Reversible Dementia in the Elderly

The New Old Age blog at the NYTimes -- hadn't read it before, but I like it -- has a post about reversible causes of cognitive decline in the elderly. I think they make a really good point: there are reversible causes to senility. Not all mental decline in the elderly is "normal" and certainly it is not always Alzheimer's:

But according to the National Institute on Aging, missed diagnoses of reversible dementia still occur too often. "Some physical and mental changes occur with age in healthy people," the agency writes in a publication called "Forgetfulness." "However, much pain and suffering can be avoided if older people, their families, and their doctors recognize dementia as a disease, not part of normal aging."

Reversible causes of dementia include the side effects of many medications. Ditropan is only the most recent addition to the list, occasioned in part by a study by U.S. Navy neurologist Dr. Jack Tsao involving 870 men and women with an average age of 75. The subjects, who were all Catholic priests, nuns and brothers, were followed for almost eight years. At a 2008 meeting of the American Academy of Neurology, Dr. Tsao reported that those who were taking anticholinergic drugs -- a class that includes not only Detrol but also drugs to treat hypertension, asthma and Parkinson's disease -- had a 50 percent higher rate of cognitive decline than those who were not.

According to Dr. Samuel Gandy, a neurologist at Mt. Sinai School of Medicine in Manhattan, drugs with antihistamines often cause mental confusion and sedation in the elderly -- especially those containing the antihistamine doxylamine, such as the sleep aid Unisom. In addition, confusion and forgetfulness in the elderly can be caused by malnutrition, chronic alcoholism and metabolic disturbances such as thyroid, kidney or liver disorders -- and even on occasion by something as common as dehydration or a high fever.

Doctors are better than they used to be at diagnosing pseudosenility, according to Dr. Gandy. "Most physicians are taught in medical schools to evaluate a patient for dementia by first excluding the reversible causes," he said.

I think that Dr. Gandy makes an excellent point. (Full disclosure: I am an MD-PhD at Mt. Sinai, and I think I have had him for lectures on occasion.)

Just a recommendation for the elderly out there or those with older relatives: if your doctor tells you to expect mental decline, make sure to hold them to a high standard. Have they excluded possible side-effects from the medications you are taking? (Because elderly people tend to be taking a lot of different pills.) The article also mentions depression -- which is also common in the elderly -- as a cause of pseudodementia. If you or your relative has been diagnosed with Alzheimer's or something like it, it might be wise to exclude depression first by trying an antidepressant.

We know that a certain amount of cognitive decline is expected in normal aging. This is not actually as pervasive as people think it is, though. I think the popular impression of cognitive decline with aging is that everything is eventually destroyed. That isn't the case. In general, we distinguish normal aging from diseases like Alzheimer's by the presence of dementia. In normal aging, there are expected declines in declarative memory -- memory for people, places, and things. But normal aging is different than dementia which -- although it often has a memory component -- is also characterized by disorientation, difficulties in problem solving, and changes in mental status (consciousness of the world around you). There is even a third -- though still poorly understood -- category called mild cognitive impairment (MCI) which we see as a preparatory step to dementing disease. (We also study it a lot because we want to know whether we can reverse the disease before it gets there.)

The point of all of this is not to worry you. The point is that I think that mental decline in normal aging has been hyped up a bit too much. We expect people to lose a little in their later years, so when it comes we never bother to inquire about whether it was a disease causing that decline -- and whether that disease can be treated. As shown in the post above, in some cases the decline is caused by something we doctors are doing.

So be an informed patient: make sure that reversible causes of dementia are excluded before you accept cognitive impairments as the inevitable part of getting older.

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In time it will be found that more and more cases can be reversed, when dementia is better understood in the future. There is some hopeful recent research suggesting this; for example some evidence suggests that ensuring proper vitamin D intake can improve this condition.

Dementia terrifies me. Having seen what it does to some people, when the body outlives the mind, has convinced me that it is much better to die somewhat younger, while still intact. I guess if some drugs lengthen your life but damage your mind, you're better off not using them at all.

My dad died last September from complications of advanced dementia. He was close to his 97th birthday. He wasn't taking a lot of medication -- his doctor had taken him off Coumadin because he was "non-compliant" about going in to have his blood drawn and tested to see if the dosage needed to be changed. He was non-compliant about a lot of things. He had probably been waiting to die since my mom died in 1989. It's one thing to know that dementia can be prevented or alleviated, but it's another to convince the person suffering from it to decide to live. And it's very hard to live with someone for years after they have decided to give up. It's hard not to follow their example.

Thanks for helping to spread the word about this crucial issue! FYI, Public Citizen just released a report with a list of the 136 drugs that can cause reversible delirium and dementia, including: widely used antihistamines such as diphenhydramine (Benedryl); a drug widely used for treating urinary incontinence, tolteridine (Detrol); a nausea treatment drug, metoclopramide (Reglan); and drugs in the benzodiazepine category such as popular sleeping pills Ambien (zolpidem) and Lunesta (eszopiclone). The full article is here:

It has been revealed that partners of persons suffering from Dementia are at a significantly higher danger of themselves contracting dementia. Stress is the proven potential risk factor to cause dementia. Men delay visiting the doctor unless prodded by their wives. This behaviour puts them at greater risk of developing high levels of cholesterol and blood pressure along with other situations, which encourages to cause dementia.

My grandmother had a DECLINED quickly over a period of a year or so, then a local Physicians Assistant (PA) testeed her for Parathyroid disease, she did have hypercalcemia after a quick surgery and parathyroidectomy in her early 90's her mental status completely REVERESED, her appetite increased and she bounced right back within 3 days of surgery HOW AMAZING. I feel sure alot of children and grandchildren take it for granted that their loves ones are just having alzheimers symptoms when a quick blood test could determine otherwise, in her case it was not ALZHEIMERS but a "HOT" parathyroid gland. DONT ASSUME anything, have grandma or grandad check for this.