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In This Chapter

▶ Spotting the early warning signs of dementia

▶ Identifying cognitive problems

▶ Understanding changes in emotional behaviour

▶ Looking at functional problems

As doctors, we love to be able to categorise diseases and our ability to do our jobs properly depends on it. It’s important to know that set of symptoms A means a patient simply has a nasty dose of the common cold, while set of symptoms B means she’s more seriously ill with influenza. Without knowing what someone is up against, we can’t advise on treatments or tell her the likely outcome of what she’s going through.

In this chapter I look in some detail at the symptoms that show that someone has dementia. And I describe the particular features that allow clinicians to tell people which type of dementia they are suffering from.

Identifying the Early Warning Signs

While dementia affects everyone slightly differently, a few common symptoms can alert you to the fact that it may well be on its way. In the early stages, though, it’s important not to panic and see dementia lurking behind every forgetful or confused senior moment, because a failing memory is often simply a normal part of the ageing process. And it is important to bear in mind that there’s much more to all types of dementia than simply becoming forgetful.

Differentiating between dementia and a few senior moments

Many things can make all of us absentminded, from simple tiredness and poor concentration to a period of low mood or actual depression. How many of us, busily caught up in an engrossing task or conversation, have forgotten a dental appointment or burnt the dinner?

Only when these symptoms become a regular feature of your behaviour, or that of someone you love, may they be a sign of something more serious. And the symptoms only really become significant when they start to interfere with a person’s ability to get on normally with everyday life.

Also, it’s rare for memory issues alone to be enough to suggest that dementia is manifesting itself. Problems with finding the right words and confusion over using money or how to follow a favourite recipe are also likely to be evident, alongside changes in mood and loss of confidence in social situations.

Dementia is not just about losing memory.

Knowing what to look out for

Below is a run-down of the top ten most important early symptoms to look out for, as voted for by pretty much every dementia charity website or research article you’re likely to come across.

Number 1: Memory problems that affect daily life

Forgetting the odd thing every now and again is perfectly normal as you get older; generally, you remember these things later. In dementia, this doesn’t happen: those forgotten things are gone. Unfortunately, you need to remember things such as the following to be able to function normally every day:

✔ Important dates and events

✔ The route taken on well-travelled journeys

✔ Where you’ve left important paperwork

✔ Names and faces of friends, neighbours and work colleagues

Number 2: Difficulty with planning and problem solving

My grandmother could cook a Sunday roast and all the trimmings with her eyes closed – until she started to develop dementia, that is. As the disease took hold, her ability to sort out the timings of meat and vegetables completely deserted her and she’d regularly burn some of the vegetables while undercooking the meat. In the end, Grandpa had to take over the chef’s duties or we’d regularly go hungry.

As well as having trouble following recipes, people in the early stages of dementia may also

✔ Become confused using a cashpoint card.

✔ Lose track of what their bank statement shows.

✔ Become confused while trying to put fuel in the car.

Number 3: Problems finding the right word

Most of us will have had the experience of frantically hunting for the right word when chatting to someone or, worse still, when giving a presentation to a group of colleagues. Eventually, the word comes to mind, the panic’s over and you stop feeling daft.

In early dementia many people find that words regularly become elusive, leading to difficulty communicating effectively and to huge amounts of frustration. People with early dementia may also substitute the word they’re after for something similar, such as a football becoming a kick ball, or a watch becoming a hand clock.

People may also have problems following the thread of other people’s conversations, and may therefore become less keen to join in and socialise with others to save themselves embarrassment. Socialising can become a particular problem in noisy environments, or in situations where there are other background conversations going on, because people with dementia will find it harder to focus on the conversation they are supposed to be having.

Number 4: Confusion about time and place

People with early dementia often lose track of time or become muddled about the date. They may also forget where they are or how they got there. As an example, a patient of mine waited in the surgery for ages, expecting to be called in for his consultation with me. Unfortunately, while he did have an appointment at that time, it was across town with his dentist.

Number 5: Poor judgement

Another of the losses that occurs in early dementia is that of good judgement. Normally frugal people may end up spending money on things they don’t need, and can be a telesales marketer’s dream customer, signing up for all kinds of contract or special offer.

Judgement about appropriate dress may also suffer, with people heading off to the beach wearing a coat, hat and scarf or, conversely, popping to the shops in the pouring rain with only a T-shirt and sandals to protect them from the elements.

Number 6: Visuo-spatial difficulties

The start of dementia can be heralded by increasing clumsiness. As people are robbed of their ability to judge widths and distances, falls and breakages are common, as are bumps (or worse) when parking or driving a car.

Number 7: Misplacing things

While everyone forgets where they’ve put their keys or mobile phone from time to time, you can usually retrace your steps and eventually find them. This ability to retrace steps is lost in dementia, and coupled with an increasing tendency to leave things in the wrong place as well (slippers in the fridge and so on), important objects increasingly go missing.

Number 8: Changes in mood

My children are teenagers, so rapid mood swings are an extremely common feature of life in my house. One minute a decision I’ve made means I’m the worst person in the world, and my children feel angry and a bit sorry for themselves; the next (usually when cash has changed hands) I’m a top bloke and they can’t think of anyone they’d rather have as a father.

As people grow up into adulthood, these extremes of mood and temperament thankfully tend to be much less evident. But in the early days of dementia this type of fluctuating mood can return, with people often rapidly switching between extremes of sadness, fear and anger. Low mood and full-on depression are also extremely common in dementia. And at times it can be hard to work out whether the symptoms of dementia are causing the depression or vice versa.

Number 9: Loss of initiative

While anyone can become fed up with work, hobbies and even social obligations, this is often a passing phase after a tough day or a bad night’s sleep, and you snap out of it. People with dementia may lose the impetus to take part in their usual activities altogether, and repeatedly need prompting about what they should be doing or simply to join in with what friends or family are doing.

Number 10: Personality change

A number of different changes are possible here, and not all people who are developing dementia will change in the same way. In fact, what changes is their normal behaviour, so a reserved and quiet person may become flirty and disinhibited, while the life and soul of many a great party may become withdrawn and reclusive. Common changes include becoming

✔ Confused

✔ Suspicious

✔ Withdrawn

✔ Angry

✔ Sexually disinhibited

As this list demonstrates, the symptoms of dementia are certainly more varied than simply being a bit forgetful. To be diagnosed, someone must show at least two, if not more, of these ten warning signs, which can themselves sometimes be fairly subtle to start with.

As the disease progresses, the symptoms become more obvious, because they become more permanent. The ten symptoms described in this section become part of a person’s usual day-to-day life and behaviour, and there’s little doubt that the person has developed dementia.

In the rest of this chapter I look in more detail at the symptoms, which can become more severe as time goes on. I split them into symptoms affecting thought processes, mood and the way people function, for ease of explanation, but often a great deal of overlap exists between groups.

For now, I focus on some of the more general symptoms of dementia. People with different types of dementia can develop other symptoms that are particular to their specific diagnosis; for example, Alzheimer’s disease or Lewy body disease. Also bear in mind that some people may be lucky enough to develop few of the symptoms I describe, and that the examples in the following section are offered as a guide to what may happen and not what will happen to someone with dementia.

Recognising Thought-Processing Problems

The thought-processing (cognitive) symptoms of dementia are all those of loss. People with dementia will, to one degree or another, lose their memory, their judgement and quite literally their way.

Forgetting

When my uncle George developed Alzheimer’s disease, he’d pop to my mum’s house round the corner four or five times a day to ask her what she was up to. If he got no reply, he’d post a note through her letterbox that simply said, ‘Muriel, where are you?’ And all this despite the fact that on his first and no doubt second visit she’d told him exactly what she was up to that day and where she was going.

In contrast, my grandmother, who had vascular dementia, was well aware of everything that was going on each day, but had an awful memory for names and faces. Not only would she mix me up with my brother, but she’d also often call me Bill, which was her son’s name.

And the many aspects of forgetting that can occur in dementia go way beyond these two examples from my own family history.

Memory for dates and times

The caricature of a person with dementia is someone who can remember every detail of the Second World War, which she lived through as a child, but can’t remember what she had for tea yesterday, or even what day it is. And in a sense, this caricature can be accurate. Dementia tends to involve a loss of short-term memory while many aspects of long-term memory are preserved.

Short-term memory is, in effect, working memory, helping you to function day by day by allowing your brain to remember lists, appointments you need to attend, phone numbers or where you put your door keys. Long-term memory, on the other hand, stores all sorts of information from the past, mingling sights, sounds, smells and the dates of events to give you a rich picture of your life going all the way back to childhood.

In dementia, this loss of short-term memory presents all sorts of problems and can lead to difficulties remembering appointments, important messages and even the day and date, so that the person becomes completely disorientated.

Childhood memories

I vividly remember the first time my dad took me to a football match, on Boxing Day 1974. Not simply because my home team, Portsmouth, beat our arch rivals, Southampton, by four goals to two, but because my long-term memory has stored the associated smell of pipe smoke that in those days wafted around the ground, the sounds of the chanting supporters and the emotional feeling of a 6-year-old doing something grown up with his dad. To this day, every time I get a whiff of pipe smoke I’m transported back to that day, sitting in the North Stand at Fratton Park watching Pompey stuff the Saints.

Memories of people and places

Forgetting other people’s names and faces is another common problem associated with dementia. These memories are often stored in long-term memory, but when a person experiences problems retrieving these memories, even family members can feel like strangers. This effect on memory can be particularly significant in the workplace, leading to the person with dementia forgetting her boss or important clients.

Forgetting places increases the chance that someone with dementia will easily get lost, even in the most familiar surroundings, and find it very hard to follow the directions of any new route you try to tell her.

Memories of self

When short-term memory malfunctions, it’s believed to result in people with dementia losing their sense of self. This mostly affects the present self, and such people may have an intact sense of who they were when they were younger, thanks to their long-term memory.

People with dementia who constantly follow their partners or carers around and keep repeating the same questions may be seeking reassurance and protection from that person to make up for this loss of their own sense of self.

Getting lost and wandering

When someone’s memory for places has ceased to function as it used to, it’s very common for her to get lost, even when travelling on extremely familiar routes. In addition, people with dementia tend to wander, which adds to the likelihood that they’ll get lost.

Wandering is rarely an aimless activity and would actually be better described as walking with purpose. It is not often obvious to carers why people with dementia sometimes wander, but some suggested reasons include

✔ Continuing with a habit: People who enjoy walking as either their main means of transport or as a hobby are very likely to continue doing it.

✔ Relieving boredom: People with dementia often don’t have a lot to do, especially as the condition progresses and they withdraw from work and socialising. Going for a walk relieves this boredom and provides a sense of purpose.

✔ Using up energy: People who were normally quite active and enjoyed exercise may feel restless if they’re unable to continue to go out. Going for a walk is a very simple solution.

✔ Being confused: People with dementia may have an idea they have to be somewhere to do something, but as soon as they’ve headed off, they become lost and keep wandering, trying to identify familiar landmarks. Sometimes, when confused about time, people with dementia get up in the night thinking it’s morning, get dressed and go out. And in severe dementia, they may simply be off to look for someone from their past.

✔ Relieving pain: People with arthritis stiffen up if they’re inactive for long periods, which makes their joints extremely painful. Going for a walk loosens things up and temporarily relieves this pain.

✔ Searching: The person with dementia may be off looking for a particular place or person. It may be a former home, or even the house she grew up in. She may be searching for old friends, family members or even long-dead parents.

Progressive lack of judgement

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