It was near the end of a routine office visit when my patient, Sam, told me he needed to talk to me about his wife. I closed his chart and gave him my full attention. “Ruth’s just not the same,” he said. “She tells me the same thing three times. She forgets when we have plans to go somewhere. I don’t know, but I think she might have that Alzheimer’s disease.” Concern and frustration were evident in his voice. “Can you check her out the next time she’s in here?” I shook his hand and promised I would.
I had known Sam and Ruth, both in their late seventies, for more than two decades, and apart from the usual infirmities of the golden years, they had managed to dodge serious illness. I saw them both regularly, and neither one had struck me as having suffered a significant decline in intellectual functioning. But it wouldn’t be unusual for early dementia to sneak in under the radar. Its first symptoms may be subtle and impossible to distinguish from the normal decline in memory that occurs with aging.
If you ask people over 60 what they dread most, dementia is almost always in the top three on their list of health concerns. After all, it is memory that makes us who we are; without it we are forever trapped in the moment, with no window on the past or the future.
There is some discussion among experts over what exactly constitutes early dementia, but they generally agree that it includes both a decline in memory (learning and recalling new information like “Where did I put those keys?” or “What did we do yesterday?”) and a decline in at least one other area of intellectual functioning. Among those areas are language (breadth of vocabulary, complexity of sentences), calculation (balancing a checkbook, figuring a tip), judgment (Is this a legitimate bill or a mail scam?), and visual-spatial orientation (becoming disoriented while walking or driving). Faulty memory alone is not enough to diagnose dementia, and the cognitive impairment must be a decline from a previously higher level of functioning.
Two weeks later as I entered the exam room and opened Ruth’s chart, I found the note I had written to remind myself to check her memory. Mindful of her husband’s concerns, I asked her how things were going.
“Dr. Kagan,” she said, “I’m worried about Sam.”
I waited for more and watched as she frowned.
“I think he might have Alzheimer’s.”
I couldn’t help smiling to myself. After 50 years, is this where marital bickering had brought them? “What makes you think that?” I asked.
“Well, I say things and he keeps correcting me. And then he gets angry. He’s so short-tempered lately. It’s not like him.”
I told her I would look into it the next time I saw her husband. After reviewing her vital signs and performing a basic physical exam, I proceeded to test her. Extensive formal testing tools exist to evaluate memory, but most clinicians rely on the Mini-Mental Status Exam (MMSE) in their offices to screen for dementia. The test takes just a few minutes and is commonly used for detecting cognitive impairment. It includes a series of questions that test orientation to place and time, recall, calculation, reading, and executive function—carrying out a complex task, such as copying a drawing of two overlapping pentagons.
Amused through much of the testing, Ruth offered an excuse or a dismissive laugh whenever she failed on some component of the exam. She was unable to recall any of three named objects after three minutes. She struggled with simple math and was unable to spell the word world backward. When we were done, her score was well below normal, placing her in the early dementia range. Depression in some cases may mimic dementia, especially when patients become withdrawn and disengaged, but Ruth showed no evidence of that melancholic state. A careful neurological examination disclosed no abnormalities to suggest prior strokes or other disorders, such as Parkinson’s disease, that may be associated with dementia.
I sent Ruth to have blood drawn and then walked over to my secretary, Carina. I asked her to schedule Ruth for an MRI of the brain.
“What’s the indication?” Carina asked. The radiologists would want to know what I was looking for.
“Put ‘Evaluate dementia’ on the request.”
She nodded and mumbled, “Oh, that explains her cookies.”