Identifying and Managing Early Signs of Dementia | Brain Talks | Being Patient

we're gonna talk about identifying and managing early signs of dementia you know we've talked to a lot of you getting that first diagnosis is often a very painful experience people it's common people are misdiagnosed so we thought we would really delve into the issue today about really what do those early signs look like how do you manage them how you get a dementia diagnosis so we're pleased today to have with us dr. Stephanie Collier she is from McLean Hospital a hospital a psychiatric hospital affiliated with Harvard welcome and thanks so much for joining us thank you so Stephanie I just really want to start first with um those you know I often we we have a series here called being patient brain talks where we look at dementia from the person's point of view the the patient's point of view and we ask them you know in hindsight how did you know something was first wrong and oftentimes it's not really memory loss that they talk about it's more of an intention problem or their productivity at work slipped to talk to us about a little bit about what are those really early signs are there any patterns that you've observed given your experience with seeing patients with dementia I'm really glad you mentioned the attentional problems because I do see that a lot where patients come in saying they used to have you know very good attention and now they're struggling this to continue the task that they started besides the attentional problems sometimes they've also noticed that they're just not able to perform as well as they could previously perform at work and they might have small memory lapses those are usually the first signs and the memory lapses are usually for things that have happened very very recently that day or the day before for example it might take him a little bit longer to remember what did they have for breakfast or who did they talk to her what was the name of the person that they had talked to an hour ago and sometimes these are so subtle that they're a little bit frightening to the patient when they're first aware that they're having these very very small memory lapses when when people come to see you as a psychiatrist is it usually and I know you see you specialize in elder patients and so I think you were telling me before you know anyone over 60 years old when is it is it usually the oh I'm starting to worry I don't know if it's normal aging or if it's memory loss is is that the starting point usually for your patients with dementia very often it could be and it's not always related to memory at all it could be anxiety disorders and people as they get older can forget short term they have a little lapse into short-term memory they might forget the name of someone or they might forget an ingredient on their shopping list and that's completely normal but if they're anxious they'll remember that they forgot it and so that might bring them in because they want to make sure that they don't have dementia and that's the diagnosis that people are very frightened of hearing and so they often you come very early and they don't always have progression to mild cognitive impairment or to dementia so and go ahead some are good the other the other diagnosis that can appear similar is depression when people are in a depression in a major depressive episode especially if it's one of their first episodes as an older adult they may worry that they're just not thinking they're not as sharp as they were previously and it's due to the depression and the memory improves when the depression is treated right so you know I want to go a little bit back into that that a DD or ADHD type of symptom because that's often explained to us you know like oh I couldn't hold my attention at work have have we are we aware of any link between attention deficit and you know maybe as an early sign of dementia so attention can be affected as an early sign in dementia absolutely but if someone has attention deficit disorder that does not necessarily mean that they're going to progress to dementia so there are studies that have looked at the association between ADHD and later development of dementia and there is a correlation but we do not have enough data to say that this is causation that there are changes in the brain that occur with ADHD that cause dementia Jenin to someone is asking us how common is out-of-body feelings in dementia like your own bubble or your own world I have heard that I haven't heard that very commonly the out-of-body experience it's interesting because I don't necessarily know if that goes with dementia more than other diagnoses as well sometimes when people experience anxiety which may or may not be due to the dementia they can also experience these out of body sensations as well well one thing that's interesting to talk about is um you know we've talked to quite a few people who have been misdiagnosed with different types of dementia right so they're given a diagnosis of early onset when they actually later find out that they had Lewy body from those early signs is it is it common or difficult is it easy or difficult to understand that there may be different dementia um in terms of looking at it up in the very early stage in a very early stage it is extremely difficult to make an accurate diagnosis because so many symptoms can overlap between different dimensions but also to other psychiatric illnesses and many people with dementia also have comorbidity of depression or anxiety that can affect their cognitive performance so longitudinal history is the best if it's a sudden onset we can think of maybe more of a vascular picture many strokes can cause symptoms that can look quite similar to Alzheimer's dementia with a Lumina body dementia that's on the spectrum of Parkinson's disease and patients often develop motor symptoms later on but early on they can have different symptoms without any they can have cognitive symptoms without any motor symptoms with frontotemporal dementia which can happen with earlier on people can have just changes in personality but they might not have the short-term memory problems that you would see with other types of dementia so also within Alzheimer's dementia there's such a variable presentation so no two patients look exactly identical yeah I mean that's also a really difficult one to just as as this viewer mentioned you know that kind of out-of-body experience is like you've heard it before but is it common and what how is it related to the brain and neuro degeneration you know there's it just makes us realize how much more there really is to study in terms of progression and diagnosis and early stage symptoms what is what is the most common thing you hear from your patients in terms of that early stage is it is it in fact depression are they come are they coming because they're depressed or they be coming because now there's clear signs of cognitive impairment it really depends where they are in the dementia so at the very very early stages people may be concerned about their memory but predominantly anxiety and depressive symptoms might be the first thing that I would confidently diagnose because there's such high comorbidity later on sometimes people aren't as aware of their cognitive deficits and it might be family members who have noticed that the patient is suffering from memory problems what the patient might not be as aware and they may not even notice that they've had trouble even though they have a significant trouble and need significant assistance from family members or other supports questions coming in someone has said my mom had early onset at 59 my grandmother and great-grandmother died from dementia should I be worried so how much when you're diagnosing how how important is that genetic link and are most people opting to find out if in fact they do have the genetic link that's a very personal decision and only a subset of Alzheimer's dementia is based on family history with early onset it's it's likelier but but by no means is it definite and people really very about whether they want to receive this diagnosis and whether they want to undergo testing early on and there's no right or wrong in deciding to pursue testing or not and as the question whether to be worried we don't know the diagnosis and it's early right now so so it's because we don't know that might be more work for some it might be more worrisome for others receiving the diagnosis might be more worrisome so do you find I mean you talked a bit about depression and how you know but depression is often people are coming in for depression to find out later that they have some sort of cognitive impairment if you have you found if you treat depression the memory actually improves a bit can't yes that way very often and that is one of the nicest things about having treated depression in older adults because people generally do worry about their memory they are feeling depressed and depression certainly affects memory the more depressive episode the person has the higher the likelihood that they will later have cognitive impairment so treating depression makes a huge difference in cognitive performance I actually have a patient who had neuropsychological testing about one or two years apart and dramatically improved and that was due to treated depression it was making why do we do we know what the exact link is do we know why so for the neuropsychological testing there's so many different domains that are involved and yes attention is impaired by depression itself but so is motivation so is the ability to sustain concentration on tasks and if the motivate these are long tests as well and so if someone's not feeling well they might not feel confident they might just give that they won't complete testing so you might not actually get an accurate picture of how they could perform during a depressive episode another question is is having trouble with sensory overload or problems with just being easily overloaded a sign of dementia it's a possible sign of dementia but it's again if this is something new it could be due to other neurologic conditions as well so I wouldn't assume that it's due to a dementia if there's no other symptoms in order to diagnose dementia it really does have to affect the activities of daily living and it has to it's generally a progressive illness too so I I wouldn't say if you just have those sensory symptoms that that's a warning sign esses airily development of dementia so we were talking about this earlier um why do most people get a diagnosis for MCI mild cognitive impairment before they get the diagnosis that it's a type of dementia it's Alzheimer's why is that so if it's an accurate diagnosis is another question sometimes people don't feel comfortable making that diagnosis without additional testing for example in a primary care office many I work with primary care physicians they do not necessarily feel comfortable making that diagnosis in a clinic setting a patient can have a very classic history before a dementia but they might not hear it from their primary care doctor because these are short appointments there may not be sufficient information and the confidence level of making the diagnosis just based on 20 minute appointments isn't there however if a patient's illness does meet criteria for MCI that's basically mild cognitive impairment is impairment in the instrumental activities of daily living so that would be difficulty with paying bills or finance other finances or cooking making shopping lists and grocery shopping and there can be forgetfulness but not to the point that it interferes with the activities such as grooming themselves bathing the activities of daily living and if it's caught early May before people do you have the diagnosis of dementia they do go through a stage where their symptoms are just not as severe and so not everyone who has mild cognitive impairment will progress that's maybe just 10 15 % of people with mild cognitive impairment that will progress to dementia but there can again be many causes of mild cognitive impairment - it could be due to small vascular insults in the brain for example that's not necessarily progressive if the cardiovascular risk factors are treated well you're just saying so of yours asking who to see my husband was diagnosed with early onset dementia several years ago by his family doctor I would like further diagnosis there was a lot a lot more information we could have given the doctor but he wasn't interested and frankly neither was my husband I'm sure he was depressed and anxious do we see a neurologist or a psychologist that's an excellent question like who do you go see and who's going to very very good question and I have to say I'm both could be qualified to provide that diagnosis a neurologist absolutely especially if there are other physical symptoms that are going along with the dementia and then it would be worth having a neurologic evaluation this for example if there's some stiffness or rigidity you want to make sure that this isn't something like a Parkinson's disease dementia or Lewy body dementia if there are no physical symptoms and a patient would like neuropsychological testing have referral to a neuropsychologist can be very helpful for this extensive testing that really measures different domains different cognitive domains including attention and memory and visual spatial and can help with the differential diagnosis - and can also make the diagnosis and say this is far enough from from the norm that we feel confident giving you a diagnosis of major cognitive in major neurocognitive disorder okay another viewer is saying you know you can tell this is a pain point for people because you know in their experience going through this it's it's not often crystal clear what our board is so it's great to have someone like you to help us navigate some of this information so this person is asking saying my husband is a typical he has multiple des benches Alzheimer's Lewy body and FTD seems like the medications are constantly being changed to address parkinsonism and sleeping as well as REM sleep disorder is this just the way of life with dementia trial trial and error with medication I'm exhausted from monitoring medication behavior changes and fall prevention I mean I can imagine I and that's a lot of dementia is at one time is that possible so that's really a very wide very wide differential very large I that's a lot of dementia I am curious how these dimensions were diagnosed I think most likely there's one or two the most common would be Alzheimer's with plus-minus vascular dementia but to have really so many different dimensions diagnosed at the same time it's a little bit unusual I have to say and so I would just be curious how these diagnoses came about and if it was by by testing or otherwise as for the medications unfortunately people with dementia are often placed on medications to control behaviors and to control mood and the medications are not without risk and sometimes the medications can worsen the behavior for example in older adults who take medications in the classic called benzodiazepines you may have heard of Valium or a tab and it can actually it's meant to sedate people but it can actually dis inhibit older adults and can make behaviors worsen so you end up giving more medications or some medications and the antipsychotic class can make people feel a little bit stiffer rigid and then you might have other medications that are counteracting the stiffness in the Raby which might cause cognitive blunting and so I'm simplifying medications is actually the majority of what I do removing medications to see what he works and only to be on medications the minimum amount of medications that help control specific symptoms so I want to pick apart this issue a little bit because again there's a lot of confusion around diagnosis I mean the fact that this person said her husband received multiple he has multiple dementia Alzheimer's Lewy bodies and FTD now I have spoken to a pathologist who told me on brain autopsies seventy-five percent of the cases is often mixed dementia it's not just one type of which is which is understandable in a very simplistic way as dementia progresses I mean I think it can impact different parts of the brain am i right in assuming that or bro absolutely right if we live long enough we will all have Alzheimer's pathology on our brain but that doesn't necessarily mean we have the sort of phenotype of Alzheimer's disease that we have the symptoms of Alzheimer's disease our brains can actually look a lot worse than a clinical presentation and vice versa our brains can look okay and we can have pretty severe symptoms there's huge variability there too so just because the pathology is there doesn't mean that's necessarily the reason so yes there might be pathology from multiple technical types and it is more common to have the vascular and Alzheimer's together for example or vascular plus another contributor for dementia right but now presumably to have also I don't know how old this person is but to have all three at one time how would you even begin to diagnose that I mean that would require a PET scan would it not or how you can you could look at imaging frontal temporal dementia again the brain doesn't always look like the clinical picture there are people with clear frontotemporal dementia who have very characteristic symptoms you have on imaging normal looking brains the dementia part on imaging the atrophy that does come later however to have all three of of those dimensions present at the same time I also wonder a little bit about the presentation of the patient because symptoms can overlap when you think of Santa temporal dementia you think of a person who may be disinhibited and with progression of Alzheimer's disease you can see personality changes and disinhibition as well so if it happened early on someone might say well this is a younger person who has more personality changes maybe this is depression temporal dementia but it's actually early onset Alzheimer's and sometimes that first symptoms of Alzheimer's this can actually be personality changes or mood changes so it is a little bit tricky clinically so and let's get let's talk a little bit more about the medications because this is also a really big pain point for people you know we hear from both sides of the spectrum my mom or my wife turned into a zombie and was not even a semblance of her personality so what was the point to you know terrible reactions to medication like you know outbursts or just completely unmanageable behavioral consequences to medication so is it true that you just it's like trial and error you have to try and then find the one but there's you know sometimes that's a really long road for people to try before they get to the right equation so how do you handle that and what question should we be asking doctors in order to understand whether it's the best fit for the person okay before even getting to medications the guidelines actually do state that nonpharmacologic options should be pursued first so in a patient who may have agitated for example non pharmacologic interventions are more effective than medications and even though they're harder to implement it is worth trying different strategies with a person to see what comes them down some people might respond to music some people might respond to touch or massage some people might respond to you just touching their hand and singing a song or opening a photo album or distracting them those can be very helpful interventions and when you know what works for a person continuing those intervention and helping to educate other family members and caregivers about what interventions work to decrease agitation medications should only be used if non pharmacologic interventions are not sufficient and when deciding which medication to start it's stream' ly important to try the lowest dose to see if it makes a difference if it does not make a difference you can consider increasing the dose if there are no side effects however you should know that the medications are not without risk and there are risks from mortality and older adults with dementia especially in the antipsychotic class so these are not harmless medications and if they are not helping to decrease the agitation or to decrease the target symptom you're looking at then there they should not be continued it's not that they should be continued an additional medication should be added so thinking about what is again the minimum amount of medication to manage a target behavior whether it's agitation when it's very severe and other other interventions haven't worked so but let's talk a little bit about depression in that regard because I'm assuming treating you know if someone comes to you and is really depressed showing signs of cognitive impairment would it be with the choice feed do behavioral modifications so strategies or would it be let's just get you on medication to cure the depression because that may help your memory yeah so unfortunately the data show that in dementia antidepressants don't really work in treating depression due to dementia so the person has a history of depression then you may respond to antidepressants but if someone does not have a history of depression and they have a diagnosis of dementia the evidence is very poor that antidepressants even work and so non pharmacologic interventions actually can be very helpful for a dementia that could involve psychotherapy that can involve also more structured interventions how do we remove activities that cause a patient to stress and schedule in things that the patient really enjoys and working with a patient to customize their day structure their day and really hit sort of the target points that bring them joy also physical activity outdoor activity especially has been shown to be a very good antidepressant and works better than antidepressants for people with dementia who don't have a history of depression often comes up on our website which is you know what do we know about CBD or marijuana based treatments I know there's the research is pretty at a very nascent stage it's really just starting but like from your experience as a psychiatrist is CBD is that something that you would tell patients to consider I think we don't have enough evidence yet we're working at it there's studies underway but at this moment we do not have enough evidence to recommend cannabis products for anxiety depression some plenty of my patients take cannabis products they may have a history of taking candidate cannabis products and it may work for them at times we do know there's sort of a dose-dependent action of cannabis products we also know that we're too early on to be able to recommend in good faith that these products are helpful for target symptoms like depression or anxiety that's I mean it will be really interesting we've interviewed researchers who are really taking on CBD to understand but unfortunately there's just not enough data yet but again we have people on our site all the time who are saying well I take it or you know I mean as a legalized a lot of people are choosing to to take it regardless of what the evidence is out there Wow yeah and people are afraid to make their own choices with that it's just not enough that we can say we have the data to suggest that this will be helpful yeah and understandable um okay so I just wanted to go into a little bit about how because there is so much confusion over diagnosis in that earlier stage yeah you know I feel like a lot of the doctors out there some doctors out there who maybe don't have the opportunity to see dementia patients that often may need help in in what's the right way to diagnose and so tell us a little bit about like how you if from the very first time you see a patient how do you conclude that it is a dementia or a type of dementia and and how do you know you're right in in that diagnosis yeah that's an extremely good question and I do work with primary care doctors expect exactly on this how do you how do you figure out whether this may be a dementia and how do you formalize the diagnosis and how do you talk to the patient about the diagnosis I I do recommend screening tools the screening tool that I recommend is called a MOCA the Montreal cognitive assessment and it's a wonderful screening tool it's not diagnostic but it does test different domains including attention and delayed recall they're five words that patients have to remember after five minutes which is pretty it's not easy and so visual spatial attention naming rare animals and alright let me let me just sorry Stephanie let me just interrupt you really quickly there because why I'm puzzled by the MOCA test because I've done it with my own my mother and yeah some days she doesn't perform so well in other days she's spot-on and she performs really well so you know again it's this pattern of well you know if I took her to the doctors on the day she's like I'm given sure probably four or five times just to see and what she scores is I mean the only thing that she messed up on every single time was the clock drawing the clock but other than that her score is vary considerably yeah I mean some days I was passing you know so and and this is a screening tool so absolutely not diagnostic however if this score does come back and it's if someone's taken the MOCA a few times they also do learn so there are different versions of the MOCA to keep in mind but if someone performs poor poorly and more than would be expected given their educational history of their professional history that can set off something to make you think about maybe something else might be going on the first thing you want to consider is is there something medical that could be contributing for example does the patient have a little vitamin b12 level and that could look exactly like cognitive impairment and when the b12 level is back to normal people's cognitive functioning goes right back to normal so exact relationship between b12 I've often wondered that too because I'm low in b12 what what's the exact relationship between memory and b12 so I don't know the exact relationship between memory and b12 we do know that in people who have low levels that they don't perform as well on cognitive testing and they don't feel as clear as well and it doesn't just affect memory it also affects mood so if a person is found to have a low b12 supplementing can be life-changing and how they feel but also how they perform cognitively so other things to think about our thyroid function both hyperthyroidism and hypothyroidism I have a patient right now with with thyroid difficulties whose cognitive functioning has changed from one week to the next so so the normalizing thyroid function to make a huge difference in cognitive performance and also medications so patients view for example takes out of an hour valium or other benzodiazepines for anxiety chronically they might feel that over time either the medication is not as effective or that they just feel a bit more sedated during the day and it can't perform as well as they used to perform on tests and actually simplifying the medications can cause an increase in their performance as well so they're there medical and medication reasons that people might not be performing at their peak and the MOCA screen shows really just a screen to see if it really matches up with the picture you see not diagnostic the history is most important and the longitudinal course of symptoms so if a patient has brand-new symptoms it's usually not really the first time that they've noticed the symptoms probe a little bit you can get a better sense asking family members friends any collateral that they're willing to share and right care doctor notes you can see if it's a gradual progression that would be more in line with a neurodegenerative process not really not medical I mean of course there could be medical causes as well but the time course if it's really rapid onset I do like to get head imaging if a patient's never had head imaging because everything can cause cognitive changes including the scary things like tumors or you can also see really what the brain looks like if it's very small for the person's age especially in a younger person you might think there might be a neurodegenerative process going on but very often the structural imaging looks fine patients brain you're talking about MCI not PET scans right you're talking about I saw the MRI MRI MRI yeah what even sometimes people have cats can stand after a motor vehicle accident or they can both give you structural pictures it doesn't show you how the brain is performing but it can show how much brain volume there is and there are ways to measure actually have the size of the hippocampus the area that's involved in learning and memory and which is affected early on in Alzheimer's disease and if that area is smaller than expected that can provide another clue that there might be something structural as well that that's abnormal in a normal-sized brain someone's interest with the vitamins with the b12 we have another question about are there any other vitamin deficiencies that should be on our radar in terms of you know cognitive loss things that improve cognition anything else we should think about often it's a vitamin b12 folate and and then there's a question about vitamin D as well and so I generally there is there's some mixed evidence but a lot of people we do know especially in northern climates are vitamin D deficient and so for also bone health it's important to make sure those levels are normalized but those are sort of those standard labs that I would get from the vitamins that's the two vitamins I'm low in by the way I saw fluorine now I'm thinking oh my god that's why there's one other vitamin that in people who might not be having a good diet or if you use a lot of alcohol and that's vitamin b1 or thiamine and you may have heard of Wernicke's encephalopathy but that's basically a deficiency of vitamin b1 usually seen in people who use alcohol and high amounts and that can absolutely cause confusion and neurologic symptoms that can look similar to cognitive impairment at times so if you drink a lot of alcohol you and like you know best thing is to not drink a lot of alcohol but if you you don't then you would supplement thiamine is that is that what counters it or yeah but it's not well absorbed if you're using a lot of alcohol and then people when we're concerned about vitamin b1 levels oral supplementation actually doesn't do that much you want to give it IV high doses to make sure that and the brain is protected okay and then another question is what what are your thoughts on using neuro Quandt MRI as a diagnostic tool over time to diagnose dementia I don't know what neuro Quandt MRIs so basically it it'll provide more information about certain areas of the brain again structural imaging provides information it doesn't 100% provide a diagnosis so the symptoms I'm assuming if they're getting a neuro quantum RI they have symptoms and the typical history the longitudinal history however to make that diagnosis of dementia again they have to have the activities of daily living that are affected and they have to have a progression and and having this imaging can be very supportive okay so I mean end of the day the more the more information probably the better right I mean it's putting putting a history together periods of time to get more information and you might have while you're waiting for some of this information you may you might have a probable diagnosis so there there really it's a very difficult diagnosis to make and while people are alive and they depending on what kind of imaging they have some imaging can actually visualize toxin toxin pangos but for the majority of people imaging is not actually what makes the diagnosis it just supports the diagnosis and it's the clinical history it's a clinical diagnosis okay well thank you so much Stephanie I think this has been hugely helpful and as you can see from the amount of questions we're getting it's really a tricky point for a lot of people out there trying to understand more about memory loss impairment the right types and medications deficiencies but there's a lot to think about and but thank you so much for sharing your knowledge with us especially from a psychiatrist seeing a lot of dementia patients it's very helpful to us so thanks so much for joining us today thank you so much for having me so if you want if you missed any of this interview you want to see more of these interviews these are being patient brain talks series where we go directly to the experts we have your questions guide us in what you want to know you can find all of these websites these interviews rather on our website at being patient calm under the tab brain talks we also have being patient perspectives that's another talk series where we feature the person diagnosed with dementia the patient's point of view about what it's like to live with dementia so please if we haven't covered a topic write to us at info at being patient calm let us know what you want to hear if there's an expert you want us to approach we're always happy to do so thanks very much for watching

Channel: Being Patient Alzheimer's

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Length: 37min 30sec (2250 seconds)

Published: Wed May 13 2020