Am I losing my memory Doc?
Over the next few years this will be a question many doctors will hear from patients. And some of us will perhaps ask this of ourselves! As the leading edge of the ‘baby boomer’ generation moves through their 60’s and 70’s many of them will start to wonder if memory complaints are the start of more serious cognitive problems or dementia. It is crucial to distinguish sinister memory problems from benign complaints that just become more common with age. Forgetting one’s keys, reading glasses, or difficulty finding a word or two in a conversation are more common as we age but are not concerning as long as they are not occurring all the time. On the other hand, frequently needing to be reminded of what one has already been told or getting lost in previously familiar situations are more worrying symptoms that can indicate serious memory problems.
It is clinically important to determine whether memory complaints reflect ‘normal’ aging or are evidence of developing pathology. Memory and cognitive testing can assist this process. Office (or ‘bedside’) testing is commonly done with the Mini Mental State Exam (MMSE). While quick and easy to administer it is not detailed enough to provide a dependable evaluation of cognition and memory, especially in mildly affected patients. I find the Addenbrooke’s Cognitive Examination – Revised (ACE-R) a more useful test. The ACE-R includes the MMSE but covers more cognitive domains in depth (attention/orientation, memory, verbal fluency, language, visuo-spatial, and perceptual abilities) (1). The test is easy to administer and takes no more than 20 to 25 minutes in most cases. A practice nurse can administer the test. The ACE-R is scored out of 100. Scores in the mid 80’s suggest serious cognitive impairment or dementia. Most healthy elderly individuals will score in the 90’s. The ACE-R can identify patterns of cognitive and memory impairment that are useful in differentiating Alzheimer’s disease from fronto-temporal dementia variants, vascular cognitive impairment, and Lewy body dementia. Some experience with interpretation of the test is needed. Occasionally more extensive cognitive testing is required and referral to a neuropsychologist should be considered. Computer-based cognitive testing programs can be helpful in some cases.
Having decided that the patient has cognitive impairment, what are the clinical conditions to consider? Where mild memory difficulties are the primary presentation, then mild cognitive impairment (MCI) – amnesic type, may be the problem. These patients do not show problems in other cognitive domains (such as attention, concentration, language, visuo-spatial skills, and executive functions). Many MCI patients remain stable over time but a proportion (perhaps up to a third) do deteriorate and covert into dementia over a two to four year period. These cases may be individuals with very early (prodromal) manifestations of Alzheimer’s disease. Unfortunately, it is not yet possible to predict with any certainty which patients will get worse as we are not clear about the causes of MCI. If cognitive impairment extends beyond memory to other domains then a diagnosis of dementia is more likely. In the ‘baby boomer’ age group and older the main dementia conditions to consider are Alzheimer’s disease, vascular cognitive impairment, a combination of Alzheimer’s disease and vascular cognitive impairment, Lewy body dementia, dementia associated with Parkinson’s disease and other sub-cortical degenerations, normal pressure hydrocephalus, and fronto-temporal dementia or similar variants (semantic dementia, progressive non-fluent aphasia, logopenic progressive aphasia, and behavioral dementia). Reversible causes of dementia need to be excluded (such as vitamin deficiencies, hormonal disturbances, or normal pressure hydrocephalus). Depressive illness and delirium can also masquerade as dementia.
Thorough investigation of cognitive impairment involves a screening physical and neurological exam as well as routine blood tests and neuro-imaging studies. A list of possibly relevant laboratory tests follows. However, the choice of tests will depend on the clinical circumstances. Consider ordering FBC, ESR, CRP, E/LFT’s, glucose, Ca, Mg, phosphate, thyroid function, cholesterol and lipid profile, vitamin’s B12, B1, B6, and D, folic acid, homocysteine, APO-e genotype, HIV and syphilis serology, urine analysis, and ECG. An MRI brain scan is the most useful brain imaging study (a CT with contrast is an alternative for patients unsuitable for MRI). In addition to the usual report ask the radiologist to comment on regional and general atrophy, presence of normal pressure hydrocephalus, hippocampal volume, ventricle size, and presence of deep white matter ischemia. Single photon emission tomography (SPECT) (and PET if available) provides information on cerebral perfusion activity patterns that can help differentiate between Alzheimer’s disease, vascular cognitive impairment, Lewy body dementia, and fronto-temporal dementia. An EEG is sometimes indicated when delirium or unusual dementia conditions or seizure disorders are being considered. In the future CSF studies of amyloid and tau protein fragments will also help with diagnosis.
Treatment of mild cognitive impairment is directed towards preventing further deterioration and maximizing cognitive function. Interventions that focus on reducing risk factors for dementia and enhancing protective factors against dementia are the most appropriate. Memory clinics that offer these types of cognitive enhancement programs are available on the Gold Coast (2). Treatment of dementia depends on the type of dementia involved. Comprehensive management involves symptom treatment (usually with cognitive enhancing medication and psychotropic drugs), education and support for patient and carer/family, and cognitive enhancement programs (2). Symptomatic treatment for Alzheimer’s disease is available in the form of cholinesterase inhibitors (donepezil tablets, galantamine capsules, and rivastigmine patches) and the glutamate NMDA receptor antagonist memantine. These medications can improve cognitive function (particularly attention and memory) and improve behavioral disturbances (such as apathy, psychosis, agitation, depression and anxiety), and maintain function over the longer term. If a patient shows benefit the medication should be continued. Dose increases may be needed. Although only approved for subsidy under the Pharmaceutical Benefits Scheme (PBS) for Alzheimer’s disease, these medications can help in other dementia conditions that have overlapping neuropathology with Alzheimer’s disease (Lewy body dementia, vascular cognitive impairment). Specialist consultation (physician, geriatrician, or psychiatrist) is required to gain access to PBS authority support for these medications.
Unfortunately, no disease modifying agents are available for the common dementia conditions at the moment. Much research is underway in this area. In the future it is possible that with early detection of individuals at risk of dementia the application of disease modifying (or ‘curative’) interventions will prevent dementia onset. Then no longer will patients have to ask if they are “losing their marbles”!
Prof Philip Morris
1. Mioshi E et al. The Addenbrooke’s Cognitive Examination Revised (ACE-R): a brief cognitive test battery for dementia screening. Int J Geriatr Psychiatry 2006; 21: 1078–1085. Access the ACE-R at www.ftdrg.org.
2. The Gold Coast – Tweed Memory Clinic, Suite 2, Level 5, Pacific Private Clinic, 123 Nerang St, Southport; phone 07 55327655.
So at age 82, some amount of memory loss could be considered normal and unavoidable (provided one has a reasonably healthy lifestyle). In that case – would you want to put an 82 year old through a whole range of tests, and or drugs which also may have side effects? There is only so much money and resources available for health issues. At what point do we say that some things don’t need to be fixed and that ageing is a normal unavoidable process. Do the best that you can with your lifestyle and otherwise age gracefully.
Memory loss that impairs functions of daily living is not typical of healthy ageing unless the person has developed a degenerative brain disorder like Alzheimer’s disease. It is reasonable to assess and investigate memory problems in older individuals in order to come to a diagnosis and provide appropriate treatment. Although there are no curative treatments for Alzheimer’s disease at the moment, current therapies can improve mental function, delay deterioration and help preserve independence.
Dear Coy, thank you for the encouragement. Please do let your associates know about my website. Philip Morris.
Hi,
Excellent blog.What will be the cut off point for MCI on ACE-R test.according to age and education also .Does MCI has any relation with DM and hypertension.
Thanks for your post. I am not sure a definite cut-off score has been determined for mild cognitive impairment for the Addenbrooke’s Cognitive Examination-Revised. I would caution against using a specific score. The literature I looked at suggests ACE-R scores at or below the low 80s carry an increased risk of a dementia condition, whereas scores from the low 90s to the high 80s are associated with MCI. I hope this helps. Philip Morris.
My mother died of Alzheimers so I have worried about it for the past 25 years or so. I find I am losing vocabulary – not names (that’s been happening for years), but normal descriptive words that I would not otherwise have a problem retrieving. I also lose my way when telling stories, not often but sometimes. Am I worrying unnecessarily? At what point should I seek to follow up on this? I am 66.
Verbal fluency problems (difficulty recalling words from vocabulary stores) can be an early sign of cognitive impairment. But this may not indicate dementia. I suggest you ask your GP to refer you to a psychogeriatrician or geriatrician or neurologist for an assessment and opinion. Philip Morris.
Thanks for posting this information. It’s informative
I am pleased it has been of assistance.
I read an article re scoring ACE-R that concluded with normative data that suggested a cut off score of 82 for dementia. However the age categories stopped at 70-75 years. In relation to a person aged 78 with high school level education would a score of 86 be considered strong indicator of dementia or MCI?
That score could be indicative of cognitive problems as below mid 80s score is regarded as the cut point indicating significant impairment. But the situation for individuals can vary. Best to see a psychogeriatrician, geriatrician or neurologist to assist with assessment and diagnosis. Philip Morris.
Hi I am 53 year old male whom suffered MRI asking to see my dead mother leaving my gas oven on for 90 minutes no flame called my daughter by other names trouble with money in shops wandering escaping out my house I’ve had a test ace-r which was 72/100 my mmse was 27 now waiting MRI in January I’ve been given admiral nurses any ideas they very strongly suspect dementia but I am little young for this surely
Dear Owen,an Addenbrooke’s Cognitive Exam – revised score of 72/100 and a Mini Mental State Exam score of 27/30 suggests further investigation is needed. Please do contact your personal physician about this. There may be other explanations than dementia.
Dear Dr Phillip, despite my mother having major memory difficulties Addenbrooke’s Cognitive Exam – revised score of 54/100 and a Mini Mental State Exam score of 21/30 Geriatrician says on balance she does have capacity to her change her will to youngest son,I disagree so should further investigation be required in the the form of lab tests and what doesa ACE-R scored 54 mean for my mother?
Capacity is not determined on just a cognitive test score. Capacity is determined by a clinical review in relation to the specific decisions to be made by the person. You should consult a local geriatrician or psycho geriatrician. Dr Morris,
My Mother has recently been tested with the ACE-R and scored 82, she scored 30/30 on a MMSE a month before. She is in a nursing home which she uses as a hotel, every morning she reads the paper and finishes the cryptic crossword, she is out and about nearly every day doing tai chi, going to lectures, looks after her own money etc.This behaviour would not seem to tally with an 82 score, what influences could contaminate the test results?
I agree the score on the ACE-R seems to be at odds with her behaviour. Although the MMSE score is more in keeping. Without seeing the person directly it is difficult to comment further. However, given the possible recent deterioration you would be advised to have her seen by her GP (primary care physician) and referred to a geriatric specialist or psychogeriatrician if needed.
Thanks. Try Alzheimer’s Australia website.
Thanks for the encouragement!
Wow that was strange. I just wrote an incredibly long comment but after I clicked submit my comment didn’t show up.
Grrrr… well I’m not writing all that over again. Regardless, just wanted to say superb blog!
Thanks. Sorry about your response getting ‘lost’.
I’m curious to find out what blog platform you hapen to be using?
I’m experiencing some minor security problems with my latest site and I’d like to find something more safeguarded.
Do you have any suggestions?
Give WordPress a try.
Hi Dr Philips,
Very interest reading. I am a 50+ Occupational Health Nurse, went to GP today,as cannot remember grandchildrens DOB,husbands and all family except my own. seems to be i cannot remember peoples names and also things i have just been told, todays date and much more. GP wants me to come back for Blood test before referring me.I am scared i will now lose my job. Help
Thanks for reply. I really needed expert opinion .And got it from you. Thanks.
My husband has Dementia in Alzheimer’s disease, atypical or mixed type. ICD 10 code. FOO.2. He was diagnosed about for years ago, but with hindsight I realise that his swings of moods and stubbornness and inappropriate behaviour could have been indications of the disease. We’ve been married 58 years and I love him dearly but it is hard being his carer. I believe in “till death doth us part” but can’t help wondering what the future holds and how long this will go on for. His mother had the disease but died in a care home. His sister also had the disease and died about five years after being diagnosed. After breaking her arm. Her husband cared for her lovingly for those five years but found it hard. I know, even as I ask, that you can’t really answer my question. But it hurts to see him deteriorating in such a way, because he was a clever, articulate man who prided himself on his mathematical prowess. He once tried to make me promise that, if he should ever be afflicted, I should smother him with a pillow. He was cross when I refused to promise. It isn’t something I would do anyway – I believe human life is sacred. But I would like to know how long this nightmare will continue – for both of us. I have a large family and a keen sense of curiosity. I want to hang around for as long as I have all my faculties so that I might see how not only the world fares but also to follow the development of my eight grandchildren. It’s like reading eight novels simultaneously and I’d love to read them to the end.
Finding your blog very interesting. My mum is 85 and has terrible memory problems . She lost her daughter feb2015 from cancer very quickly over 4 months. She has always been a chronic insomniac. Waiting for memory clinic appointment but in meantime is it worth trying sleeping tablets and or anti depressants ? She had bloods for dementia screen which were negative. She has mild DM 2 (no meds)and hypertension. She forgets stuff almost immediately.
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My 83 year old mother had an EEG and ACE-3 memory test. We met with the doctor to go over the results and her total score was 62. The doctor said that wasn’t terrible, but everything I read seems otherwise. Should we have her further tested?
Yes. With that score she deserves to be further investigated. A geriatrician, psycho geriatrician or neurologist might be the best clinicians to go to next. Dr Morris.
very usefull
Excellent article. I’m going through some of these issues as well..
My husband of 65 years had a stroke at the age of 59 years. He has recently had a memory test and scored 72/100. He is awaiting a brain scan. The memory nurse told me the score was low but I was afraid to ask “what to expect”. He will only eat cakes and cheese slices now. He has gone downhill fast since contracting shingles last November i.e. losing mobility and falling.
Just want to be as prepared as I can -also what is the life expectancy of someone with mixed dementia.