Questions I and My Family Should Ask?

• Have you noticed, or has someone who knows me well noticed, any changes in my thinking, such as memory? Am I forgetting more than usual?
• Has my use of language, vocabulary, or way of speaking changed?
• Have you noticed, or has someone who knows me well noticed, changes in my behavior?
• Have you noticed, or has someone who knows me well noticed, changes in my ability to perform functional activities, such as managing finances, driving, or taking medications?
• Have you noticed, or has someone who knows me well noticed, repeated questions, poor planning, or forgetting appointments?
• Have you noticed, or has someone who knows me well noticed, forgetting people’s names or faces, or losing things?

What actions should I take after reviewing this section?

• Consult your family physician, neurologist, or geriatrician about your concerns regarding dementia.
• Dementia is usually assessed in outpatient clinics.
• Ensure that a family member or a trusted friend who knows you well accompanies you to provide additional information about your past history, with your consent.
• Even though reversing dementia is not currently possible, studies show that you can continue performing tasks you want to do if you practice them regularly. Therefore, even if dementia progresses, you may retain this ability.
• Studies indicate that the best way to maintain brain health and reduce the risk of dementia is to exercise at least five times per week for 30 minutes per session.
• A healthy diet has been shown to help reduce the risk of dementia, although evidence is limited.
• Support from loved ones in performing functional activities can help you complete daily tasks. Check whether you are eligible for a home care support program in your area.
• A schedule organizer, calendar, or any visual reminder system can assist in completing daily tasks.
• Ensure that your personal instructions and legal documents, such as powers of attorney, are completed. These legal documents designate who will act as your agent and make financial and healthcare decisions on your behalf if you become unable to do so. See the End-of-Life Planning section for more details.

What Is the Mind?

• The mind encompasses a set of brain functions known as cognition.
• The mind is responsible for thinking, memory, awareness, language, and many other functions.
• As we age, natural changes occur in the brain, causing some decline in brain functions.
• However, there are abnormal changes that can occur due to disease.
• These diseases are not a normal part of aging.
• An example of brain changes not caused solely by aging is cognitive impairment.
• One cause of cognitive impairment in older adults is dementia.

What Are Cognition and Dementia?

• The medical term for brain functions or thinking is cognition, which consists of multiple components that enable the brain to function.
• Knowledge is the mental process of acquiring understanding and comprehension through thought, experience, and the senses.
• Dementia is a broad term with many types, the most common being Alzheimer’s disease, along with other types as well.
• Another term for dementia is major neurocognitive disorder.
• Dementia causes abnormal changes in knowledge and cognitive abilities, which are not part of normal aging.
• Memory is one component of cognition.
• Other aspects of cognition may also be affected.

What Are the Types of Dementia?

Alzheimer’s disease is the most common type of dementia.

• The second most common type is Alzheimer’s disease with vascular changes, known as mixed dementia.
• The third type involves pure vascular changes from strokes only.
• These types can sometimes overlap, making it difficult to distinguish between them.
• There are rare types of dementia, for example: Lewy body dementia, Parkinson’s disease dementia, frontotemporal dementia.
• We will not cover these rare types here.
• Dementia is an abnormal change in brain function, usually more than just memory changes, and may not be reversible.
• It is not part of normal aging but a disease that requires attention and management.

What Are the Symptoms of Dementia and How Do They Appear?

A person with dementia may not notice the changes in their thinking, behavior, and functional abilities.

A close family member or friend may need to observe these changes and report them to the patient and physician.

The most common symptoms are memory changes and forgetfulness; however, dementia may also cause changes beyond memory, affecting other aspects of thinking.

Dementia is not routinely screened in older adults who show no symptoms, as routine screening has not been proven effective.

Assessment is generally done for those with concerns, either by the patient or their family.

Is Forgetfulness a Normal Part of Aging?

• Changes occur in our brains as we age, which are natural, including changes that may affect memory and language but do not impair daily function.
• Dementia, however, is a disease that causes abnormal changes in the brain. Determining whether changes are normal or pathological requires evaluation by a healthcare provider.
• This may involve discussions with you, a close acquaintance or cognitive testing.

What Is Mild Cognitive Impairment (MCI)?

• Mild cognitive impairment (MCI) is also an abnormal change in brain function and is not part of normal aging.
• Healthcare providers detect abnormal changes during assessment, which may not be sufficient to diagnose dementia.
• To simplify, the main distinction is changes in daily functioning:
• If there are no changes in daily functions, it is likely mild cognitive impairment.
• If there are changes in daily functions, the diagnosis would be dementia.
• Keep in mind that a diagnosis of MCI increases the risk of developing dementia by approximately 10% per year.

In Summary

• Natural brain changes occur with aging.
• Mild cognitive impairment is abnormal, yet daily functions remain intact.
• Dementia is abnormal and involves loss of functional abilities.
• Dementia may limit your ability to drive safely; consult your healthcare provider regarding this.

Why Is Dementia Risky?

• Dementia causes abnormal changes not only in thinking and cognition but also in behavior.
• It can lead to loss of ability to perform usual tasks.
• Daily functions can be divided into:
• Basic Activities of Daily Living (ADLs): walking, using the toilet, bathing, personal hygiene, eating, dressing.
• Instrumental Activities of Daily Living (IADLs): cooking, household management, laundry, driving, taking medications, using the phone or computer, managing finances.
• Dementia initially impairs the ability to perform IADLs and progresses to affect the ability to perform basic ADLs as the disease advances.

What May Increase the Risk of Dementia?

• There are many factors that can increase the risk of developing dementia, and some of these factors can be managed.
• Reducing these risks is important for managing dementia and preventing it as much as possible.
• There are also factors that cannot be changed and that increase the risk, such as aging, female sex, race, family history of dementia, and head injuries.
• On the other hand, some factors can be modified, including high blood pressure, diabetes, smoking, alcohol consumption, high cholesterol, poor nutrition, and lack of physical activity.
• There is no specific test for dementia. The main symptoms are the loss of functional abilities, which requires a detailed evaluation by a physician, including medical history and cognitive assessment.

Can the Course of Dementia Be Reversed?

• The first thing a physician does when evaluating a person for dementia is to ensure that the individual does not have a type of dementia that can be reversed or another alternative diagnosis.
• There are other medical conditions that may mimic dementia and can be reversed.
• An example is delirium, which is different from dementia.
• Delirium resembles a rapid brain event that causes confusion and loss of attention.
• It may be triggered by medication changes, infections, or other illnesses. (See the Delirium section for more details.)
• Other examples of potentially reversible dementia include abnormal thyroid function, hearing or vision loss, head trauma, medication changes, mood changes, and various other conditions.
• Unfortunately, the types of dementia mentioned above, such as Alzheimer’s disease, cannot be reversed and typically progress over time.
• Your physician must ensure that there is no alternative diagnosis or reversible type of dementia before diagnosing conditions like Alzheimer’s disease.

How Is Dementia Diagnosed?

• There is no single test that can diagnose dementia;
• Diagnosis is made clinically. Clinical diagnosis involves reviewing the patient’s medical history and symptoms.
• An observer or someone who knows you well can provide information about your condition.
• Your physician must obtain your consent before discussing your case with another person.
• It is important to conduct a cognitive assessment, which usually involves paper-based tests that take a few minutes to complete with a trained examiner.
• There is no specific blood test or imaging study that can diagnose dementia. However, some tests may be useful to rule out alternative diagnoses or reversible types of dementia.
• Your physician may order blood tests and brain imaging, such as a CT scan, MRI, and cognitive testing.
• Please refer to the Clinic Visits section for more details.

What Is a Cognitive Assessment?

• A cognitive assessment is usually a paper-based screening tool used by a healthcare provider to check for signs and symptoms of dementia.
• Evidence does not support screening all older adults who have no symptoms. These assessments are typically conducted in the appropriate context, such as concern from family members, caregivers, or referrals from healthcare providers.
• These assessments are administered by trained healthcare professionals, and the results should not be interpreted in isolation. It is important that the evaluation includes other components, such as the patient’s medical history, to make a diagnosis.
• I Heard We Can Test Genes to Detect Dementia. Should I Get Tested if My Family Has a History?
• There is no evidence that genetic testing for dementia changes the approach to diagnosis, management, or treatment. Currently, genetic testing is primarily used for research purposes, and it has not been shown to provide meaningful benefits for general population screening.
• Some individuals may carry a gene but never develop dementia, while others may not carry it and still develop the disease. For this reason, many experts advise against routine genetic testing.
• The risk of developing dementia increases by approximately 30% if a first-degree relative (parents, siblings, or children) has Alzheimer’s disease.
• Cognitive functions in the brain can be affected, including memory, orientation to time and place, recognition of people, language, judgment and planning.

Is There a Cure for Dementia? Are There Treatments?

• Although there is no cure for dementia, there are treatment approaches that fall into two main categories: lifestyle modifications and medications in certain cases.
• Lifestyle modifications focus on activities that help maintain optimal blood flow to the brain, including controlling diabetes and high blood pressure, managing cholesterol levels, avoiding alcohol and smoking, improving diet, exercising regularly, and maintaining good sleep.
• Some evidence suggests that medications may help slow the progression of dementia, but they do not provide a cure.
• This class of medications is known as cholinesterase inhibitors.
• Even in these cases, the medications have a moderate effect at best and are usually prescribed for individuals with mild to moderate dementia, but they are not used in severe dementia.
• Examples of these medications include Donepezil, Galantamine and Rivastigmine. Another medication, Memantine, is not classified as a cholinesterase inhibitor but has been shown to be effective in severe dementia.
• Consult your physician to determine whether taking these medications is appropriate, as it is important to understand what to expect from them and their potential side effects.

Who Decides Whether to Take Dementia Medications?

• These medications usually do not provide significant benefit, but they may help in some cases, depending on your physician’s evaluation.
• Although evidence is limited, some studies suggest that these medications may reduce behavioral problems associated with dementia, but their effectiveness depends on each individual case.
• It is important to remember that the evidence for these medications mainly applies to Alzheimer’s disease. They may be used in other types of dementia, but their effect is not strong.
• Unfortunately, the side effects in some cases may outweigh the potential benefits, making it inappropriate to start treatment.
• Always consult your physician about these medications. Continuous evaluation is necessary to determine whether the benefits outweigh the risks and whether starting the medication is justified.
• The decision to take dementia medications is complex and depends on the individual case, as well as the values and preferences of the patient and family.
• Due to the moderate effect of these medications, exposure to potential side effects may not be worthwhile.

Are These Medications Effective in Mild Cognitive Impairment?

• Unfortunately, there is no evidence that using these medications is beneficial in cases of mild cognitive impairment (MCI). In fact, some evidence suggests that they may cause harm or side effects in such cases.

What Are the Side Effects of Dementia Medications?

• Runny nose and nasal discharge.
• Nausea, vomiting and diarrhea.
• Increased mucus in the lungs, which may cause breathing difficulties if you have a pre-existing lung condition.
• Irregular heartbeat and slow heart rate.
• Urinary symptoms, such as urinary incontinence.
• Weight loss.
• Rare but serious side effects include muscle weakness, which may lead to kidney failure.

What About Behavioral and Psychological Aspects of Dementia?

• Dementia does not only cause problems with thinking and cognition, but it can also lead to behavioral and mood symptoms.
• These changes are referred to as the behavioral and psychological symptoms of dementia (BPSD).
• Examples include aggression, irritability, hallucinations, depression, and anxiety.
• Managing behavioral and psychological symptoms can be challenging because their presentation varies from person to person.
• The key point to note is that most studies suggest managing these changes through non-pharmacological methods.
• Evaluating these symptoms may take time and requires expertise, so it is recommended that your physician conduct a comprehensive assessment.
• Although some evidence suggests that cholinesterase inhibitors and memantine may have preventive effects, their effectiveness in treating behavioral and psychological symptoms of dementia has not been proven.
• Antipsychotic medications have shown benefits in managing behavioral and psychological symptoms of dementia; however, they are not used in complex cases with severe behaviors and are not the first-line treatment.
• It is important to note that the use of these medications must balance the potential benefits against the risks and side effects, and they should be used only in severe cases with complex behavioral issues. This is a complex decision that requires detailed evaluation by healthcare providers, the family, and consideration of the patient’s values and goals.
• Behavioral and psychological symptoms may appear in dementia, but treatment usually relies on non-pharmacological approaches.

Are There Other Medications or Supplements That Can Prevent or Slow Dementia?

• Few studies have shown potential benefits of certain supplements or medications in managing dementia.
• Evidence regarding Ginkgo biloba, a plant extract, indicates that it may not be beneficial and is not considered a treatment.
• Studies on vitamin E have been conducted, but evidence for cognitive improvement is weak, and it may be harmful, especially for individuals with heart problems.
• Unfortunately, statin medications, omega-3 fatty acids, estrogen, anti-inflammatory drugs, and marijuana have not been proven effective in treating dementia.
• Many other medications have either not been studied or have been shown to cause harm. Always consult your physician before starting any medications or supplements.

If There Is No Cure, Why Do We Care About Early Diagnosis and Management of Dementia?

• Early diagnosis and management of dementia help in many aspects of our health.
• The benefits and effectiveness of early intervention include:
• Knowing that it is a disease, and not the person’s fault for changes in thinking or behavior.
• Maximizing the person’s freedom and independence as much as possible.
• Delaying the need for nursing home care or rehabilitation.
• Supporting family members and avoiding caregiver burnout.
• Providing strategies to address cognitive, behavioral, psychological, and functional problems, whether with medications or without.
• Assessing safety needs, such as driving.
• Dementia is irreversible, long-term, and may worsen over time. Delirium, on the other hand, is short-term, reversible, and has multiple causes.
• Dementia may also increase your risk of developing delirium.

What Is the Difference Between Dementia and Delirium?

• Delirium, also known as an acute brain episode, is a rapid-onset state of confusion, with the main symptom being impaired attention.
• Delirium can occur due to multiple causes, but it is usually reversible. The treatment for delirium focuses on addressing the underlying cause. Please refer to the Delirium section for more details.