Dementia Basics

In this episode, Dr. Mia talks about the common questions that come up in memory clinic such as: 

Chapters

00:00 Understanding Dementia and Alzheimer's Basics
02:54 Differentiating Between Mild Cognitive Impairment (MCI) and Dementia
06:19 Exploring Types of Dementia
11:01 Stages of Dementia Explained

Transcript

0:00

Welcome back to Ask Dr. Mia podcast. Today, I want to hit the basics of dementia and Alzheimer's disease and share with you some of the most common things that I talk to with my patients and their families in memory clinic. So one of the first things that I talk about when I'm seeing someone who is coming in for memory is I'm trying to put them into three big buckets. One is, is this normal for your age? As we get older, we all have trouble with multitasking, walking into a room and forgetting why we went into the room. You don't need to be an older adult to have that problem. And the next big bucket is what's called mild cognitive impairment. Mild cognitive impairment is also called MCI. And this is an intermediate stage between normal age-related memory changes and dementia. However, MCI is not normal for age. For a lot of people, MCI could be very subtle. It could be in terms of people's short-term memory, but their long-term memory is excellent. or it can come in symptoms that are more like irritability or disinhibition. So saying things or doing things that just seem a bit out of the norm for your loved one. However, they're functioning normally and are independent. And some of the hardest things that we all need to do in order to maintain our independence is driving. managing our finances, if you have a number of medications that you're taking, remembering to take those medications, shopping, cooking, household chores, the adulting stuff, I should say. When people are starting to have impairments to their cognition that limits their ability to be fully independent, then that's when we start going into the bucket of dementia. And dementia itself can have mild, moderate, and severe stages. But before we get into even mild dementia, we want to look at how many of these instrumental activities of daily living, so the cooking, the shopping, the finances, the driving, if people are still working, how they're doing at work, the most cognitively challenging tasks that we need to do. on a daily basis to be independent. And as always, we try to compare people with their baseline. So if you're someone who has never cooked, then cooking is not a function of your daily activity that we should measure on when you do have memory changes. the first differentiation is, is this normal for your age? Is this not normal for your age, but you're functioning normally and mild cognitive impairment? Or is it dementia? Meaning you do have significant memory changes that affect your function. Once we get into dementia and MCI, I like to highlight that these are general terms that describe the symptoms, but don't tell us what is the underlying cause. Just like dementia is an umbrella term that covers many different types of dementia, of which Alzheimer's disease is the most common type and oftentimes used interchangeably with the word dementia, but actually do not mean exactly the same thing. The words My cognitive impairment is also an umbrella term. That means that you have abnormal changes to your memory that we don't think it's just due to age. However, that could be a number of different causes. So what could be the causes of MCI? Well, this is where a comprehensive memory evaluation tried to exclude other things that could be causing memory changes. that are not normal for your age. So some of that may include low vitamin B12 level, low thyroid, other medical issues that could be affecting your memory. A lot of people are taking medications that may negatively affect their memory and attention, or taking over-the-counter medicines like Benadryl or Benadryl-similar meds to help them sleep. These, even though they are over-the-counter, definitely can deplete a chemical we all have in our brain called the cholinergic molecules that help with memory and attention. Other common reasons might be undiagnosed sleep apnea, meaning people are having apnic events while they're sleeping where they have pauses in their sleep. They may wake up feeling like they can't get a good breath or that their bed partner noticed that they have pauses in their breathing. Oftentimes people with sleep apnea also feel tired. the next day and do not feel like they got a restful night of sleep when they wake up in the morning. And people do not have to be obese to have obstructive sleep apnea. I've seen plenty of times when a person is slim and of normal body weight and still have obstructive sleep apnea. It has to do with the soft tissue in the back of our throat that relaxes when we're sleeping and falls back. and closes on the airway. Other reasons for mild cognitive impairment may be the very beginning signs of a type of dementia or a process, a disease going on in the brain. And we happen to catch people before they start having functional changes in their daily activities. And mild cognitive impairment could be due to Alzheimer's disease. It could be due to underlying vascular disease. It could be due to Lewy body dementia and other types of neurodegenerative diseases. Once we get into dementia, as I talked earlier, Alzheimer's is the most common type of dementia, but certainly not the only kind. We used to call a lot of things as Alzheimer's disease when we have excluded things like strokes, medications, low thyroid, low B12, and could not find other reasons why people might have memory changes. we used to lump a lot of people into the words Alzheimer's dementia when actually what is happening in their brain may not all be the same. Over the years, the definition of Alzheimer's disease has really changed from the symptoms of what someone may appear to look like on the outside and how they're functioning in daily life into a biomarker, or pathology-based definition. So now people who are cognitive specialists, we do not consider someone as having Alzheimer's disease unless they have abnormally high levels of amyloid protein. Now there's probably a lot of different causes to Alzheimer's disease, some of which we have not even uncovered yet, but By definition, according to the Alzheimer's Association and the National Institute on Aging definition of Alzheimer's disease, elevated amyloid levels is a, definition, a requirement for having Alzheimer's dementia or Alzheimer's disease. But we don't always check for biomarkers because amyloid can also be seen in older adults in their 70s and 80s, and they might have totally normal memory. Actually, this group of people is rather controversial because some scientists think that they have what's called preclinical Alzheimer's disease just by elevated amount of amyloid in the brain, while other people, like including myself, I'm hesitant to call someone as having Alzheimer's disease when they have no memory problems, both subjectively and objectively on memory testing and only have elevated amyloid because amyloid is not a perfect relationship with symptoms. However, we do know that people who have elevated amyloid in their brain do decline in their memory faster as they age compared to people who don't have elevated amount of amyloid in their brain. I used an analogy of cholesterol and heart disease. You don't have to have high cholesterol to have a heart attack, but having high cholesterol does increase your risk of having a heart attack. Amyloid is a similar pattern. Many older adults have elevated high amyloid and they never have heart attack or they never get diagnosed with Alzheimer's dementia. and that people can have dementia without having amyloid or Alzheimer's dementia. So other type, the second most common type of dementia is called vascular dementia. I think there is a lot that we still have not yet learned about the relationship between amyloid and small vessel disease in the brain. Just thinking about how common it is for Americans to have heart disease of some kind or have narrowing of their arteries as we age due to high blood pressure, high cholesterol, diabetes, obesity, sedentary behavior. All of these things can increase the risk of someone having vascular dementia. However, usually we say that having had prior strokes, even if they're small strokes, is likely suggesting that small vessel disease or vascular dementia is at least a part of the picture that is contributing to someone's memory loss. Two other types of more common dementias that we diagnose, one is called Lewy body dementia. I have had a previous episode talking with Dr. Bateman about Lewy body disease, which is really uh very related to Parkinson's disease and Parkinson's dementia in many ways, but it's its own slightly separate entity. Then uh frontal temporal dementia, which I've also had a previous episode with Dr. Halima Amjad talking about the different subtypes of frontal temporal dementia. One other basic thing to understand about Alzheimer's disease is that The disease can be very different when people are presenting with symptoms younger than the age of 65 versus people who present with the disease later in life in their 70s, 80s, or even 90s. For people who have early onset Alzheimer's disease, meaning symptoms start before the age of 65, unfortunately, early onset Alzheimer's disease is a more rapidly progressive disease course than people who die with Alzheimer's disease later in life. Unfortunately, a lot of people with early onset Alzheimer's disease die from the Alzheimer's disease. And these are oftentimes really devastating cases where people have to stop working. They may not even be old enough to qualify for Medicare because they are not 65 and have young children and working spouses at home. The opposite end of the age spectrum is also interesting in that not all people in their 80s and 90s have Alzheimer's disease because there's a separate process that can happen in the very old, so 80s and 90s, that is not related to amyloid. And this is a separate process called LATE or limbic associated telepathy. I won't go into the details of LATE except to say that we don't have a diagnostic way, a sure way of knowing whether someone has it, except to say that it tends to be a slower progressing disease when people are in their late 80s and early 90s coming in for evaluation for memory loss. So that is your quick and dirty basics of dementia and the most common types. Finally, I am going to talk about stages. And I tend to think of dementia in the form of mild, moderate, and severe stage. So mild stage, not to be confused with early onset or earlier in the disease course. uh Early onset means the age of onset versus when people are talking about early stage or mild stage, they are talking about the symptoms of dementia being mild. Moderate stage is where people tend to need help with their activities of daily living, meaning uh commonly first ADL that is impaired. is needing some reminders for bathing and dressing appropriately. But for people who have mild dementia, this is where the instrumental activities of daily living, where the managing of our finances, driving, cooking, remembering to take our medications, those are usually the first things affected in the mild stage. And the mild stage can be an excellent time to really plan ahead and really consider driving as well as money management to have some additional set of eyes taking a look at. The moderate stage or the middle stage tend to be the stage where people have the most symptoms, where there oftentimes can be a lot of emotional changes in addition to physical changes and memory changes. Physically, people might have more balance problems or falls during the moderate stage. From an emotional standpoint, there might be more anxiety, more depression, confusion, as well as delusions or false thinking, thinking that someone has stolen from them when they misplace something but don't remember where they put it, or even hallucinations. So seeing or hearing things that are not actually there. The moderate stage tend to be the stage where families really struggle in terms of managing their loved ones at home. And then finally, the severe stage or the late stage of Alzheimer's disease tend to be when people are losing their ability to walk and may need additional hands-on help with things like dressing, toileting, and transferring from sitting to standing. You may also hear of a different staging system called the seven stages of dementia. I'm not a fan of this staging system because stages one through three are actually not dementia. Stage one is where someone has no cognitive decline and stage two just says very mild versus stage three is really what we think of in terms of mild cognitive impairment. So stage four is usually when in the seven stage model that we get into mild dementia category. And then as between stages four, five and six, That's where we get into moderate stage. So needing help with dressing and bathing versus stage seven, which is the last one, corresponds with the severe stage of the mild, moderate, severe stage that I talked about earlier. I do want people to know about the seven stages of dementia because I know sometimes when we are talking about hospice, or eligibility for certain additional services, people might be using the seven stages model, although the first three are not dementia at all, because people don't necessarily have impairments in their activities that keep them independent, like driving and managing finances. So I hope you find this helpful in terms of the basics of Alzheimer's and dementia. And please share with someone whom I enjoy or leave me a review on Apple or Spotify podcast by scrolling down to the episode. Thank you and talk to you next time.