What is Dementia?

Dementia refers to a decline in a person’s memory and other cognitive abilities that interferes with normal daily life. An estimated five million people in the U.S. are currently living with dementia. While age is the greatest risk factor, dementia is not a normal part of aging. Beyond your age, your cardiovascular health is the most important indicator of dementia risk.

The most common cause of dementia is Alzheimer’s disease, accounting for more than 80 percent of all cases. “Alzheimer’s is a progressive disorder,” says Christopher Weber, Ph.D., director of Global Science Initiatives for the Alzheimer’s Association. “This means the signs of dementia start out slowly and gradually get worse, so it’s important to watch for subtle changes that are more than normal aging and could indicate dementia.” Other conditions can also lead to cognitive changes, including a brain tumor, sleep disturbances, severe vitamin B12 deficiency, dementia with Lewey bodies, frontal-temporal dementia, and Parkinson’s disease.

Beyond Normal Aging.

“We all forget things at times—misplacing car keys, forgetting the name of a person you just met and recalling it later,” says Richard M. Dupee, MD, MACP, AGSF, a gerontologist and clinical professor of medicine at Tufts University School of Medicine. “We might even need to make lists more often as we get older. Minor memory problems such as these, as well as decline in other thinking skills, are what we call age associated memory impairment, and are of no concern.” These lapses are manageable, and do not interfere with function and normal day-to-day activity, he explains.

With dementia, things that were once commonplace mental activities become difficult. For example, if someone who always balanced their checkbook or followed recipes can no longer do so, that could be a sign of dementia’s onset. (This would not be a sign of dementia for someone who was never good at these tasks.). Getting lost while driving in a familiar place is another example of a common warning sign. If you find your lost keys by the refrigerator and suddenly remember you set them there when your arms were full of groceries, that’s normal. If you have no recollection of how they got there, that’s a warning sign for the onset of dementia.

Early Detection.

“Some causes of memory problems are treatable,” says Dupee. “And if not, such as in the case of Alzheimer’s, there are medications that may slow down the loss of memory.” Early diagnosis is essential for determining and starting treatment. It is also an opportunity for people with dementia and their care partners to get information and support as quickly as possible. “People who are diagnosed early have more time to make decisions regarding their care plan,” says Weber, “including building a care team, budgeting, receiving counseling, outlining their advanced directives, enrolling in clinical trials, and addressing driving and other safety concerns.” Knowing what’s coming empowers people to make decisions for themselves while they still can.

What to Do.

If you notice consistent changes in your cognitive abilities that seem beyond the normal changes of aging and interfere with your normal daily activities, talk to a doctor. If you notice these changes in a friend or loved one, have a trusted person approach that person at a quiet time and place to discuss these concerns and next steps.

No matter what your current situation, take steps to protect your brain. “Lifestyle behaviors that benefit heart health, like exercise, quitting smoking, and consuming a healthy dietary pattern, will also benefit the brain,” says Weber. “In general, it is best to eat a hearthealthy diet low in saturated fats and high in vegetables and fruits.” It’s also beneficial to keep the brain stimulated by learning something new, doing puzzles you find challenging, and staying socially engaged. Additionally, minimize the risk of head injury by using a safety helmet when appropriate and practicing fall prevention, and try to get seven to nine hours of sleep a night.

Be familiar with the warning signs of dementia, trust your perception of changes in your abilities, take the concerns of family and friends seriously, and don’t be afraid to talk with a healthcare provider.

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Simply put, dementia is an umbrella term covering symptoms such as memory loss, difficulties with language, and declines in thinking skills, problem solving, or judgment. Alzheimer’s disease (AD) is a specific brain disease that causes dementia, but it’s just one of several causes.

“Dementia is a clinical diagnosis describing moderate-to-severe impairment of memory or thinking ability that results in loss of independent function in daily activities,” says Massachusetts General Hospital psychiatrist Jennifer Gatchel, MD, PhD, noting that occasional memory lapses or moments of confusion don’t always rise to the level of dementia. That’s why it’s important not to chalk up forgetting a name or a computer password once in a while as a sign of AD or any other cause of dementia.

What Is Dementia?

In trying to grasp what dementia is, it may be helpful to understand what dementia is not. Occasionally or infrequently forgetting today’s date and the name of a former neighbor are not common signs of dementia. More worrisome would be persistent forgetfulness,  not knowing the current year or having trouble recalling the name of a person in your family or your relationship to that person. Misplacing your glasses periodically is normal, but losing things frequently or putting items in places where they don’t belong are signs worth noting. Occasionally forgetting where you parked your car at the airport is normal, while doing this repeatedly or becoming confused and lost on familiar roads near your home is problematic.

Minor, but still frustrating, age-related thinking-skills changes are normal. As we get older, the brain changes in several ways. Brain volume decreases, for instance, and myelin—the thin sheath that covers nerve fibers in the brain—shrinks, leading to slower processing and changes in cognitive function. In addition, older brains tend to produce fewer chemical messengers (neurotransmitters) to facilitate communication between neurons. This, too, can affect cognition and mood.

Dementia, however, is the result of significant damage to and death of brain cells (neurons) and their ability to communicate with each other on a much more serious scale than what occurs with normal, age-related cognitive decline.

“AD is the most common cause of dementia with late-life onset,” Dr. Gatchel says. It accounts for about 60 to 80 percent of dementia cases. But it’s one of several conditions that can trigger dementia. Three others, Lewy body dementia, vascular dementia, and frontotemporal dementia, each account for 5 to 10 percent of dementia cases. Less common conditions that can trigger dementia include Parkinson’s disease.

Other causes of cognitive impairment, some of which may be reversible, include:

• Depression
• Medication side effects
• Excessive alcohol consumption
• Thyroid disease
• Sleep apnea

What Is Alzheimer’s Disease?

AD is a progressive neurodegenerative disease, as its symptoms gradually worsen over time. It occurs when brain cells and the connections between brain cells degenerate and die. This cell damage is often the result of abnormal clumps of amyloid-beta protein in between brain cells and the formation of neurofibrillary tangles of tau protein inside the brain cells. Amyloid-beta (AB) and tau are the two pathological hallmarks of AD.

Recent research is also focusing on the role of chronic inflammation and other molecular changes in creating an environment where abnormal protein buildup and other unhealthy changes in the brain can flourish.

AD is not a normal part of aging, though advanced age is the greatest known risk factor for the disease. About one in 10 people ages 65 and older have AD, while nearly one-third of people 85 and older have the disease.

Alzheimer’s symptoms tend to start out mild and then steadily worsen until a person with AD needs help with every aspect of life, including basic functions, such as bathing and dressing. Late-stage AD dementia patients lose the ability to carry on a conversation or respond to their environment and their own needs. Life expectancy for people with AD is typically four to eight years, though some patients live longer with the disease. There is also now evidence that the pathological changes of AD—accumulation of AB and tau proteins in the brain—begin decades before the onset of clinical symptoms of mild cognitive impairment and dementia.

There is currently no cure for Alzheimer’s disease, though there are some medications that may help slow the progression of symptoms.

Diagnosing Causes of Dementia

In diagnosing the cause of cognitive impairment, doctors first consider subjective factors, Dr. Gatchel explains: “Is the person noticing any changes or are people close to them noticing changes? What is the frequency of cognitive lapses, and how much change do they represent from where a person might have been a few years ago or a decade ago.” For many individuals experiencing cognitive decline, a spouse or adult child can better explain symptoms to a doctor, who will want to know the nature of changes to memory, thinking, and behavior, as well as the severity and duration of these symptoms.

“We also recognize that behavioral changes may be among the earliest symptoms in dementia syndromes, so we ask about any emerging anxiety, sadness, loss of interest in previously pleasurable activities, irritability, or impulsivity,” Dr. Gatchel adds.

A doctor will then look at objective criteria, including scores on tests of cognitive ability and whether the individual has had to make adjustments to daily living because he or she can no longer do things, such as drive safely, cook and care for themselves, or keep track of doctor appointments and other responsibilities. “Test scores are compared to those of other people with similar backgrounds,” Dr. Gatchel says. “We also look at functionality. Do they need compensatory strategies? Has there been any loss of independence despite compensatory strategies?”

When cognitive changes are present, a doctor will initially need to rule out acute causes, such as medication side effects, infections, and metabolic disorders. “If they’re ruled out, that would prompt a further, thorough ongoing workup,” Dr. Gatchel says, noting that it will be important to get a medical and psychiatric history of the individual and the person’s family.

“There is a degree of detective work involved,” Dr. Gatchel adds. “This involves reviewing all the medications a person takes and medical problems, examining substance use, and looking at any co-morbid conditions, such as depression and anxiety disorders, which can also contribute to cognitive impairment.”

She adds that a key part of diagnosing Alzheimer’s disease is whether the pattern of cognitive changes, progression of symptoms, and brain pathological changes follow a pattern and timeline that is typical of AD. Comprehensive office tests of memory and thinking and brain imaging are thus used as part of the workup to help make a diagnosis and distinguish between causes of dementia.

Other imaging tools, such as brain computed tomography (CT) scans and magnetic resonance imaging (MRI), may be helpful in showing the loss of brain mass that can occur with Alzheimer’s and other causes of dementia. These scans, which provide doctors detailed images of brain structure, may also confirm or rule out other cognitive or behavioral changes due to tumor, stroke, and hemorrhage. Discovering changes to circulation in the brain can lead to a diagnosis of vascular dementia, a broad term that refers to cognitive problems resulting from impaired blood flow to the brain.

In addition, more specialized brain scans—positron emission tomography (PET) scans—can detect amyloid protein plaques and are tools that may one day help doctors diagnose AD well before symptoms appear, though Dr. Gatchel says PET scans for AD aren’t yet used widely in clinical practice.

Takeaway

Concerns about developing dementia tend to grow steadily as we get older. Some of that, Dr. Gatchel suggests, may be due to a lack of understanding of the spectrum of changes that occur in “normal” aging vs. in dementia. Not all “senior moments” are dementia.

“If you’re noticing a change with memory or thinking skills, don’t immediately assume it’s Alzheimer’s or some other cause of dementia,” Dr. Gatchel says. However, if the changes do signify dementia, early detection and determination of the cause can be key to treatment and planning, including referral to clinical trials, when appropriate.  This may become even more relevant in the near future as our treatment options for these devastating disorders expand.

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Dementia statistics suggest that genetic background is certainly a factor—but not the only factor—in the risk for irreversible dementia. For example, although risk for frontal lobe dementia (also called frontotemporal dementia) is significantly increased among individuals who have relatives who have developed the disease, more than half of people diagnosed with this form of dementia do not have such a family history.

The Role of Genetics: Is Dementia Hereditary?

When considering whether dementia is hereditary, the role of genetics is similar in the case of Alzheimer’s disease, which accounts for up to 80 percent of all dementia cases. Researchers have discovered a number of single-gene mutations that are directly associated with early-onset Alzheimer’s disease, which develops before age 60 and affects fewer than 5 percent of people with AD.

Mutations in the amyloid beta A4 protein precursor (APP), presenilin 1 (PSEN1), and presenilin 2 (PSEN2) genes cause the production of abnormal proteins that trigger the brain damage associated the signs of early onset dementia.

The picture is less clear with regard to the late-onset form of Alzheimer’s disease. Scientists have been unable to find specific gene mutations to blame for late-onset AD. They have, however, found a gene variant that appears to increase a person’s risk for both AD, and vascular dementia (VaD), the second-most common form of dementia, which is caused by vascular problems affecting memory regions and supporting structures in the brain.

The gene variant, called apolipoprotein E (ApoE), provides instructions for the production of a protein that helps transport cholesterol through the bloodstream and remove it from the body. About 25 percent of the population has at least one copy of ApoE4, a variation of the ApoE gene that has been associated with a higher risk for Alzheimer’s. Although ApoE4 does not cause Alzheimer’s or VaD, it may lead to brain changes that affect cognitive decline.

It is not yet clear precisely how ApoE4 affects the brain, but it looks like people who have the ApoE4 gene experience a more rapid loss of nerve cell functioning in the frontal lobe, which is important in maintaining higher mental functioning. It might be said that the brains of people with the ApoE4 gene age at a faster rate and that this acceleration may increase the chances of progressing to dementia.

ApoE may help break down sticky clusters of beta-amyloid protein that can clog the spaces between brain cells. In people with the genetic variation ApoE4, the ability to degrade beta-amyloid is impaired. This is why studies have associated the ApoE4 variation with an increased number of beta-amyloid plaques in the brain.

There is abundant evidence that people who inherit two copies of ApoE4 have a greater risk of developing Alzheimer’s than those who have just one copy. But, because not all people with Alzheimer’s have this ApoE4 genetic variation, and not all people who have the variation will develop the disease, testing for it is not currently considered a useful predictive tool.

Other Alzheimer’s Genes Identified

In the past few years, scientists have identified a number of other genes that are suspected of playing a role in the development of AD and other neurodegenerative disorders. These gene variants are linked to:

• the sortilin-related receptor 1 (SORL1) gene, which may be involved in the abnormal production of beta-amyloid plaque in the brains of people with late-onset Alzheimer’s disease;
• the cell division cycle 2 gene (CDC2), which has been associated with increased production of the tau protein; and the protein ubiquilin-1, which controls the gathering, deposit;
• and degradation of several proteins associated with Alzheimer’s disease and other dementias.

Is Dementia Hereditary—And Should You Be Tested?

It is possible to request genetic testing to determine whether you have inherited some of the genes associated with AD or other dementias, but there are both advantages and disadvantages associated with undergoing this process.

Since testing for many of the genes associated with the most common forms of dementia cannot indicate definitively whether an individual will or will not develop a neurodegenerative disease, fears may be raised or eased in error.

What’s more, given the fact that there is currently no dementia cure available to halt or reverse the progression of most types of dementia, genetic testing may be unnecessarily distressing and ultimately pointless for many individuals. In the majority of cases, deciding to forgo testing and instead adopt lifestyle strategies that maximize physical and mental health may provide the best response to worries about inheriting dementia.

Originally published in 2016, this post is regularly updated.

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Dementia is a term used to describe significant impairment of two or more critical brain functions (such as memory, language, judgment, or reasoning) that impacts a person’s ability to function in daily life. Dementia can be caused by a number of different diseases and conditions. While Alzheimer’s disease (AD) is the best-known cause of dementia, there are many other causes of dementia ranging from vascular disease (e.g., stroke or vasculitis) to rare inherited forms of dementia (such as some forms of frontal lobe dementia).

Dementia Statistics in Men

Statistics from the Aging, Demographics, and Memory Study (ADAMS) revealed that approximately 14 percent of Americans 71 years and older have some form of dementia. The prevalence is slightly higher among women; the same study showed that 16 percent of women 71 and older suffer from dementia, compared with 11 percent of men.

The reasons for this gender difference are still unclear, but theories include longer life expectancies in women, hormonal influences or genetic risk factors (the effect of estrogen on the APOE-e4 gene for AD), and historical differences in education (low education is a known risk factor for dementia).

What Are the Signs of Dementia in Men?

Dementia signs and symptoms can vary from person to person over time (particularly if it is a progressive form of dementia), depending on the underlying cause. Certain signs, however, are relatively common to many forms of dementia.

Cognitive Changes

• Memory loss: Memory impairment, particularly with remembering recent events, is a hallmark of most forms of dementia.
• Difficulty with planning or organizing: Tasks that involve the need to account for multiple factors or details become increasingly challenging.
• Communication impairment: Difficulty communicating, especially in finding the right words to use, is a common feature of dementia.
• Disorientation: Problems with geographic directions and time orientation can also be present. This can range from someone forgetting dates to forgetting where they are and how they got to that place.
• Difficulty with numbers or problem-solving: People suffering from dementia may have trouble handling money, paying bills, or solving problems such as managing a budget at work.
• Problems with spatial relationships: Some individuals may have difficulty perceiving differences in distance, color, or contrast that can impact activities ranging from playing a sport such as golf to driving.

Behavioral Changes

• Poor judgment: Patients with dementia may experience deterioration in their judgment leading them to make decisions they may not have made before such as buying large quantities of items they don’t need or wouldn’t have had interest in before.
• Mood alteration: Dementia can result in significant changes in a person’s mood ranging from depression to anxiety to paranoia. It may be difficult to reason with a person suffering from dementia.
• Social withdrawal: As tasks become more challenging for someone with dementia, they may begin to withdraw from activities and social interactions they used to participate in.
• Inattention to personal grooming: Dementia can cause an individual to begin to neglect his or her personal hygiene and grooming.

Physical Changes

Physical changes associated with dementia are more significantly associated with the underlying etiology of the dementia (e.g., a stroke that results in partial paralysis) and tend to occur later in the course of the dementia, but some common changes include:

• Loss of coordination: People with later stage dementia tend to have difficulty moving and performing tasks in a coordinated fashion and often appear clumsy. In the very latest stages of dementia, many people may even lose their mobility altogether and become bedridden.
• Loss of speech: While language or word recall is often an early sign of dementia, some individuals go on to lose the ability to speak at all.
• Incontinence: As dementia progresses, loss of bowel and bladder control can occur.

Differences in Signs of Dementia in Men and Women

While many dementia signs and symptoms are common to both men and women, research has demonstrated that there are gender differences in the rate and degree to which people experience some of these symptoms.

• Verbal skills: A study published in the journal Neurology demonstrated that men with dementia retained verbal fluency, the ability to correctly perform naming tasks, and the ability to successfully perform delayed recall of words longer than women with dementia.
• Subjective memory complaints: One study demonstrated a significant difference in the appearance of memory disturbances between men and women. Women experienced memory impairment earlier in the course of their dementia than did men.
• Depressive symptoms: Another study found that men who experienced depressive symptoms had a significantly higher risk of developing dementia, particularly AD, than did women with depressive symptoms.
• Rate of symptom progression: A recently published study from Duke University suggests that once the initial symptoms of dementia appear in men and women, they tend to progress at a faster rate in women compared to men. As CBS News reported, “Researchers from Duke University Medical Center looked at about 400 men and women, mostly in their mid-70s, with mild cognitive impairment, a condition involving a slight but noticeable decline in memory and thinking skills. Over the course of up to eight years, the data showed that the cognitive abilities of the female participants declined twice as fast as their male counterparts.”

Lead researcher Katherine Amy Lin, the Wrenn Clinical Research Scholar in Alzheimer’s disease at Duke University Medical Center, summarized the results in a statement issued to the media.”These results point to the possibility of as yet undiscovered gender-specific genetic or environmental risk factors that influence the speed of decline,” Lin noted. “Uncovering those factors should be a high priority for future research.”

Originally published in 2016 and updated.

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Diagnosing the cause of dementia is critical, because some forms—such as vitamin deficiency or thyroid-induced dementia—are reversible if treated. For those causes that are progressive and incurable, diagnosing the dementia as early as possible allows healthcare providers to initiate treatment of symptoms and allows caregivers to make the necessary plans for the future.

What Is a Dementia Test?

The diagnosis of dementia is actually not made by one single test but rather by a combination of tests. This is why organizations such as the American Academy of Neurology and the Alzheimer’s Association recommend against individuals taking a dementia test online or a so-called Alzheimer’s test online.

Furthermore, a recent evaluation of many of the available dementia tests online by an expert panel of physicians, psychologists, and ethicists found them to be unreliable. Thorough evaluation for dementia involves performing a number of tests: medical and personal history, physical examination, neurocognitive testing, laboratory testing, depression screening, and neuroimaging.

• Medical and personal history: If you or your loved one is being evaluated for dementia, your healthcare provider will inquire about any medical conditions you have or medications you are taking. They will want to hear you describe the changes or problems that have prompted you to seek evaluation for dementia. Any family history of dementia will be especially important to share.
• Physical examination: A detailed physical examination, including a comprehensive neurologic examination, is a critical part of any dementia test. Specific neurologic deficits might suggest a particular cause of dementia such as a stroke or frontal lobe dementia (also called frontotemporal lobe dementia). Physical signs of thyroid disease or nutritional deficiencies might provide clues to metabolic causes of dementia.
• Neurocognitive testing: This part of the dementia test evaluation is what most people think of when they hear the term “dementia test” as it provides an assessment of the cognitive brain functions that can become impaired in dementia. The two general cognitive screening tests recommended by the American Academy of Neurology for use in detecting cognitive impairment are the Mini Mental Status Exam (MMSE) and the Memory Impairment Screen (MIS):

1. Mini Mental Status Exam (MMSE): This test evaluates a range of cognitive functions including memory, concentration, communication and language, attention, ability to plan, and ability to comprehend instructions. Patients are asked to perform tasks such as writing a short grammatically correct sentence, memorizing a brief list of objects and then repeating it a little while later, and answering time-orientation questions. The maximum score you can achieve on the MMSE is 30 points. Scores of 20-24 are suggestive of mild dementia; scores of 13-20 are suggestive of moderate dementia; scores below 12 are suggestive of severe dementia.
2. Memory Impairment Screen (MSI): The MIS, as the name applies, is a test designed for recent memory evaluation. Patients are shown a list of four words and are told that each word falls in a different category. They are then told a category cue (such as “game” for the word “checkers”) and asked to identify which word that category applies to. Inability to associate the words with category cues is suggestive of cognitive impairment. The patient is then distracted with other activities, including exercises such as counting backwards from 20, for two to three minutes before they are asked to recall the four words on the list they were originally shown. If they are not able to recall each word, they are then told the category cue to see whether it prompts word recall. The patient receives a score for each word (2 points for free recall; 1 point for cued recall; 0 points for no recall). A score of 5–8 suggests no impairment. A score of 4 or less suggests possible cognitive impairment.

Scores on either of these tests that are suggestive of cognitive impairment may prompt healthcare providers to order more in-depth neurocognitive testing (e.g. the Neurobehavioral Cognitive Status Examination, Kaplan Baycrest Neurocognitive Assessment).

• Laboratory testing: Laboratory testing to assess overall health and to look for possible metabolic causes of dementia are part of the dementia test evaluation. These laboratory tests include: a complete blood count, glucose level, thyroid function tests, electrolytes, blood urea nitrogen and creatinine levels, B12 level, and liver function tests.
• Depression screening: Symptoms of depression can overlap with those of dementia. These overlapping symptoms include memory problems and loss of interest in hobbies, social activities, and life in general. Assessing an individual’s mood or sense of well-being is therefore an important part of the general dementia screening process.
• Neuroimaging studies: Performing magnetic resonance imaging (MRI) or computed tomography (CT) studies to look for structural abnormalities that may be a cause for dementia is part of a standard dementia work-up. These tests can reveal evidence of stroke, tumors, or changes such as the brain atrophy (shrinkage) seen in frontal lobe dementia that can all be causes of dementia.

Originally published in June 2016 and updated.

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Learning more about this condition may help provide reassurance for many, and for others, may indicate when changes in memory and other basic mental processes indicate the need for further assessment. (See also “Dementia Stages: What to Expect.“)

Dementia is a term that describes a deterioration in mental abilities that interferes with the ability to engage in the activities of daily living. Individuals with dementia show signs of decline in memory, reasoning, judgment, language and other mental faculties.

What Is Dementia? The Two Types, Explained

There are two dementia types:

• Primary dementias—such as Alzheimer’s disease or Lewy body dementia (DLB)—involve damage to or wasting away of the brain tissue.
• Secondary dementias are cognitive and memory loss symptoms caused by mental or physical disorders, such as vascular dementia, depression or dementia caused by thyroid problems.

Changes in brain function with dementia can alter virtually everything about you—including your personality and behavior. According to diagnostic criteria, serious memory lapses may indicate dementia if they are accompanied by at least one other symptom of cognitive decline.

Dementia symptoms may include:

• Asking the same questions over and over.
• Losing the ability to accomplish complex tasks, such as cooking a meal.
• Becoming lost in once-familiar places.
• Forgetting names of familiar people.
• Having trouble using language, or putting words together.
• Failing to remember regular appointments.
• Neglecting personal hygiene—such as brushing your teeth or showering.
• Showing signs of mental confusion.
• Having difficulty recognizing common objects, like a toothbrush or TV set.
• Having trouble coordinating movements.
• Experiencing mood symptoms such as anxiety, unusual irritability, or depression.

For more on this topic, read our post “Worried About Dementia Symptoms? Train Your Brain to Fight Back.” See also the following:

• “Early Signs of Dementia”
• “Dementia Test: Sorting Out Options”
• “An Overview of Dementia Medications”
• “Dementia Stages: What to Expect”

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Originally published in June 2016 and updated.

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