House Call: Coping with forgetfulness, dementia and Alzheimer’s

A question I get often from senior patients or family members is: “Is this Alzheimer’s?” This question encompasses the enormous fear that patients and family members have about this disease, and rightfully so.

Lately, we hear about COVID-19 mortality: approximately 1% to 1.5% in the senior population. Less often, we hear about Alzheimer’s dementia, which carries a mortality of 100% and is prevalent – it affects about 8% of people older than 65.

Those diagnosed are facing a terminal illness, and the effects on patients and families are devastating. A typical patient was brought into my office the other day. Living alone and failing, unable to drive, pay bills or manage shopping, a family member brought the patient to live with them.

They were now doing all the care assistance, finances and managing health care in addition to working full time. What a load! Unfortunately, this story is typical. It is usually a family member who first brings the concern to a health care provider and manages much of the care.

Fortunately, there are things we can do to prevent or delay the progress of Alzheimer’s. There are also ways to manage daily living with dementia and to plan for the more intense management and care needed down the road.

So, how do you decide if it’s just mild cognitive impairment (often a part of normal aging) or the beginnings of Alzheimer’s or other types of dementia? Let’s review some guidelines. People often are in denial, brush off single incidents or don’t want to acknowledge the difference between minor forgetfulness and more serious cognitive issues.

We’ve all probably walked into a room, gotten distracted and forgotten what we were doing when we got there. Someone might forget to serve a side dish only to laugh later finding it sitting on the kitchen counter. That’s different than not being able to remember how to prepare the meal, having trouble following the recipe or being confused about how you got in the room.

Just 26% of people with dementia (a spectrum of memory loss and cognitive issues) receive a timely diagnosis, and early intervention matters. Mild Cognitive Impairment shares short-term memory loss with early Alzheimer’s dementia; however, only 10% of those with MCI will progress to have Alzheimer’s.

The diagnosis of Alzheimer’s includes gradually progressive short-term memory loss (amnesia), difficulty with executive processing, trouble remembering familiar faces or travel routes (agnosia), difficulty with language and word finding and difficulty with routine tasks like motor skills such as tying a shoe or knitting (apraxia).

When all of these are present and they interfere with daily functioning, it’s likely Alzheimer’s, but a full evaluation is necessary to confirm this diagnosis because many other conditions can mimic some of these changes. It’s time to get evaluated if you or a loved one repeatedly experiences any or all of the above.

A primary care provider can provide a “mental status evaluation” and set a baseline to re-evaluate over time. This might include a short test of various cognitive measures, a review of medical history to look for other factors in dementia like mini-strokes and may include a physical exam and lab work.

Memory and cognitive problems can have other causes, including depression and anxiety, infections or side effects from medications, so it’s important to get screened to consider other causes, as well.

Preventing and delaying Alzheimer’s

It’s true that Alzheimer’s is not reversible or curable, and medical treatments so far have limited impact, but the rate it progresses is extremely variable from person to person. It can take years to develop from the earliest stages. Healthy lifestyle changes can often delay or mitigate this progression.

A long-standing, observational study at Kaiser Permanente Washington of more than 5,000 participants older than 65 – the Adult Changes in Thought Study – has found many connections between healthy aging care and lowering risk for or slowing dementia.

The ACT study found that a healthy diet and moderate exercise – even a 15-minute walk three times a week – can lower risk and delay the progression of dementia. Mental activity, staying social and connecting to friends and family are key for healthy aging (and are healthy at every age).

Isolation can exacerbate dementia and leave new problems unnoticed. Try something seemingly simple like learning to tie your shoe with your left hand or engage in an activity like chess or playing music that stimulates your brain.

There are medications for treating dementia and Alzheimer’s that can reduce symptoms in some situations, but they may not make a difference for everyone. Talk to your provider to discuss if there is medication that might help.

Planning and managing Alzheimer’s care

Managing Alzheimer’s requires anticipating difficulties ahead. Planning for them can make transitions and tasks easier. Support groups can help in navigating practical needs and in processing the stress and emotions of caring for and about someone with dementia.

Transportation can become difficult as sense of direction and motor skills decline, so create a plan for alternatives like rideshare apps and public transportation. Try to have a conversation ahead of time about when it’s time to turn the car keys in and let others do the driving.

Family and caretakers often need to manage finances for people living with Alzheimer’s. Make a list of what needs to be managed and find ways to simplify such as auto-paying bills, signing up for electronic statements and an app to keep track of passwords.

Developing routines make life with dementia simpler both for the person coping with it and for family and friends. Try routines like writing down where you’re going and how to get there, a schedule for daily activities and plans for meals. You can also bring in outside support with home health aides who help with chores, bathing and meals.

Because Alzheimer’s is a progressive disease, you may need to plan ahead for assistance or full-time care. Research your options to set realistic expectations on what’s affordable and financial factors like using equity in a parent’s home to help pay for care with a reverse mortgage.

There are wonderful, assisted-living environments that start with some home and meal support and transition to options with increased levels of care and memory care as needed. Assisted living offers key benefits that can slow Alzheimer’s progression, too, like social interaction and activities, exercise facilities and opportunities and healthy meals.

It’s a tough conversation, but many people are grateful that they discussed end-of-life care early on when the person with Alzheimer’s can participate more fully in the conversation. That includes Advanced Directives on wishes for treatment options, plans for a Durable Power of Attorney for both financial and medical decision-making and trust or estate and will planning.

Discuss options like palliative care, which focuses on quality of life along with treatment, and hospice care, which focuses on care, comfort and quality of life, typically in the last 6 months of life. One thing often overlooked about Alzheimer’s is that while its progression is inevitable, the notion that “nothing can be done about it” is not.

It is a disease that calls for advanced care planning, anticipating changes in how you manage daily living and honest and open discussions with loved ones and caregivers. Together we can make this tragic disease much more tolerable for all.

Dr. Jeff Markin is a family medicine physician practicing at Kaiser Permanente’s Veradale Medical Center.