Doc, I Lost My Keys Again!

If only we had a nickel for every time we’ve heard this: “My memory isn’t what it used to be, but, hey, I’m 75 now so what can I expect?” Great question. Are we destined to be more forgetful as we age? From time to time, most of us find ourselves misplacing something or forgetting a piece of information we thought we should remember. We sheepishly laugh and say, “I’m having a senior moment.” But what really is happening?

As our bodies age physically, so do our brains. An older brain requires more attention to maintain good memories, and it may take longer to retrieve information we are trying to recall. Is that a function of the aging process? Or is that the beginning of dementia?

Some changes that accompany aging are almost universal. Just about everyone needs “cheaters” to read the fine print, everyone’s hair turns grey eventually, and nearly everyone’s brain slows down as we get older. So what we sense is a decreased ability to absorb, store, and retrieve information. We feel as though we are losing memory. But just because brains move more slowly as we age, it doesn’t mean we will lose our memory-making ability altogether. In fact, up to 50% of those aged 85 and older have no serious decline in their cognitive abilities. But for the other 50%, function is lost. When people have an inability to make a memory, that memory loss then impacts their ability to function, and it gets progressively worse over time. That memory loss is a symptom of dementia.

You probably remember from medical school the conventional wisdom that if someone thinks he has Alzheimer’s disease, he probably doesn’t have it. Well, that may have been true in the past, but in recent years the level of awareness about Alzheimer’s disease has increased, and more of us know someone with this dreaded illness. Patients may, in fact, come in and voice concerns at an early stage of dementia. More recent studies found that patients were quite accurate in predicting their cognitive abilities.1 So if Mr. Jones reports that his formerly impeccable memory is lapsing, take it seriously.

First, ask patients what difficulties they are having, how much of a change it is for them, and how much of a problem it is creating for them. These are key pieces of the history. Review the medical history for risk factors including diabetes, hypertension, cerebrovascular disease, smoking, and obstructive sleep apnea. Family history also elevates the risk.

The Alzheimer’s Association, the world leader in Alzheimer’s research and support, has developed the following checklist of 10 common symptoms to help recognize the warning signs of Alzheimer’s disease, the most common form of dementia:

• memory loss;
• difficulty performing familiar tasks;
• problems with language;
• disorientation to time and place;
• poor or decreased judgment, often seen in early stages in the area of personal finance;
• problems with abstract thinking;
• misplacing things;
• changes in mood or behavior;
• changes in personality; and
• loss of initiative.

If patients have any positive warning signs and/or high risk factors, you should proceed to additional cognitive testing. I favor the Montreal Cognitive Assessment for the patient (MoCAtest.org) and the AD8 caregiver questionnaire as first-line assessments. You can see demonstrations of these diagnostic tools in use at www.alz.org/documents_custom/ad8.pdf. If available, referral to a geriatrician, neurologist, and/or geriatric psychiatrist for additional evaluation is helpful.

Clinical Pearl
When should you worry about a report of memory loss, eg, my mother keeps repeating herself?

What’s the appropriate course of action if someone else believes an individual has Alzheimer’s disease? Is a secondhand complaint more accurate? In my experience, it can be. And keep in mind that if someone else is noticing a change, there has likely been a significant progression to allow symptoms to be observed. You should take the report seriously and complete an evaluation. I favor the Montreal Cognitive Assessment for the patient (MoCAtest.org) and the AD8 caregiver questionnaire (www.alz.org/documents_custom/ad8.pdf) as first-line assessments.

— Rosemary Laird, MD, MHSA, AGSF, is a geriatrician, medical director of the Health First Aging Institute, and past president of the Florida Geriatrics Society. She is a coauthor of Take Your Oxygen First: Protecting Your Health and Happiness While Caring for a Loved One With Memory Loss.

Reference

1. Snitz BE, Morrow LA, Rodriguez EG, Huber KA, Saxton JA. Subjective memory complaints and concurrent memory performance in older patients of primary care providers. J Int Neuropsychol Soc.2008;14(6):1004-1013.