Dementia: assessment and care

Dementia is a syndrome: an acquired, progressive decline in several cognitive functions, such as memory, language, orientation, reasoning and the ability to plan, marked enough to interfere with everyday independence.¹ It mainly affects older people, but it is not an inevitable consequence of age.

Besides cognitive changes, changes in mood, anxiety, sleep and behaviour are common, such as apathy, irritability, agitation or hallucinations. These symptoms weigh heavily on the quality of life of the person and the family, and many of them can be treated.

• Alzheimer’s disease, the most common cause, which usually begins with problems in recent memory;¹
• vascular dementia, linked to disease of the brain’s blood vessels, often with slowing and difficulty planning;
• dementia with Lewy bodies, with fluctuating attention, visual hallucinations and parkinsonian symptoms;
• frontotemporal dementia, which may begin with changes in behaviour or language, sometimes before the age of 65;
• mixed forms, mainly Alzheimer’s disease with vascular disease, which are common at older ages.

With age, some slowing and occasional forgetfulness that does not affect independence are common. In mild cognitive impairment, the difficulties are greater than expected for age and are noticed by the person or the family, but daily life is essentially preserved. In dementia, the difficulties already interfere with tasks that used to be simple, such as managing medication, bills or getting around.

Not everyone with mild cognitive impairment goes on to develop dementia. This is why reassessment over time is part of follow-up. See also the page on cognitive difficulties.

Before talking about dementia, the assessment looks for causes that may explain or worsen the complaints and that can be treated:

• depression, which in older people may show mainly as problems with attention and memory;
• medication with sedative or anticholinergic effects, and alcohol;
• vitamin B12 deficiency, thyroid changes and other metabolic changes;
• sleep disorders, including sleep apnoea;
• cerebrovascular disease and uncontrolled vascular risk factors;
• delirium, a state of confusion that develops quickly, often linked to infections or other acute illness, which needs urgent medical assessment.

Late-onset depression is also associated with a higher risk of dementia,² and treating it always matters.

When there is frequent forgetting of recent events, repeating the same questions, difficulty finding words, disorientation in familiar places, difficulty managing money or medication, or changes in personality and behaviour. Often it is the family who notices first.

A sudden change in memory or consciousness, with confusion that develops quickly, should be assessed immediately at an emergency department.

The assessment starts with a detailed clinical history, ideally with input from a family member or someone close, and with cognitive screening tests. It includes a review of medication, blood tests (for example, a full blood count, vitamin B12, thyroid and kidney function) and, when indicated, brain imaging and a more detailed neuropsychological assessment.³ Whenever needed, it is coordinated with Neurology and with the family doctor.

There is still no cure for most dementias, but a great deal can be done. In Alzheimer’s disease and some other forms, certain medicines (cholinesterase inhibitors and memantine) can help with cognitive symptoms at certain stages.³ Treating depression, anxiety, sleep problems and behavioural symptoms improves quality of life. At these ages, medication is chosen with particular care, because the risk of side effects is higher.

The plan also includes information and support for carers, adapting routines and the home, physical and social activity and, when the time comes, planning future decisions with the person and the family.

According to the Lancet Commission, around 45% of dementia cases may be linked to 14 modifiable risk factors across life, such as high blood pressure, diabetes, smoking, physical inactivity, uncorrected hearing or vision loss, depression, social isolation and high LDL cholesterol.⁴ Looking after the heart is also looking after the brain: see how the heart, the brain and mental health influence each other.