Early Signs of Dementia

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The following session, Early Signs of Dementia, overviews some of the early signs of
dementia such as occasional difficulty with memory, thinking, and/or understanding and
speaking to others.

[Note: Dementia is the decline of mental abilities while the person is alert and awake to the point of interfering
in daily tasks and interactions. The decline may involve memory, decision skills, communication, and/or other
thinking skills.]


Occasional Early Changes in Memory or Thinking Function


Early changes in short-term memory or other thinking functions may, at first, occur
occasionally. The changes may occur in subtle ways. The change in ability may be noticed
by the person who is having the difficulty. Or, instead, the change may be noticed only by a
family member who interacts daily with the person. The change may be denied by the
person who has the disorder. Sometimes the family member or close friend, who visits once
or twice a year, is the one who first notices the change.

Examples of early, subtle changes in short-term memory may include, not remembering
important details from a brief newspaper story that you just read. Another example is not
remembering what just happened and what should happen next in a meeting or not keeping
up with the flow of the discussion. When talking, the speaker may struggle to remember the
name of a person or a specific product. While cleaning up the kitchen after a meal, the
person may be distracted by a short telephone call and then forget to refrigerate the leftovers.
A wallet may be left a couple of times in the sport’s locker after a workout at the gym or in the
car when going shopping. The person may go to the grocery store and buy many items but
forget the most needed item that triggered the trip to the store.

Examples of early, subtle changes in communication may involve struggles to recall
the right words while discussing or explaining a thought or idea, or having difficulty
understanding what is said when trying to follow a story on T.V.

Examples of early problems with thinking functions include difficulties: adding,
subtracting and doing other activities with numbers such as keeping score; understanding
what others say and expressing yourself; planning an activity and doing it; prioritizing steps in
a big activity such as a garage sale or buying an appliance or car; organizing and supervising
people; understanding and expressing emotion; using objects to do tasks such as combing
ones hair or vacuuming the floor; or recognizing people you see often.

A problem with understanding where things are located in space or losing a sense of
direction (also thinking functions) may result in being unable to follow directions to a friend’s
new home across town. When driving home from a gathering of friends, the person may take
a wrong turn and get lost.

Changes in the ability to do any of these functions or activities may be an early sign of
dementia.


Signs of Mild Memory or Thinking Changes


^ Difficulty remembering appointments
^ Difficulty recalling the names of friends, neighbors and family members
^ Using the wrong word when talking
^ Jumbling words: mixing up or missing letters in words when talking
^ Not following the conversation of friends or coworkers
^ Not understanding an explanation or story
^ Difficulty recalling whether a task was just completed the day or week before
^ Difficulty keeping up with all the steps to a task
^ Difficulty planning and doing an activity such as a board meeting or family
reunion
^ New difficulty filling out complicated forms such as income tax forms
^ Different behavior: restless, quick to get angry, constant hunger (especially for
sweets), quiet or withdrawn, etc.
^ Buying items and forgetting there is plenty at home
^ Struggling with work or home tasks that used to be routine and easy
^ Loss of interest in meeting with friends or doing activities

The key is repeated changes that reflect behaviors or abilities that differ from what is
typical for the person. Repeated experiences where there are changes in ability to
remember, to communicate, or to do functions that require thinking are signs of early
dementia. A medical exam as soon as possible is very important, because the doctor
may be able to fix the problem or recommend ways to slow down the health changes
leading to the problems.

Sometimes people will offer excuses, such as being extra tired or sick with the flu, for their
absent-mindedness or inability to express themselves well. They may use the excuse of
worry, such as being worried about: the children, the grandchildren, mounting bills, overdue
taxes, upcoming holidays, traffic, being late to a meeting, problems at work, etc. If the
memory problems or difficulties in thinking skills differ from typical behavior, then these
difficulties may be early signs of a fixable or a progressive memory disorder such as
Alzheimer’s disease or a related dementia.


Importance of an Early Medical Check-Up


People should be aware that any struggles in their ability to remember or to manage their
daily routine and pile of responsibilities may indicate changes in brain health. A question of
changes in brain health should lead to setting up a medical check-up with the doctor. Health
problems such as changes in blood pressure, heart disease, or hormone balances can affect
brain health. Brain health changes may also result from poor diet, lack of exercise or brain
stimulation, and not drinking enough water every day. Brain function may change as a result
of stress, medicines, and many other reasons. Such changes in brain cell function, if caught
early enough, may be easy to fix.

Other changes may need some therapies such as medicines to stabilize a chronic health
condition that can affect brain cell health. Some of these conditions are: high blood pressure,
very low blood pressure, uneven heart beat, or a heart beat that is too fast or too slow. Other
conditions such as diabetes affect arteries and veins and thus may limit a good flow of blood
throughout the brain (and body). Better control of the diabetes may result in less damage to
the health of the blood vessels, less damage to blood flow, and less damage to brain cells.
In some cases of progressive dementia such as Alzheimer’s disease, the doctor may offer
some recommendations including some medicines that may improve or boost brain cell
function.


More Information on Early Changes in Brain Function


Some of the changes in behavior and abilities, such as memory, communication, emotion,
judgment, decision-making, and learned skilled movement, that may occur early in the course
of dementia are discussed more fully in the following section.

Memory and Older Age

Some people blame memory difficulties on “old age”. The truth about the aging healthy brain
is that even the ninety year old who has probably lost about 10% of brain cell volume should
be able to remember details such as when a visitor is coming or a hair cut appointment. The
healthy ninety year old should be able to get information easily into the brain, make the
information “stick”, and recall most of the details, though it may take more time and more
effort. It may take more effort to pay attention to what someone is saying or showing to you,
especially if there are hearing or vision problems. Extra effort to make sense of new
information and to link it to previously stored details helps the new information stick better in
the older memory systems.

Not only may it take more effort to pay attention, but it also may take more time to recall the
information. But the ninety year old healthy brain should be able to get the information into
memory stores and to recall it later. Any changes in short-term memory should be a sign that
a visit for a medical exam is in order.

Early Changes in Communication Skills

Essential to relationships, communication involves understanding messages and giving
messages to others. Understanding messages may involve hearing what others are saying
or listening to the radio, T.V., or latest computer program. Understanding may involve seeing
what others are saying, such reading a note, newspaper, book, or iPod message.
Responding to others with language may involve speech (or singing) or writing a message to
someone.

Early signs of difficulty with communication skills may show up as forgetting the name of the
person whose card or letter you just read. You may not be able to name the simple title of a
book you have just read and are recommending. Some of the words may be out of order or
mispronounced. Other expression errors may include using the wrong word in a sentence
such as saying “store” instead of “school”, putting the wrong letter in a word such as “fencil”
for “pencil”.

Circumlocution may be an early sign of brain cell changes. The person may be unable to
express the specific word they need for their sentence. As a way to get around being unable
to recall the exact word, a person may talk all around the word, talk about the word, describe
the features of the specific item, or the way the item is used, but not use the exact word.
When an excellent speller starts misspelling words or a writer can’t write or put together a
correct sentence, these changes need to undergo a medical evaluation. In some cases the
communication difficulty may be so uncommon, that a medical specialist such as a behavioral
neurologist may be needed to identify whether the change represents a possible early sign of
a progressive dementia such as early Alzheimer’s disease or a less commonly occurring
dementia that affects communication, such as a primary progressive aphasia or a semantic
dementia.

Early Changes in Emotion

Changes in the ability to express or understand emotion may be an early sign of a depression
or a progressive dementia. Emotion is expressed in words, not only the particular words
used, but also in the tone of the words spoken, in loudness (or a whisper), and in the rate of
speed of the words being spoken. The face or body movements used when speaking add to
the emotion of the words.

Sometimes the ability to understand emotion remains accurate while there is less ability to
show emotion in the speaker’s voice or face. Or, the opposite may occur; the ability to
express emotion may be normal but the person may be unable to understand other people’s
emotion being expressed in speech or facial expressions.

These changes need a medical evaluation. There may be a fixable cause such as a
depression. Or the change may be a sign of the early stages of a treatable condition such as
Parkinson disease. The changes may be a sign of a progressive condition that is more
challenging to treat (as of 2008) such as a frontotemporal lobar degeneration (for more
information on Frontotemporal Lobar Degeneration, see www.AlzOnline.net).

Early Changes in Judgment

Changes in the ability to use good judgment when talking or acting may be an early sign of
decline in brain cell health. The person who has a typically shy personality and becomes
outgoing with anyone even strangers may be showing lack of judgment. They are not
thinking of possible consequences and are just moving ahead with a sudden interest or
desire to act.

When a person acts quickly without thinking of consequences or when a person acts quickly
without weighing possible negative results, such spontaneous actions may end up with
actions that show a lack of good judgment. An example of poor judgment is when a diabetic
eats too many sweets and ignores the predictable consequences of having a bad reaction.
Talking about private family matters with a stranger may lead to unpleasant responses from
the stranger. Discussing intimate feelings with a stranger or touching the stranger
inappropriately may lead to unpleasant reactions such as a call for help from a law
enforcement officer.

Early Changes in Decision-Making

Changes in the ability to decide from among several possibilities may be an early sign of
decline. The person who faces a menu with several food items or a closet with several
possible outfits and pairs of shoes, may be stumped with all the possibilities. They may feel
overwhelmed and unable to choose because of failing brain cell health. The struggle to
choose which social function to attend, which movie to attend, which store to start shopping
at, may be an early sign of difficulty in thinking. The change in now not being able to sort
through choices to identify a clear preference or appropriate choice may indicate changes in
brain cell health.

Early Changes in Learned Skilled Movements

Using the hands in skilled ways is a learned behavior. Learning about objects, such as a
spoon or wheels on a toy, and learning how to use objects, such as using a key to unlock a
door or scissors to cut paper, are actions that fall under the control of the brain. When
changes in these abilities occur, a person should undergo a medical evaluation.

The changes may show up as a new clumsiness when using a tool to replace the car battery
or plumbing under the kitchen sink. The clumsiness may be one-sided, that is, it may show
up in one hand while the other hand works normally. The clumsiness may occur in how one
walks, occasionally stubbing the toes or walking a bit off balance or leaning to one side. The
clumsiness may occur in moving from one position to another such as sitting down or getting
up from a chair, walking up or down stairs, getting into a car, or stepping off a curb. These
changes in ability should lead a person to set up a medical exam as soon as possible to
pinpoint a health problem and receive help to improve function.


Summary


When changes in memory, thinking abilities, and communication skills occur, it is important to
notice these changes and to see a doctor about them. People, who notice occasional
struggles to remember details such as the name of a person or specific object or whether a
task was completed, may be experiencing a change in brain health. It may become difficult
to select from many choices, such as which errand to do first. Changes in memory or
thinking skills (such as understanding, speaking, planning ahead, making choices,
understanding and expressing emotion, or using ones hands to perform a task) may begin to
show up occasionally in subtle ways.

The key point is noting the change from usual abilities to remember, communicate, do
activities in a typical way, or think carefully to make good decisions. The change in ability
may be noticed by the person who is having the difficulty. Or, instead, the change may be
noticed only by a family caregiver who sees the person every day. Sometimes the distant
relative who visits once or twice a year is the person who notices the change.
Any notice of such a change should lead to an appointment with the family doctor for a
medical check-up as soon as possible. The change in ability may result from a health change
that is easy to fix or easier to manage when caught early on. The physician or other health
provider may identify a health condition that is fixable or manageable enough to slow down or
change the course of the dementia. Even a progressive dementia such as Alzheimer’s
disease may benefit from therapies and medicines that a physician can offer to boost
memory and thinking skills.

More information is available on early memory or thinking changes under the titles
Evaluating Memory Changes, and Mild Cognitive Impairment (MCI) at
www.AlzOnline.net.


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Prepared by: Leilani Doty, PhD, Director, University of Florida Cognitive & Memory Disorder Clinics (MDC), Box 100236,
McKnight Brain Institute, Gainesville, FL 32610-0236, Office (352)273-5555; Memory Disorder Clinic Appointments
(352)265-8408. Partially supported by the Florida Department of Elder Affairs Alzheimer’s Disease Initiative. (2008)