- Elliott M. Stein, M.D.
Cognitive Impairment and Dementia in the Elderly
Cognitive Impairment and Dementia in the Elderly
Dementia is the medical term for a syndrome in which there is deterioration in memory, thinking, behavior, and the ability to perform everyday activities. Dementia has a physical, psychological, social, and economic impact, not only on people with dementia, but also on their caregivers, families and society at large. Dementia is one of the major causes of disability and dependency among older people worldwide.
Although dementia mainly affects older people, it is not a normal, inevitable part of aging, and not every older person develops a memory disorder. Twice as many Americans fear the loss of mental capabilities as the loss of physical ability.
As cognitive problems develop, a person’s ability to recall, process information, think logically, understand, and make decisions may become impaired, and this can affect their capacity to make decisions, and their vulnerability to undue influence and elder abuse.
Dementia may be unrecognized and untreated
All too often, older people may develop a dementing disorder relatively slowly over a period of time. Their gradually worsening cognitive function may go unnoticed or may be mistakenly attributed to normal aging. Family members and other caregivers may compensate for the advancing deficits, and interact with the sufferer as if there was not a problem. This might include expecting the person to carry out tasks and make decisions that they may no longer be capable of doing well, if at all. These could include asking the dementing person for opinions, advice and decisions involving finances and investments, health and healthcare treatments, living setting, inheritance matters and others. Other problems associated with dementia can develop such as impaired functioning and psychiatric symptoms. Over time the person may remain in their usual setting, while the burden on the caregiver grows. By the time the problems reach the point where help is sought, the illness may have been present for an extended period of time.
The estimated proportion of the general population aged 60 and over with dementia at a given time is between 5-8%. Alzheimer’s Disease is the most common type of dementia. One in 10 people age 65 and older (10%) has Alzheimer's dementia, an estimated 5.8 million Americans, as of 2020. Eighty percent of Alzheimer’s sufferers are age 75 or older. By 2050, this number is projected to rise to nearly 14 million. At the end of life, one in 3 seniors will die with Alzheimer’s or another dementia. Alzheimer’s in the 6th leading cause of death in the US overall, but it is the fifth-leading cause of death among those age 65 and older and a leading cause of disability and poor health. Among people age 70, 61% of those with Alzheimer's dementia are expected to die before the age of 80 compared with 30% of people without Alzheimer's, a rate twice as high.
Types of Dementia
Doctors have commonly estimated that there are over a hundred different conditions that can cause cognitive impairment and dementia, with some people suffering from combinations of more than one condition. Estimates of the most common types of dementia are Alzheimer’s Disease (about 50-70%), Vascular (about 25%), Lewy Body Disease (about 15%), Frontotemporal Dementias (15% overall, but may be present in 20-50% of those diagnosed with dementia in those under 65 years old). The boundaries between different forms of dementia are indistinct and mixed forms often co-exist.
Treatment of Alzheimer’s disease and related neurocognitive disorders leads to a significant toll on the formal and informal healthcare and caregiving systems; this includes increased utilization of acute healthcare services, with high rates of medical comorbidities. Dementia costs (including out-of-pocket expenses) in the last 5 years of life are often are higher than other conditions such as cancer and cardiovascular disease.
Almost two-thirds of Americans with Alzheimer's are women. Racial and ethnic differences are found in the incidence of Alzheimer’s disease and related dementias among African-Americans and Hispanic-Americans, which appear to be related to a higher incidence of risk factors, including high blood pressure and diabetes and psychological stressors, as well as socioeconomic factors including lower income and lower access to nutritional resources and healthcare. Older African-Americans are about twice as likely to have Alzheimer's or other dementias as older whites. Hispanics are about one and one-half times as likely to have Alzheimer's or other dementias as older whites.
Alzheimer’s disease is an incurable brain disorder that slowly worsens with time, affecting a person’s memory, cognition, personality and even physical abilities. Memory impairment, especially for recent events, is often one of the first symptoms of Alzheimer’s. The disease severely affects memory, thinking, learning and organizing skills and eventually affects a person’s ability to carry out simple daily activities. Alzheimer’s disease is not a normal part of the aging process. As the disease progresses, it becomes harder and harder for the person to complete daily activities independently.
Symptoms of Alzheimer’s may also include: confusion about events, time and place, repeating questions, trouble managing money and paying bills, putting objects in odd places, trouble performing/taking longer to perform familiar tasks, getting lost/wandering, not being able to sleep, changes in personality and behavior including agitation, anxiety and aggression, having groundless suspicions about family, friends and caregivers, poor judgment or reasoning, trouble recognizing family and friends, difficulty learning and remembering new information/recent events, having hallucinations, delusions or paranoia. As the illness progresses there may be difficulty speaking/finding the right words, difficulty performing multistep tasks, such as dressing or cooking, difficulty reading, writing and working with numbers, difficulty walking, difficulty swallowing.
People age 65 and older may survive an average of 3 to 11 years after a diagnosis of Alzheimer’s dementia, yet some live as long as 20 years with Alzheimer’s. This reflects the slow, uncertain progression of the disease. Often, the onset is gradual, and the worsening symptoms are denied or not noticed by family members or others, who may attribute them to “normal aging.”
Vascular dementia is a progressive condition that impairs memory and mental function due to decreased blood flow to the brain. It’s the second most common cause of dementia after Alzheimer’s disease. Vascular dementia can also occur along with Alzheimer’s disease. There are some differences between vascular dementia and Alzheimer’s disease. One of the main ones is in the early symptoms. In Alzheimer’s disease, it’s usually forgetfulness. In vascular dementia, this usually isn’t the case. Instead, early symptoms tend to include slowed thought and problems concentrating, making decisions, following directions, planning and organizing. The two diseases become more similar as vascular dementia progresses.
Vascular dementia progression can vary with the underlying cause of the disease.
When it results from a stroke, symptoms are more likely to begin suddenly. About 20% of people who suffer a stroke will develop vascular dementia within six months. Whether or not changes in thinking, memory, or mental ability occur will depend on the area of the brain the stroke affected. The extent of the stroke can influence the severity of the symptoms.
Cognitive symptoms tend to develop gradually when the underlying cause is a chronic blood vessel problem. This can include such conditions as atherosclerosis (hardening of the arteries), autoimmune vascular diseases, diabetes, and high blood pressure. These chronic conditions narrow the small blood vessels throughout the entire brain, progressively depriving brain tissue of vital oxygen. Vascular dementia due to these problems can result in subtle changes over time. This type of disease progression is less dramatic than the sudden changes after a stroke, which tends to affect that specific region of the brain supplied by the blocked, or occluded blood vessel.
Another possible cause of vascular dementia is a series of mini-strokes caused by interrupted blood supply to the brain. Vascular dementia stages or steps characterize this form of the disease. Symptoms aren’t sudden or gradual, but follow a noticeable stepwise progression instead. With each mini-stroke, additional symptoms appear or worsen. Then, symptoms remain stable for a period of time, until the next mini-stroke.
Regardless of how the disease progresses, people in the later stages of vascular dementia will show overall decline in cognitive and physical abilities. It is difficult to predict how quickly a person with vascular dementia will decline. In general, the vascular dementia survival rate is lower than the survival rate and life expectancy with Alzheimer’s disease. The average vascular dementia life expectancy after diagnosis is about five years. Some research suggests it may be shorter, at three years, in people who have the disease due to stroke. It’s common for people with vascular dementia to die from a stroke or another event related to the underlying causes, such as a heart attack.
Lewy Body Dementia
Symptoms of Lewy Body Dementia can fluctuate but usually become progressively worse over time. Early in the disease, fluctuations between normal and abnormal behavior, mood, and cognitive ability can occur. A central feature of this disease is progressive dementia shown by problems such as deficits in alertness, attention and thinking, hallucinations, parkinsonian symptoms, sleep disturbances, behavioral changes, that may start in the early stages and can progress to severe dementia.
Although the rate of progression varies, in general, on average, life expectancy with LBD is five to seven years, although the range is known to be between two and 20 years. Lewy body dementia doesn't typically progress as predictably as Alzheimer's does. Rather, because one of its characteristics is that its symptoms can fluctuate, progression in Lewy body dementia may vary significantly from one person to another.
Frontotemporal dementia (FTD), a common cause of dementia, is a group of disorders that occur when nerve cells in the frontal and temporal lobes of the brain are lost. This causes the lobes to shrink. The causes of FTD are not known. FTD can affect behavior, personality, language, and movement. These disorders are among the most common dementias that strike at younger ages. Symptoms typically start between the ages of 40 and 65, but FTD can strike young adults and those who are older. FTD affects men and women equally. There are several variants of FTD; these different types can affect the ability to speak, or affect the ability to understand language, or affect behavior and personality. A less common type affects movement. The disease takes from three to ten years to progress, although there are instances of much shorter or longer times. The average life expectancy of a person diagnosed with frontal lobe dementia is eight years.
Symptoms of FTD start gradually and progress steadily, and in some cases, rapidly. They vary from person to person, depending on the areas of the brain involved. Common symptoms may include: behavioral and/or dramatic personality changes, such as swearing, stealing, increased interest in sex, or a deterioration in personal hygiene habits, socially inappropriate, impulsive, or repetitive behaviors, impaired judgment, apathy, lack of empathy, decreased self-awareness, loss of interest in normal daily activities, emotional withdrawal from others, loss of energy and motivation, inability to use or understand language; this may include difficulty naming objects, expressing words, or understanding the meanings of words, hesitation when speaking, less frequent speech, distractibility, trouble planning and organizing, frequent mood changes, agitation, increasing dependence, some people have physical symptoms, such as tremors, muscle spasms or weakness, rigidity, poor coordination and/or balance, or difficulty swallowing. psychiatric symptoms, such as hallucinations or delusions, also may occur, although these are not as common as behavioral and language changes.
Eighty-three percent of the help provided to older adults in the United States comes from family members, friends or other unpaid caregivers. Nearly half of all caregivers who provide help to older adults do so for someone living with Alzheimer's or another dementia. About one in three these caregivers (30%) is age 65 or older. Approximately two-thirds of caregivers are women; more specifically, over one-third of dementia caregivers are daughters. Most caregivers (66%) live with the person with dementia in the community. The Alzheimer’s Association estimates that 18.5 billion hours of services were provided by informal (i.e., non-professional), unpaid caregivers in 2018. These caregivers are at significantly increased risk that they themselves will develop psychiatric and medical illnesses, as well as detrimental effects on relationships, paid employment, and leisure activities.
For attorneys, legal professional and individuals representing or involved in legal matters surrounding contested wills and trusts, capacity, financial elder abuse, undue influence, and other cases requiring forensic geriatric psychiatric matters as part of their case, please contact Dr. Stein to set up a no-obligation 30-minute consultation:
Elliott M. Stein, M.D.