Dementia; Recognizing Early Signs Of Cognitive Impairment
The Importance Of Early Detection
Of all the major diseases, those classified as neurodegenerative are among the most difficult to accurately assess in the early stages by clinicians and the most challenging to deal with by family members in the later stages. The majority of these diseases exist within the final frontier of medicine and we’ve only just begun to make significant strides in better understanding their origins in the last two decades or so. The onset of neurodegenerative disease and subsequent gradual loss of independence very compellingly emphasizes the need for earliest detection of its presence for a variety of reasons. Of greatest significance is the recognition that family members may be the very best source of early detection possible.
Of all the body’s major organs, the brain is inarguably the most complex in terms of function. It houses the very essence of who we are as individual human beings and expresses the total sum of how we react to the environment around us. As critical as our brains are in orchestrating body functions and cognitively expressing thought & personality characteristics, it is catastrophic when these particular elements of life are subjected to disease. Equally troublesome is the fact that we presently have very few weapons in our arsenal to combat these diseases, certainly not from a curative standpoint and our ability to stave off progression is still proving to yield minimal results at best.
The value of early detection not only benefits everyone who may subsequently be impacted in some way by the progressive course of these diseases, but also to highlight the fact that a respectable number of non-neurological diseases that produce neurological symptoms are treatable. It is therefore critical to establish the best possible means of recognizing the early features of cognitive impairment and seeking subsequent evaluation.
In possibly no other arena of healthcare does the family of a person afflicted with cognitive impairment become such a vital part of efforts to help accurately diagnose and provide the best standards of care possible. Likewise, the presence of actual neurodegenerative disease in a loved one produces a significant impact upon the family as well. As a result, it has often become the practice by physicians to vocalize these concerns when meeting with both the family and the patient, providing assistance to everyone involved where possible.
Dementia; A Vast Territory
When most people think about dementia, they consider the term to be synonymous with Alzheimer’s disease but it’s important to realize that dementia is more accurately a generalization of impaired cognitive function that is present in many different neurodegenerative diseases. In approaching the task of early detection then, it is imperative to focus on identifying very specific elements of impaired cognitive function rather than merely the presence of dementia in general. This is critical because the exact nature of onset with respect to many neurological diseases can be highly valuable to the clinician in accurately determining the particular disease that may be responsible.
Is It First Something Treatable?
Before moving along into discussion of the early signs of cognitive impairment, it’s important to provide the caveat that impaired cognitive function can arise for many reasons that do not necessarily implicate the presence of neurological disease. Therefore, in the interest of a stepwise approach, it’s important to touch on some of the most common reasons wherein people of advanced age may demonstrate impaired cognitive function. Additionally, all of the following causes of cognitive impairment are treatable in some manner.
Polypharmacy, Overmedication, or Medication Side Effects –
People of advanced age who take a broad spectrum of medications can sometimes demonstrate cognitive impairment from the effects of polypharmacy (simultaneous treatment with a multitude of prescription medications), where two or more medications may be interacting in a negative manner. Signs of overmedication typically appear as an over-dramatization of the drug’s primary effect in most instances but depending upon the specific drug, can produce an opposite reaction in certain instances. The side effects of most all medications are available in the disclosure that came with the medication or can be found online. The potential for cognitive impairment will be listed among patient complaints or observed by clinicians during clinical trials if it was encountered. Questions of cognitive impairment related to any of these potential causes should promptly be discussed with the prescribing physician.
Clinical Depression –
The cognitive impairment associated with clinical depression can sometimes be quite remarkable, so much so that depression has been characterized as pseudo-dementia in some regards. Cognitive impairment occurs in persons with clinical depression because the nature of the disorder interferes with cognitive processing. In other words, the brain must effectively be able to attend to, and sequentially process, incoming information in order to work with it accurately, factors that are both disturbed by the presence of clinical depression. It’s also important to note here that depression in the more elderly person often appears different from signs in younger individuals. The features of depression in older persons will often present as forgetfulness, geographic disorientation, inability to concentrate and agitation. Older persons need not appear despondent or be anhedonic for depression to be present. If the depression is severe enough, some patients can even demonstrate psychosis in some instances but such presentations are uncommon. The key here is that the onset of cognitive impairment in depression is relatively insidious but highly treatable, so recognition of the signs and discussion with the primary health care physician is critical.
Vitamin & Metabolite Deficiencies, -
This one’s a bit complex from the standpoint of precisely being able to determine whether a deficiency exists with respect to B12 and implications of cognitive impairment. It is important to note that total vitamin B12 levels are somewhat misleading, so simply having serum B12 levels checked during routine office visits does little if anything to implicate the presence of an actual deficiency. Instead, clinical lab studies should target levels of holotranscobolamin (holoTC) and methylmalonic acid (MA) as indicators of true B12 status, supported by a third test to determine levels of homocysteine.
Instances of cognitive impairment arising from the direct deficiency of B12 are far less common but do occur, most commonly presenting as problems with memory and the presence of mild confusion. Studies, however, are presently mixed regarding whether deficiencies truly impact cognition either way. It is, however, a very treatable condition and treatment is nevertheless vital to avoid problems other than cognitive impairment such as anemia.
As an important caveat, in any instance where B12 & B9 Folate levels are found to be deficient through testing as described above, patients should never be administered Folate supplements alone, always making absolutely certain to provide B9 and B12 simultaneously in all instances. Additionally, B12 & B9 Folate supplementation in the absence of a deficiency does not correlate with enhanced cognitive function.
Hearing Problem –
Interestingly enough, the presence of an undiagnosed hearing problem can lead to the erroneous conclusion that cognitive impairment may be present. This is particularly the case wherein patients misinterpret what they hear and tend to respond in a manner inconsistent with a person’s question or statement to them. The key to watch for here is the interspersion of body language and vocal responses that indicate the inability to effectively hear what is being said, i.e. turning one’s ear toward the person speaking, holding a hand to the ear, leaning toward the person speaking or constantly asking for information to be repeated. The stigma of a hearing problem causes most individuals to try and conceal its presence as well. Auditory testing should be established in any such instance where signs are present.
A Final Word On Treatable Causes
The treatable conditions above generally represent chronic circumstances capable of inducing cognitive impairment. There are many acute conditions such as urinary tract infection that commonly produce altered mental status in the manner of delirium in persons of advanced age. In the interest of brevity, rather than list and discuss the rather expansive acute factors, it is sufficient to state that the presence of any acute change in mental status warrants immediate medical evaluation. Acute in this instance is defined as hours to days rather than weeks and months associated with more chronic variations.
What Is Cognitive Impairment?
To exercise recognition of early cognitive impairment, it’s important to know the formal definition and common features. Cognitive impairment is any expression or characteristic that act as a barrier to normal cognitive processing.
Mild Cognitive Impairment (MCI)
Mild Cognitive Impairment, or MCI, is a relatively new classification and specifically related to mild memory impairment in the clear absence of any other cognitive dysfunction. Some disciplines define MCI as either amnestic or non-amnestic, but the most narrow definition is that memory alone is affected.
The effects of MCI upon memory might be very subtle, sometimes discounted altogether by the person affected and family members as merely a by-product of advanced age. The misconception that memory loss is somewhat normal in persons of advanced age is responsible in large part for why patients are evaluated at later, rather than earlier, stages of progression. In truth, age has no bearing on memory performance and although many factors of aging affect memory, they are pathological nonetheless. The major distinction with MCI is that its effects do not interfere with normal daily living. The signs are present, but are typically overcome by compensatory measures.
Some common examples of signs associated with MCI exist as initially forgetting where articles in daily use have been placed, forgetting names, phone numbers or instructions that were recently provided. The affected individual might ask for information to be repeated a number of times or alternatively find it necessary to make notes for tasks that are very simple in nature.
Cognitive Impairment (CI)
Cognitive Impairment expands the impairment of memory to include problems with executive function, or in other words the process of more complex behaviors over longer time periods such as judgment, planning, decision-making and impulse control. The expression of problems in these areas most often typifies more advanced cognitive impairment.
Symptoms of CI might be expressed as the inability to properly sequence a set of tasks to reach a cumulative goal, like recipes or constructing models. Decision-making problems most typically appear as the inability to express a prompt decision regarding simple matters that are otherwise easily accomplished by others in the same age group, i.e. unable to make the decision to eat out or stay at home and cook. Impulse control problems arise in the manner of speech or action that is socially unacceptable, i.e. discussing sexual matters in public or otherwise sharing thoughts that are normally restricted to privacy, demonstrating social withdrawal, diminished empathy for others, overeating, general absence of manners, unwarranted aggression, etc.
Symptoms of CI might also include semantic disfluency, or in other words the inability to form meaningful sentences. Problems in this area may initially begin with a descriptive substitution of the actual word for something generally descriptive, i.e. “you know, the “thingy” the whatcha-call-it.” While many people do this under pressured circumstances during casual conversation, the person with actual impairment is producing such speech regularly.
Other symptoms of CI might be the observation of aphasia in the inability to either properly pronounce or annunciate words or word substitution. Mild forms of such impairment would be the need to constantly repeat a certain word and each time pronouncing it close, but never really exact, i.e. “we then took his cadillan . . . cadlle . . .. .cadda . . . . .cadillade” in the attempt to say the word Cadillac. Another example might be a person who begins using the term “poon” to describe a spoon.
This list of early signs is by no means all-inclusive, but it provides family members and prospective patients with a concise list of commonly present signs that may otherwise be overlooked in their earliest stages. Again, it must be emphasized that these signs represent the mildest range and typically advance to worsening stages in the instances where disease is actually the cause. Also it is the constant or repetitive presence of these signs that should alert the observer to a problem rather than isolated or infrequent instances. In other words, it’s not a sign that has been observed all along in someone, but rather the appearance of change from the normal state to one similar to that being described here.
Again, remember that family members look for signs of its presence over an extended course of time and in the absence of trying to implicate it as part of any specific disorder or disease. The key for family members is to detect it and for the doctor to define it.
Cognitive impairment can range extensively and the full complexity of signs and symptoms must without doubt come under the evaluation of a licensed physician or specialist. It is purely the aim of this article to scratch the surface far enough to provide family members, caregivers and even prospective patients with enough information to promote and improve early detection of a problem.
While the prospect of neurodegenerative disease is unappealing at the very least, frightening at most, it is nevertheless vital to seek formal evaluation to determine whether the observable signs are being caused more commonly by an entirely treatable condition. It is also important for anyone suspecting the early signs of cognitive impairment to engage the matter as early as possible in order to vastly improve the network of awareness regarding both treatable conditions and neurodegenerative disease with the hope of increasing the quality of research and care for those affected.