A memory lapse, a few seconds of confusion, or any other noticeable moment of trouble with thinking skills can set off alarm bells. Are these early signs of dementia or typical episodes you might expect as you get older?
The distinction between normal, age-related changes in thinking skills and something more concerning—like mild cognitive impairment (MCI) or dementia—isn’t always crystal clear. However, each phase of brain change may be accompanied by a set of characteristics that can help determine where someone falls on the spectrum, explains Jennifer R. Gatchel, MD, PhD, a geriatric psychiatrist at Massachusetts General Hospital.
She adds that the onset of dementia caused by Alzheimer’s disease (AD) is often gradually progressive over years, so by the time the early signs of dementia are obvious, there has likely been a prodromal period of more subtle yet noticeable problems in thinking skills or behavior. However, some causes of dementia, such as prion disease, can lead to a more rapid progression of dementia symptoms. Vascular dementia is also characterized by a series of abrupt changes, though they are often separated by periods of relative stability.
Before exploring signs of dementia, you may find it helpful to learn what is considered “normal” cognitive change and how that differs from MCI.
What’s Normal?
Dr. Gatchel explains that age-related cognitive changes—including changes in processing speed, multitasking, and immediate recall—are expected with brain aging. While the specific changes may differ from one person to another, they share something in common: They do not interfere with an individual’s daily life and function.
She adds that normal changes may manifest as “tip of the tongue” phenomenon, meaning you may have more difficulty recalling a name or that it simply takes a little longer to do so. You may also experience more episodes of entering a room and initially not recalling why you’re there. Misplacing items also can occur more often.
“This is often mild, infrequent, and does not impact function,” Dr. Gatchel says. “It is not accompanied by noticeable mood or behavioral changes, or other physical symptoms, such as changes in movement or increased stiffness or rigidity.”
Other normative changes include being more easily distracted, taking longer to learn new information or skills, and having more difficulty multitasking. “Basic function remains intact,” Dr. Gatchel says. “People still manage work, finances, medications, and daily routines independently.”
What’s MCI?
In contrast to ‘typical’ age-related changes in thinking skills, MCI is a mild, measurable, and objective change in thinking abilities relative to one’s baseline, or to those of individuals of similar ages and educational backgrounds. Dr. Gatchel notes that everyone has a unique baseline, so signs of MCI may look different from one person to the next. It’s important not to assume noticeable thinking skills are automatically signs of early-onset dementia.
“The changes are greater than those associated with normal aging but not severe enough to interfere significantly with daily independence,” she explains.
Dr. Gatchel lists some common signs of MCI as:
- More frequent memory lapses that may lead to repeating questions and forgetting recent conversations
- Noticeable difficulty with complex tasks, such as managing finances and planning travel
- Losing track of tasks more often
- Trouble with decision-making or problem-solving
These changes also become more frequent, more measurable, and observable. People with MCI remain independent, but tasks that used to be easy may require more effort, organization, or support. “Changes in personality or behavior may also emerge” Dr. Gatchel says.
It’s also worth noting that while MCI is often a precursor to dementia, not everyone with MCI progresses. Depending on what is causing the change in cognition, MCI may remain relatively stable for a long time, improve, or progressively worsen. MCI can sometimes be an indirect consequence of a separate medical condition, drug side effect, or substance use of psychiatric disorder.
“Identifying MCI early allows monitoring, planning, and addressing reversible causes and contributors, such as sleep problems, depression, medications, vitamin B12 deficiency, etc.,” Dr. Gatchel says. “When Alzheimer’s disease pathology underlies MCI, early detection allows for treatment with newly approved agents for Alzheimer’s disease.”
What Is Dementia?
Dementia refers to moderate-to-severe cognitive decline that interferes with everyday functioning, resulting in partial and eventual complete loss of independence, Dr. Gatchel says.
Early signs of dementia can occur sporadically. For example, someone with dementia may have difficulty performing familiar tasks, like cooking a known recipe or managing bills, on some days, but on other days have no noticeable problems. Other early dementia symptoms include:
- Getting lost or confused in familiar places.
- Language struggles, such as more frequent word-finding difficulty that interferes with normal communication and conversation.
- Poor judgment, such as making unusual financial decisions or starting to engage in uncharacteristic and risky behaviors.
- Withdrawal from social or work activities because tasks feel harder or situations start to seem overwhelming.
- Declining ability to plan or problem-solve, beyond what’s expected with aging.
“Cognitive decline is significant enough to affect independence,” Dr. Gatchel says. “People may need increasing support for daily life, and this progresses to eventually needing full support.”
Dr. Gatchel also notes that early signs of dementia aren’t always related to thinking skills. For example, early signs of dementia in men often involve changes in mood or personality. Early signs of dementia in women are more likely to affect memory or thinking skills. These changes are known as prodromal symptoms.
One telltale indication is whether a person’s reaction or mood doesn’t fit the circumstances. Someone in the late stages of MCI or early stages of dementia may get overly upset in response to a minor inconvenience or become especially anxious about a routine matter.
Other mood and behavioral changes may include moodiness, anxiety, apathy (loss of interest in usual activities and the world around them), paranoia (convinced someone is stealing from them or that there is spousal infidelity), hallucinatory experiences, dream enactment, perceptual disturbances, fluctuations in orientation, disinhibition, new obsessions or compulsions, changes in appetite and sexual activity, irritability, and impulsivity (particularly in frontotemporal dementia).
Changes in movement/rigidity may also become evident, typically related to Parkinson’s disease dementia and/or dementia with Lewy bodies.
Responding to Dementia Symptoms
If you notice symptoms of dementia in yourself or a loved one, share the concerns with a primary care physician, who will perform an initial cognitive screening and a mood and psychiatric symptom screening.
“Based on these results, he or she may refer you to physicians who specialize in evaluating cognitive changes: a behavioral neurologist, geriatric psychiatrist, and neuropsychologist,” Dr. Gatchel says. “This more advanced workup may include additional tests such as more detailed cognitive tests, brain scans, blood tests, and/or spinal taps.”
Together, these tests can help determine the cause(s) of the cognitive impairment, she adds. Identifying the cause is especially important now that anti-amyloid therapies for cognitive impairment due to Alzheimer’s disease have been approved. A person with dementia symptoms also may be a candidate for more experimental therapies through clinical trials.
Dr. Gatchel also explains that a primary care physician may be able to discover or rule out reversible causes of cognitive impairment. Sometimes, early dementia symptoms can resemble those of delirium, which can have a sudden onset.
Involving family members early on is critical. “Individuals, together with family, should appoint a health-care proxy and complete a ‘goals of medical care’ discussion in addition to legal counseling and estate planning. This ensures that the individual can be involved in making these decisions and discuss his/her preferences so that future actions are aligned with his/her preferences,” Dr. Gatchel says. “And to the extent possible, individuals with MCI or dementia can still carry out strategies to optimize brain health through social engagement; regular physical activity/movement; blood pressure control; a heart-healthy diet, such as a Mediterranean diet or MIND diet, treatment of psychiatric conditions and substance abuse; and optimization of vision and hearing.”
