One of the most common things primary care physicians (PCP) see seniors for is evaluation of cognitive decline. Often PCPs do not refer the patient out, but instead enter a diagnosis of dementia in the patient record based on the family report and then give a prescription for Aricpet or Excelon, drugs that can treat the symptoms of dementia.
Many families are content with this process, as it confirms their suspicions. However, a lot is missed in simply labeling cognitive decline dementia. This would be similar to a dermatologist labeling all presenting problems as “rashes” and prescribing the same cream.
The term dementia encompasses a wide range of diagnoses and symptoms. Where there are common symptom presentations across dementias, the specific diagnoses are unique and carry with them differing prognoses (expectations of lifespan and the nature of decline), treatments, symptoms, drug interactions and support needs for family members and caregivers.
Families often assume that dementia and Alzheimers’ are synonymous, and that all dementias follow a common course. This is not true. There is value in clarification of what kind of dementia a person has.
Common Changes Among All Dementias
Memory loss is the first and most common complaint in patients and families concerned about dementias. All people with dementia experience loss of independence with Activities of Daily Living (ADLs), such as brushing their teeth, dressing, feeding themselves, and Instrumental Activities of Daily Living (IADLs), such as driving, taking medications, paying bills. Additionally, across all dementias it is common to see “masking” behaviors, when people with a dementia are able to rally in the moment (usually at the doctor’s office!) and have a clear, thoughtful discussion that is quite different from their presentation when at home. This can be quite frustrating for caregivers.
Different Types of Dementia
Alzheimer’s Disease. This is the most common form of dementia, accounting for 60-80% of the diagnoses. It is a slow progressing disorder, and ususally presents a memory loss, progressing to further impairment across cognitive domains. Alzheimer’s dementia is one of the few dementias for which acetylcholinesterase inhibitors (ex. Aricpet, Excelon) and multi-receptor antagonist (Namenda) may actually slow symptoms. It is important to note that these drugs are often prescribed to everyone who has a diagnosis of dementia. However, they are only FDA approved to treat Alzheimer’s Disease. It is unknown if they are helpful in treating other dementias.
Vascular Dementia. This is a form of dementia resulting from vascular complications. It can often be the result of a series of strokes. It accounts for about 10% of dementias. Unlike Alzheimer’s, vascular dementia often presents as impairment in judgment, reasoning, and executive functions (poor decisions) rather than memory loss. Treating vascular dementia focuses on treating the underlying vascular conditions to slow decline.
Lewy Body Dementia. LBD is a lesser-known, and therefore under-diagnosed, form of dementia. It is characterized by cognitive changes in combination with problems with movement (issues with walking, tremors, stability) and visual hallucinations. The importance of knowing the diagnosis of LBD is most significant when it comes to medications. Up to 50% of patients with LBD who are treated with any antipsychotic medication may experience severe neuroleptic sensitivity, such as worsening cognition, heavy sedation, increased or possibly irreversible Parkinsonism, and other complications that can be fatal. Given that many Alzheimer’s patients are treated with antipsychotics for behavioral and sleep problems, this difference is very important to know.
Parkinson’s Disease. Today, PD is being combined with LBD due to their common foundations-protein deposits in the brain. The difference between LBD and PD is mostly in the order of presentation of symptoms. PD presents first as a movement disorder. One of the pricipal treatments of PD is l-dopa, which is a synthetic drug designed to increase the amount of dopamine in the brain, which results in better movement. Sadly, a common side effect is hallucinations, for which doctors often prescribe the neuoleptics that are very dangerous to LBD and PD patients.
Fronto-Temporal Dementia. FTD results from degeneration of the frontal lobes of the brain (responsible for reasoning, decision making, impulse control, and some emotion regulation), and the temporal lobes (responsible for language and some aspects of memory). There are 3 forms: behavioral variant (marked by personality changes, impulse control, and sometimes violence), semantic dementia (loss of verbal memory and understanding), and progressive non-fluent aphasia (changes in the ability to speak, read, write, and understand what others are saying.
Why Diagnosis Matters
Due to the unique variations across types, one can begin to see the value of more specific diagnoses, whether it relates to medication planning, family education, and treatment considerations. In some cases the difference can mean life and death!
Adapted from CSA Journal number 64, Autumn 2015
by Carilyn Ellis, PsyD