Give Me an ‘A’…

Complex symptoms at play in dementia—simplified into seven terms

Dementia can be tricky to diagnose because its symptoms often begin with minute changes in behaviour.

“Often there is a delay between first seeking medical attention and getting a firm diagnosis,” says Dr. Duncan Robertson, specialist in geriatric medicine and medical adviser to the Alberta Dementia Strategy and Action Plan.

This delay in diagnosis can be as long as five years—or even more. That’s because it’s easy to miss early indicators of dementia, and doubly so when loved ones and the person themselves tend to attribute symptoms of dementia to the normal aging process, Robertson says.

“It’s a process of elimination,” he says. “It’s a process of identifying potentially correctable causes of cognitive changes and identifying progression to a point where a diagnosis can be established clinically.”

In order to diagnose dementia there must be a significant presence of one or more of the following conditions in a person, with other correctable
causes ruled out:

1  |  Abulia

“Abulia is the inability to initiate and sustain purposeful activity,” says Robertson.

Staying involved in a conversation, for instance, or participating in well-loved hobbies, may start to become difficult for a person as the result of abulia.

In earlier stages of dementia, abulia may be interpreted as depression, which may be treatable. However, in moderate to advanced dementia, abulia is even more pronounced and while it may not respond to antidepressant medication, the person with dementia may respond to physical activity, music and mental stimulation in a group setting or individually.

2  |  Agnosia

Imagine the shape of a number four made up of much smaller number fives. A person with agnosia—in cases of moderate to severe dementia—likely wouldn’t be able to recognize the number four, only the small fives.

The brain no longer makes the same interpretive connections between what is sensed and what is understood, and this includes all major senses: taste, touch, smell, sound and sight.

“Agnosia is literally the inability to take in a stimulus from one of the senses and comprehend it in a way that they did at a previous point,” Robertson says.

3  |  Altered Perceptions

Altered perceptions are the behavioural manifestations of agnosia. For example, a person might be unwilling to cross an uneven spot or change of pattern in the carpet, seeing a barrier where there is none.

4  |  Amnesia

Often called the “hallmark of dementia,” amnesia can be defined as both short- and long-term memory loss.

Some memory decline in any person over time is natural, Robertson says. Differentiating amnesia associated with dementia requires observation of a change in everyday function of the person.

“Amnesia in dementia is well beyond that seen in age-associated memory changes, well beyond mild cognitive impairment, and it has reached the point where it interferes with everyday functional abilities,” he says.

Change in function, such as a failure to complete tasks that are usually second nature, and also being unaware that he or she has not completed those tasks, indicates the possibility that an individual may be developing dementia.

5  |  Anosognosia

When a person is no longer aware that something is wrong with him or her, the medical term for this is anosognosia.

“Essentially, anosognosia is a denial of an illness or a disability, but it’s not a denial in a cognitive sense, it’s that one doesn’t acknowledge that there’s an issue,” Robertson says.

For example, someone may have difficulty managing household affairs like paying bills on time, but when asked about it he or she fails to recognize the bills have been neglected.

Recognition of this symptom—and many others—usually depends on the presence of a family member or caregiver who can report observations.

6  |  Aphasia

Repetition of simple words, a lack of understanding of more complex conversation and a general decline in the “colourfulness of language” can indicate aphasia.

Aphasia, though commonly associated with stroke, also appears as dementia progresses; it is the overall loss of language skills and the ability to express oneself.

“Within dementia it affects both receptive language and interpretation of what one hears, as well as vocabulary—people with aphasia tend to use non-specific words,” Robertson says.

7  |  Apraxia

Coordinated activities like tying shoelaces, preparing food and driving start to become difficult with the apraxia of dementia.

Things like getting dressed, which is done is stages, are a challenge because the brain no longer recognizes the “automatic sequence of stages” required to do so.

“It results from the loss of the synaptic connections that interfere with coordinated, integrated brain function,” Robertson says.

Age: the Other ‘A’

A new field of research is trying to understand the link between aging and dementia

It’s easy to blame dementia on aging. And, statistically speaking, age is the biggest risk factor for dementia; one in 11 Canadians over 65 has dementia, and the older people get the more likely they are to develop dementia.

But raw numbers don’t answer all the questions—such as, why doesn’t every person who ages develop dementia?

Enter the study of epigenetics, where researchers like Dr. Benedict C. Albensi—a neuroscientist and Dementia Research Chair at the University of Manitoba—are discovering that the likelihood of dementia may have less to do with your inherited DNA than it does with how you lived your life.

This research examines why some of an organism’s genes get switched “on” or “off” as they age, important because certain genes appear to be related to dementia.

“It is an emerging field and I think it has tremendous potential,” Albensi says. “For many years we thought we inherited a set of genetics, we got our parents’ DNA and that’s what we have to live with—and that’s only partly true.”

Epigenetics research presents the idea that lifestyle factors—for example, your level of fitness, exposure to toxins and whether or not you smoke—affect your genes in meaningful ways.

“There’s such a huge environmental component in aging and in dementia,” Albensi says. “What genes get turned off or on are largely influenced by the way we live.”

Meaning that while aging may not be preventable, certain types of dementia may be blocked by taking measures like restricting calories and introducing exercise.

“This epigenetics thing is a whole new wrinkle; it’s a whole new angle on environmental influences,” Albensi says. [ ]