Forgetful, or Something More? Dementia, Delirium or Normal Ageing | Dr Stephanie Ward | Club Sandwich

People with early dementia, they drive, they play tennis, they're active in church, they write poetry, they sing, they play musical instruments, some continue to work, keep doing

When you know what's going on, that's when you can then start to look at strategies for that person to live their best life.

Good morning, Sarah.

Yeah, really great question. We do expect some subtle cognitive changes as we get older and the way that we think and function, it's also influenced by things, by stress or how we're sleeping or if we're trying to manage multiple things at once so you're not alone. You're not the only person that's walked into a room and forgotten what they needed to get. And that's a common experience for a lot of people as they get older. And that generally can be just part of normal aging. The same as sometimes forgetting the names of people that you don't see very, very often, or someone on television for example. But sometimes you might notice some differences with a loved one that does seem a little bit out of the ordinary. When we're talking about things like dementia, we're looking for changes in people's what we call cognitive abilities and often we think it's just memory. And memory is a really common one. So it might be repeating a question that you've already asked, repeating a story that you've already told somebody, forgetting something that happened earlier in the day or the night before. Those types of things might be a bit out of the ordinary and probably warrant a little bit more monitoring and possibly some follow up as well. Early signs of dementia can actually be pretty heterogeneous.

There can be a lot of different signs. It may not just be be memory. For a lot of people it is some changes in memory. But in other people it might be the first signs you might notice is just that someone's not functioning the way that they used to. So it could be that bills are starting to not get paid. There might be some changes to driving ability. Maybe people are missing tablets that they weren't before.

as much as before or making some errors with cooking.

Well, yeah, that's, that's, that's one. But also just getting the recipes wrong or choosing to some. I've sometimes going from being able to execute really complex meals to simplifying things, struggling with the computer or using the smartphone and having more and more phone calls about that. Now that's a difficult one because I think we all suffer or I do suffer from a little bit of technology ineptness from time to time, especially older people. And for older people and you know, it is much more of a challenge and everything keeps changing and it keeps getting updated. But when there can be questions about things that you used to be able to manage, things like messaging or phoning or getting anxious about things, they can be signs as well.

and also things that you might do for a hobby. So sometimes people find that their loved one's not really reading anymore. They used to really enjoy reading or reading more complex material, but now can't quite follow along. Often people won't say to you, I'm noticing a few changes, or I'm having troubles. They just won't do things anymore. So you might notice some memory changes, but you might see some changes in the way people are living day to day. But there can be other ways that symptoms of dementia can present as well. So sometimes it can be starting to show itself in changes in behaviour as well.

So sometimes people might become a lot more apathetic and not have a lot of motivation to do things that we used to do, or they might become a lot more disinhibited or not care so much about their personal hygiene and their appearance. Or they may become very different in the way that they interact with people. Perhaps overly familiar or have difficulty regulating their emotions all of a sudden, or controlling their emotions. That's not always dementia, by the way.

So that is the tricky thing.

It could be a number of different things. It could be being medically being unwell with an infection. It could be due to alcohol use or other substance use, could be due often to things like depression or anxiety. And that really underpins the reason why, when you notice changes going and getting an assessment is really helpful so you

So you can work out what it is.

So what you're describing is all of a sudden someone's getting a bit more confused than they usually are. They've changed, you know, overnight or in the last few days, and it turns out it's because they had an infection. But young people get urinary tract infections and we don't tend to get that confusion so often do we? We get the flu, we get a bit sort of fatigued and we get Covid. We're not so well, but we generally oriented. We, you know, we might be A bit, you know, flat. We may not work, but we don't have those huge changes in our abilities. And what you're describing is something we call delirium, which I'm sure a lot of listeners will know what we're talking about. But delirium is an acute change in the brain's function and that can manifest as changes in your cognitive abilities, your thinking abilities, but also in terms of your behavior. Some people can experience, quite frighteningly, hallucinations or paranoid thoughts, or some people can become really, really, really withdrawn and not initiate things. And deliriums do tend to. To get better if you treat the underlying cause. Although it's interesting in that you're more likely to get a delirium when you're older because your brain's already a bit more vulnerable. Right?

Correct.

And sometimes it's also that perhaps you've had some changes in your brain, but because really well supported or you've got what we call a cognitive reserve. You've kept your brain active all your life, you manage day to day, but then you get sick and it all becomes unmasked and you do get better. But we do know that deliriums can happen often in people who might have those changes in the brain that are leading to dementia but just haven't manifest yet. And we also know that people who've had delirium are at increased risk of going on to get a dementia down the track. But it's not a fake. And plea. But that's why it is really important that when you notice changes in people, sometimes I think what can happen is that people notice someone's getting a bit forgetful or there are some changes and we say, well, it's just age. Oh, there's nothing we can do about it, and perhaps don't feel the motivation to perhaps get that looked at. But it's not always something like age. It's not always something like a dementia either. And even if it is a dementia, you know, there's things we can. We can do about it.

Oh, absolutely. So there's a stigma around the diagnosis of dementia, unfortunately. There's often fear about what it would mean in terms of independence and being able to have agency and autonomy over your life. Worries about what will this mean for driving? And there's also. The other factor is that sometimes there's also a lack of awareness of these changes. So we call that. Got a nice medical name for that, anosognosia, but it's actually really common, particularly as things progress, that when we're experiencing changes in our memory and our thinking, we're not so aware of it because

And so it's people around us that are aware of us. Sometimes we do become aware of these things early in the. In the trajectory and we may or may not want to go and get those symptoms assessed because we're frightened. And understandably, I think people are. Are frightened about what this can mean. So dealing with a lack of insight as well as the fear, it's something that, as, you know, as children of people who are affected, we have to recognise. And so sometimes you're in the position where somebody agrees, yes, I'm worried and I want to go and get an assessment, I want to go and get help. But I think that most people don't put up their hand and say, I want to go to the doctor. And that's when you've got to sort of be a bit more creative.

Going to a GP first is a great first option. And sometimes it can be good to just coax it in terms of a general health check. Sometimes, if you're able to have a word with the GP yourself, as a concerned family member ahead of time or privately about your concerns, especially if they

Yeah, yeah.

That's helpful. I think it's sometimes really hard if you're the child and you're sitting there with a mum or dad who is in denial or who's upset about this. You don't really want to make them feel bad and you don't want to say things that you're noticing in front of them. So I think it's always important that you can have a private word with someone about what you're observing. And I will tell you that doctors, we're pretty used to the fact that people don't want to be there and that they don't have insight. And often a lot of us will coax it in terms of doing a general check of all different types of things and then include memory and thinking amongst that. GP is a wonderful place to start and sometimes it might need a few assessments and you might need to have some blood tests as well, because often when we're approaching a diagnosis of dementia, we're trying to work out, you know, is this something that's chronic and likely to progress? What are, you know, what we expect a dementia is. Is this the UTI that you mentioned? Is this some anaemia? Is it a vitamin deficiency? Is it some hormonal imbalances. And so usually you have a series of blood tests done. Usually you'll have at least a scan of the head done as well.

Yeah, a brain scan like a CAT scan. Or you might go on to have an mri and that just helps us to have a look at the brain to give us a bit more information about whether there are some structural changes there and also to help us work out what type of dementia somebody might be having.

The GP can organise the CAT scan and the blood tests. Often there's an out of pocket cost for an MRI when it's ordered by a GP and not so much by a specialist, but the blood test and CAT scan, definitely a GP can arrange in a basic cognitive test. A review of medications is important because, you know, some of the medications that we take can actually make us confused, can affect your memory and that's more so as we get older as well, you know.

Isn't totally is because managing medications is something I really worry about for who've got some cognitive problems because it is easy to forget things and if you do make errors with medications, they can cause a lot of problems as well. But I have cured dementia before by just stopping one or two tablets in people.

Yeah, yeah, totally.

You know, a rough rule of thumb is a rough rule of thumb. But around one in five people who come in worried about, you know, changes in memory or thinking it's due to things like mental health problems. So anxiety or depression as well can affect how we think all the side effects of medications. So that's why it's important to go.

of GPs prefer to do that and they may refer to, yes, a geriatrician, so a specialist doctor. For older adults they may also refer to a neurologist or an older age psychiatrist or a neuropsychiatrist. Remembering that not all dementia occurs in Older age as well, 90% over the age of 65, but around less than 10% under the age of 65. They may refer to specialised memory clinics as well, which are multidisciplinary clinics specialised in the early diagnosis of dementia. When it's a little bit more unclear, have a little bit more multidisciplinary resources to help make that diagnosis.

But when it depends earlier in the pace and it's not quite clear if something is going on, then it's great to go and get to a more specialised service. But I can imagine as I'm speaking that there are a lot of people listening saying, oh, that's really, really well and good in my region, it's a year's wait to get into one of these specialists because I know that that is the case.

A GP can and lots of wonderful gps do. And I think that there is, you know, a piece of work around supporting, you know, more gps to be able to do that. But GP is absolutely fantastic and, and I think it's. It's a process of working, working together. So at least raising it with your GP is a really great start. And particularly, you know, gps have that privilege often of having had a long standing relationship with somebody as well.

Yeah. So gps often do a short cognitive screen when you go to see a specialist. They'll often do those same cognitive screens sometimes cognitive thinking tests, often a bit. I always feel like I've got to do a bit of a longer one. I got to feel like I've got to justify myself. And then sometimes where it's not clear as well, people might go on and have additional thinking tests. Sarah. So they might see a specialist in A neuropsychologist to do more detailed testing, just where it's a bit unclear and to really characterise what the issues are. And I've been talking before about things like, you know, is this dementia or. Or isn't it? But it might be helpful if I mention what dementia actually is.

Yeah. So dementia, I always tell people the same thing. I say dementia. It's a word, it's a label, it's what we call a clinical syndrome. So there's not a blood test, it's not a scan of your head, it's not a particular result on a test that says, yes, you have dementia or no, you don't. It's a word that doctors, clinicians use to describe a situation where you meet three criteria. This is how my brain works. I like it simplified.

One is that your thinking skills have changed from what they used to be. Now, that could be your memory. It could also be your use of language. Understanding language or being able to speak or knowing lots of words for things. Could be your ability to pay attention or shift your attention. Could be your ability to plan and make decisions, your executive function. It could be your ability to manage your behavior, for example. Could be your ability to orient yourself in space or process visual information. Whatever it is, it needs to be a change from what you were like before. I see people. I've never had a good memory. Oh, I could never do this. I could never do it. Count backwards from seven. But we're looking for a change, a change that maybe you've noticed as yourself, maybe family have noticed. And when we test you, we can say, yeah, actually, that's a little bit weaker. I would have thought, for your age and education level, your memory or your attention might have been a bit better. So we're looking for that, number one. Number two, we call it dementia. When it's starting to make life a bit more difficult, it's starting to have

Yeah. And it's often those things that are more difficult that become impacted first. So if it's in a younger person or we know people can work into older age, it might be your ability to do your job, to work. It might be your ability to do some more of your complex activities and hobbies. Reading, playing computer games. Or more complex financial management, or then it might be things, more day to day things. So managing your medications, cooking, driving, managing your household, making decisions about administration and your day to day life. As things progress, it starts to affect more inherent skills like getting dressed and remembering to do that and remembering to keep your house clean. So we look that there's some impact on function, so change in thinking, some impact on function. And the third one, you're very clever. You intuited a little bit before your question. Could it be a uti, third one, not due to something temporary or short term that we can treat like a uti, like a thyroid problem?

side effect of a medication, for example. So I'm looking for those three things. And there's a lot of reasons why people get dementia. There's a lot of different changes that can happen in the brain that can lead to this syndrome. Alzheimer's disease is something that most people have heard of. I can call it little protein plaques in the brain. They're called amyloid plaques and that's what

If you do a very specialised scan, has a bit of out of pocket cost, but about 70% of people with dementia have Alzheimer's plaques. But there can be other reasons too, Sarah. So people have blood flow changes, what we call vascular dementia. Maybe they've had strokes, but often it's more. You can see there's just been years of sort of not great perfusion in the deeper parts of the brain.

Oh, blood flow, thank you. Blood flow.

So dementia's. It's a really great question because often people say, well, isn't this just part of age? Well, dementia per se isn't a normal part of aging. Although the reality is the older we get, the much more common it becomes. So it almost seems like it's a normal part.

Not all 90 year olds do have changes in thinking. Some of them are frightfully clever. Amazing, but, but it is really common in our 90s. It's almost roughly two in five. One in two people are living with dementia in our late 80s. It's almost around one in three for women in our late 80s. So it becomes really, really common. And so we also see some other different types. Some people might have heard of things like a Lewy Body dementia, which often can coexist with signs of Parkinson's disease. And then there are less common pathologies as well. And I wanted to make a point that sometimes people say, well, I've noticed thinking changes in my loved one or they've gone and seen somebody, but it's not really affecting their day to day life. But those thinking changes, you know, they are a bit more than we'd expect for normal aging. And that's what we call a mild cognitive impairment. And a mild cognitive impairment is also frightfully common as we get older, probably one in five.

Yeah, well, not so much. So mild cognitive impairment, it's something that you can pick up on a test. You can do a test and say, yeah, you know, you're not quite where I would have thought.

No, not necessarily. Not necessarily. Which is why I wanted to bring it up because I think some people here will have heard about it. So. And it's not having an effect on day to day life. We're not having very, very minimal effect. So it's really common. And if you have a diagnosis of mild cognitive impairment, you are at increased risk of going on to get dementia syndrome. Yes, that's what I meant. But it's not a fake. And plea. Okay, okay. Some people do remain stable for quite a period of time. And sometimes people do transition if you follow people up from the back to a normal level. So it can depend upon what's going on underneath that.

Yeah.

So I have a lot of people that I see who are worried that they're getting dementia or they're worried, their family members worried that they're getting a dementia. And we think actually, no, it's actually a mild cognitive impairment and we might follow people up for, you know, quite a period of time and still chugging along really well. So that's really helpful to know. And I wanted to bring it up because sometimes people have Heard of this and don't quite know all that.

Well, I think it's making the best of life. Just because you have some cognitive changes doesn't mean you shouldn't be able to have a good life and enjoy yourself as much as you can for as long as possible. And I think that this is a really important message to get across in that getting a timely diagnosis of either dementia or a mild cognitive impairment is the first step in living your life the best way you can with those changes. First of all, you can get education and some understanding about what you're experiencing and it's not your fault. And I find that really helpful because if you are getting a bit forgetful, it can lead to some arguments within family context and to understand it's actually not their fault, it's very difficult to remember. That's helpful. But you can also have a focus on what we call re enablement and focusing on the skills that you can do. So supporting somebody to be as independent as they can and supporting people in the areas where they are struggling, and that's different for every person. But just because you have a dementia doesn't mean you can't do a myriad of different things. And people with early dementia, they drive, they play tennis, they're active in church, they write poetry, they sing, they play musical instruments, some continue to work, keep doing that, right?

When you know what's going on, that's when you can then start to look at strategy for that person to live their best life. You can also get access to information and planning for the future. So we know that as we get older, doing things like organising future decision makers through enduring powers of attorney, enduring guardianships and even thinking around advanced care, health planning, it's important at any age, as we get older. But if we know that there's starting to be some cognitive changes as well.

Yeah, it is the time. And yes, you can make those things. It's. It's neither black nor white. Okay. Whenever we have to do anything legally, we need to have capacity to be able to do that. We need to be able to demonstrate we understand what we're doing and why we're doing it, and we're operating free of coercion, of pressure from somebody. And dementia. Yes. Can affect those thinking abilities that allows us to do those things. So it is a conversation to have with the clinician and with the lawyers supporting you. There can be cases where somebody really can't sign a legal document because they don't understand what they're doing. And that's not right, that's not legal. But many people with cognitive changes can understand the decision that they have to make, and that's why getting a diagnosis earlier. It's important to understand what someone's real preferences are, what matters to that person, knowing that this is happening, how they prioritise the rest of their life. So some of it's this boring administrative stuff. Right. But it's important, sorting out future planning, sorting out your advanced care wishes. Some of it's saying, I want to do this trip now.

In the next six or 12 months. Yeah.

Yeah, absolutely. And so risk is a really big part of working out what you do at this point. And I'm always thinking about risks. Often say, I'M paid to worry, which is good because I was born worrier. But it seems like often, yeah, driving is something that once you have a diagnosis of dementia, you do need to disclose that, but it doesn't mean you have to stop driving. But your fitness to drive will continue to need to be assessed. And for most people with a diagnosis of dementia, there is going to be a point where you have to stop driving. And I do like to talk to people about this because knowing that it's coming, it's important in terms of that planning, because you have to have a plan. How will you stay mobile in the community? You need to get ready when that happens. So driving is something that's important and financial management is another one. The scams and the emails, just knowing to keep an eye on things. I also worry a bit about nutrition for people as well. I've noticed that often people maybe don't eat as much or initiate the whole meal. Planning and medication safety, these are probably the four things I tend to worry about the most. And sometimes you can, or quite often you can help manage those things just with some very gentle interventions as well. So you mentioned a Webster pack or a dosette box, sometimes tied with a phone call, or just going over and checking and getting people used to these things can help having things around the house just to help using appliances.

Yeah, clocks. Some signs as well, some very clear instructions if things are difficult so that you can be independent. I always think of it, it's like, you know, if your phone or your computer used to run out of storage, you can just put something else onto a hard drive. We've got to think about that with our brain as well. If we're having trouble remembering things, put it onto something else, like a piece of paper, use a diary, get used to using a diary, used to a calendar. If memories not so good. Getting into routines and structures is incredibly helpful.

Yeah, in the beginning phases, yeah.

I would say that. And you can always also contact Dementia Australia. They have a 1-800-number which can provide some over the phone advice, especially when you're negotiating getting somebody into a clinical assessment. Be gentle. People often don't like having their deficits pointed out. Understandably. Right. None of us like to be told we're doing the wrong thing or we're forgetting things. So often, coaxing things in terms of a general health check can, can help being persistent and being kind to yourself. If you, for the life of. You cannot get somebody to get an assessment because sometimes you can't and sometimes that means you're going to have to wait until things fall off. There's only so much we can do.

But be persistent and be gentle and that can help. And we've talked about some of the reasons why getting a diagnosis can help and we will talk about medications next episode. But some of those medications are most efficient, efficacious in the early stages as well. And there isn't any cure. But there are medications that might be able to help.

That's the key, if you can. But I think if you're listening, you're doing a great job.

I feel like it's a bit of a throwback to an earlier episode, Sarah. But I've been practising the double bass.

And I've been using the bow this time.

And I've got a very complicated relationship with the bow. It's a bit of a situationship. We don't like each other, but it's been getting a Guernsey, let me tell you.

You're making friends.

You make one phone call to get help for your ageing mum or dad and suddenly you are drowning in acronyms and waiting lists. The aged care system, it's a bit of a wall of these acronyms, phone calls, waiting lists and nobody's really giving you a map or a guide. Well, we see you. We want you to know that you're not behind, you haven't left it too late, and wherever you're starting from is the right place to start. You don't have to hold all of this in your head on your own. And you can keep what matters most to your ageing mum or dad right at the centre of every decision. That's what Vera is here for, any time of the day or night at Vera Guide. It's free, safe and secure, built right here in Australia with families and the experts who know this journey.