What does detection of dementia mean?
Detection of dementia must be looked at from two sides: From the perspective of the person in whom dementia is detected and from the perspective of the person who detects dementia.
At the stage of incipient dementia, most people are aware of their problems and reduced abilities. Often they feel embarrassed, frustrated or ashamed. It is very painful to acknowledge difficulties, and even more to reveal them to others. Therefore, people with dementia tend to downplay, hide or disguise their problems. For example, they may insist that nothing is wrong despite obvious lapses, errors and mishaps (denial). Or they may quit activities and tasks they feel they will have trouble coping with, perhaps explaining that these activities are no longer important or interesting (avoidance, withdrawal).
As dementia advances, the insight into own problems gradually fades. At the stage of severe dementia, awareness can be completely lost (anosognosia). In those cases it is impossible and should not be attempted to convince the person that they have problems and need help.
To be able to detect dementia you should be familiar with the earliest signs of dementia in terms of changes in cognition, daily activities, behaviour, and interpersonal relationships. Detecting dementia must be distinguished from identifying the disorder that underlies dementia.
What are the early signs of dementia?
Early signs may relate to any aspect of the symptom pattern of dementia. Here are some examples:
Attention: Being easily distracted, losing the thread in conversations, absentmindedness.
Memory: Forgetting names, dates or events, repeatedly asking for the same information, frequently misplacing or losing objects.
Orientation: Confusing time of day or day of week, getting lost in unfamiliar surroundings, e.g. in a hotel.
Language: Lack of depth, logic and precision in conversations; verbal expressions becoming vague and sparse of meaning; difficulty with reading and writing; difficulty finding words while speaking.
Executive functions: Difficulty making or following a plan or completing multi-step tasks; problems operating a computer, operating domestic appliances; problems organising the household, doing minor repairs, or traveling.
Judgment and problem-solving: Difficulty understanding what is fair and reasonable; paying too much for things; being easily persuaded to buy things that are not needed.
Visuospatial abilities: Problems identifying objects, judging distances, discriminating between colours.
Activities of daily living: Tasks take longer, problems at work particularly with more complicated tasks; reduced productivity; inability to manage previous routine tasks; impaired driving quality in terms of accidents or traffic violations.
Behaviour: Reduced initiative, changes of social contact, irritability, impatience, socially inappropriate behaviour, repetitive or stereotyped behaviour, disinhibition.
Interpersonal relationships: Less empathy and affection, less interest in others, increased friction; less or more interest in intimacy and sex.
This implies that a lot of things are likely to have happened before people with possible dementia and their carers come to the attention of a healthcare professional. They may have experienced failures, mishaps or accidents, conflict and dispute, and most probably feel worried, uncertain or alarmed. In this situation of uncertainty and tension, the professional’s role is to clarify what is going on and potentially to break bad news.
When family members or other observers become aware of cognitive impairment, lapses in daily activities or changes in behaviour in someone, they are likely to have feelings of insecurity, anger, impatience, embarrassment or helplessness, and may be torn between the wish to help and the fear to invade privacy or being offensive.
Who should be able to detect dementia?
Since dementia becomes more frequent with increasing age, everybody who has regular contact with older adults should be aware of the warning signs for dementia. Of course this applies to health and social professions including physicians, psychologists, nurses, hospital staff, social workers, occupational therapists, physical therapists and pharmacists. However, education about dementia and its early manifestations should also include the police, shopkeepers, people working in public transportation, bank employees, and others. Increased public awareness of dementia is not only a prerequisite for timely diagnosis and treatment, but is also important to provide help and support to people with dementia and develop a dementia-friendly society.
What should people do if they suspect dementia?
It can be very painful for an individual when their reduced abilities or changes of behaviour are revealed. Therefore, it is important for professionals and lay people not to be blunt, but to broach the person very gently and diplomatically, starting with the things that have been noticed. Talking about observations should be done with empathy, understanding, and in a mood of help and support. Whenever possible and appropriate, people should be encouraged to talk to their family physician or to contact a patient organisation in their area. When people with dementia are completely unaware of their problems, they should not be forced into accepting the symptoms that others see. Instead, a respectful, non-judgmental relationship should be created with the aim working together to mitigate the impact of dementia on daily life.
What are the benefits of detecting dementia?
Early detection offers a number of benefits to help individuals who dementia and their families. Due to the progressive nature of most dementias, the best opportunity for individuals to benefit from available treatments, enrol in clinical trials, express their wishes and carry out advance planning, is in the early stages of the condition. People who are aware of their problems and their caregivers can plan for the future by providing advance health directives and making financial and legal arrangements before the cognition becomes worse. They can also address safety issues and seek counselling on how to cope with behavioural changes associated with the progression of dementia. Early detection can also help health care providers deliver better care. Early signs of dementia may also be attributable to other causes. Therefore, recognition of these signs enables physicians to identify and treat reversible conditions such as depression or physical diseases.
Detection of dementia in the physician’s office
GPs and their staff are in a unique position for detecting dementia, as they often have known the people who come to their office for a long time, and are likely to notice subtle changes in cognition, functional abilities or behaviour. At the GP level, brief tools for the detection of cognitive decline may be used, complemented by interviews with carers. Assessments need to take into account the individual’s age, family history, educational level, socio-economic status, comorbidities, medication list and the range of habitual daily activities.
Aspects to be taken into account when evaluating cognitive decline
Detection of dementia in the general hospital
About 40 % of older adults who are admitted to a general hospital have dementia. Only half of them had been diagnosed with dementia prior to admission. Usually, people are not admitted because of dementia, but because of another (physical) health issue. Systematic screening for dementia is rarely performed in general hospitals. The suspicion of dementia only arises when people exhibit behaviours that do not fit the structures and processes of a hospital. For example, people may not find their way in the unfamiliar environment, misinterpret situations, have difficulty expressing their needs, refuse treatment, exhibit night-time restlessness, or develop delirium.