prof. Reppermund says while there are certain types of dementia which have genetic links, dementia is most probably acquired by a mix of neurobiological and environmental factors.

“There are certain risk factors that make it more or less likely to develop cognitive decline and dementia, including physical and social inactivity. Being inactive, not engaging in social activities, a poor diet and too much alcohol are all risk factors.”

Even then, Prof. Brodaty says, “it’s never too late to start, and never too early to start” making changes that maintain and protect your brain health into old age.

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