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The Challenges of Recognizing Dementia

Introduction

How can you tell when someone is showing signs of declining brain wellness?  It’s not like physical wellness where we might run the same distance each year to measure our speed or endurance.  Solving the same puzzle or taking the same quiz doesn’t work; our memory can remember the answers from year to year – at least some of them.  So, we rely on less objective measures: “I used to be able to balance my checkbook without mistakes” might be one such data point.  Of course, if there were reliable and widely recognized tests for measuring brain wellness my sense is that few adults would take them regularly or willingly.

The “mini-mental” used by neurologists and other practitioners relies on a set of questions often mocked for their simplicity and relevance. Spell WORLD backwards or draw a clock with a specific time.  A couple of years ago I attended a lecture by Greg O’Brien, a journalist diagnosed with early-onset Alzheimer’s.  During the talk he rattled off the three words he was supposed to remember as part of the mini mental!  Obviously, the value of this test diminishes over time – some would even suggest it starts with little value!

So how do we measure if our brains are not working as well as they used to?  Can we measure both the amount and rate of decline?  And if we can, how can that help us provide better care or support?

A Wide Gray Area

When it comes to cognitive wellness there is black, there is white, and there is gray.  People who are sharp-minded or clearly have a cognitive impairment are obvious.  It’s the wide gray area that is the challenge.  Consider that even if we had some sort of test, unlike blood pressure levels, there is no defined “normal” range.  Why?  because our brains are far more varied than our bodies.  People with strong language or oral skills have a different brain make-up than someone who is great with spatial concepts or math.  Some of us get lost easily while others have a great sense of direction.  So, for someone with a poor sense of direction, getting lost is not a good yardstick for measuring mental competence.  Likewise, someone with a poor vocabulary being unable to recall a certain word.

Thus, recognizing or measuring cognitive decline must rely on less formal analysis.  Do we seem more vague than usual?  Are we more forgetful or confused than last year?  Do we not get a joke without an explanation?  Do we miss appointments with friends because we forgot what day it was?  Do we show less interest in intellectual activities like lectures or our book group?  All these things are indicators of mental decline but often can be easily explained away.

Then there are the secondary symptoms.  Is our mood different?  Frustration and confusion are indicators but so many variables cause frustration and confusion that to discern one cause from another must rely on qualitative and subjective guidelines.  Is it hard to remember which suit is trump at bridge club because you were distracted?  Is someone who orders bacon and eggs for dinner acting a little more eccentric than usual or do they not realize it is dinner time?  Compounding the challenge is that these “secondary symptoms” of mental decline are easy to cover up and when someone does cover their family or friends are often not inclined to say or do anything for fear of offending that person.

Why is Brain Wellness Hard to Acknowledge?

My take on why brain wellness is such a touchy subject is two-fold:  It can be quite subjective and because our “cognitive self” defines who we are.  Many will admit to losing strength as they age but few will admit to being less sharp mentally – unless they are covering up!  There is a social stigma attached to it.  There are many in the field who believe that people with above-average intelligence show less decline or will still be sharper-minded than someone with below-average intelligence with the same period of decline.  As a result, they may be more capable of covering up more effectively or simply being less affected by dementia.  Of course, someone’s emotional well-being and type of dementia are also factors.  So in my opinion, the jury’s still out.

We Are Left With Subjective Measures

Regardless of many attempts, I don’t believe that there is any clear measure of mental competence when assessing someone in the gray area.  Thus, we are left with the challenge of deciding when someone should stop driving or when a power of attorney or health care proxy should be enforced.  Compounding the problem is that, as with almost anything, the decline is not usually steady or readily predictable.  Some people have good days and bad days and even some Alzheimer’s sufferers have lucid moments.

If assessing someone were not difficult enough we need to remember that some people can make up for one deficiency with other strengths.  Consider cavemen.  A smart caveman may be able to find twice as many deer than a caveman of average intelligence but both will bring home the same amount for dinner if the average one is twice as accurate with his spear.  And the caveman with below average intelligence and below average aim will still match his contemporaries if he can endure twice as long a hunting trip.

In prehistoric times it is unlikely that the measure of a man’s self worth rested on his intelligence, more likely it was based on his ability to bring home venison.  But in today’s society our minds are more critical to our existence than our physical strength, especially as we get older.  For most people, it seems that a decline in mental competence can be embarrassing.  We see this in the ongoing discussions about how to address mental health as a whole.  But when it comes to dementia and the elderly there is an added emotional aspect as well: often the elder is being told by their own child, to whom they may have been god-like, that they are not as “smart” as they used to be.  The Catch-22 here is that it is often the loved ones who are much more aware of the symptoms of decline than others.

Conclusion

So, now what?  There is no easy answer.  But there are ways of handling it that seem to work better than others.  It is important to find ways of measuring that fit the individual and then compare notes with others.  My experience is that someone who is aware of their own decline but is embarrassed or afraid to confront it will become adept at screening their symptoms.  One way is to not sharing everything with everyone around them.  One adult child will be told about the missed hair appointment and another is aware of the missed dental appointment.  When you see only a small part of the overall picture, behavioral patterns aren’t obvious.

So, I recommend sharing your observations with other family members and friends.  Yes, it can be fraught with emotional stress and it can lead to some hurt feelings, but the alternative could be far worse:  a kitchen fire from a stove left on, a car accident more severe than a fender bender, or medications that are not taken properly with dire results.  Identifying patterns of behavior is still the most effective way to recognize dementia before it can lead to consequences.