“Niece”

My 75 year old aunt is very fearful about developing dementia because her father developed Alzheimer’s in his late seventies.  She is energetic, very engaged in her community, stays physically active, and eats a healthy plant-based diet.  She is an avid reader and pays close attention to research about maintaining brain health.  To me, her mind seems quite sharp, though she seems to have some occasional lapses in short-term memory.  I try to reassure her that she is not genetically destined to develop Alzheimer’s, but I don’t know enough to be very specific about this.  How does one differentiate between memory problems that are a normal part of aging and signs that may indicate a more serious problem like Alzheimer’s?  

Dear “Niece”:

This is Cliff. First, some definitions. Dementia is a syndrome of cognitive impairment (memory and thinking) severe enough to prevent a person from living independently. People with mild dementia may only need help with finances, medications, transportation, etc., whereas people with severe dementia lose ability with more basic functions, including walking, talking and controlling body functions. Mild cognitive impairment is a term used to refer to condition in which there is some loss of short term memory, new learning or thinking ability, but is not severe enough to be considered dementia (at least not yet). Alzheimer’s disease is the most common cause of dementia in older adults and people with the disease will usually pass through a phase lasting months or years in which they have mild cognitive impairment but do not yet have dementia. They struggle with short term memory, but maintain high levels of intellect and independent function. Your aunt is probably concerned that she is in this “prodrome phase” of Alzheimer’s disease. This is a concern of many middle-aged and older people who are frustrated by memory lapses. If they happen to have a parent who had Alzheimer’s disease or another form of dementia, they may be especially worried.

There are several known genetic risk factors for Alzheimer’s disease. Some genes, are “mutations” (alterations in chemical sequences comprising genes) that causes people to develop dementia in mid-life, but the most common ones affect risk for the disease late in life. The influence of these genes is potentially modifiable by the things we believe contribute to healthy aging, such as physical activity, cognitive activity, life-long learning, good stress management, social connections, adequate sleep and a diet rich in vegetables and fruits (or “plant-based” as in the diet your aunt follows……..better hide the rhododendron when she visits!).  Avoiding brain injuries, smoking and substance abuse are other important factors. One parent with onset of Alzheimer’s disease after age 65 generally means there is a 25% risk by age 80 (versus about a 10 to 20% risk for the general population). Two parents with Alzheimer’s disease as a cause of their dementia means a 50% risk. So your aunt is at a slightly elevated risk (assuming her father actually had Alzheimer’s disease as a cause of his dementia). But it sounds like your aunt is mindful of good health practices, which would likely reduce her risk.  At the present time, we have no proven means of decreasing that risk further beyond the health and diet factors outlined above.

That said, most people will develop some form of dementia if they live long enough. By age 90, most people have at least some cognitive impairment, if not dementia. Even healthy older adults will not have the ability to recall names or recent events as efficiently as younger people do. And the decline in recent memory and word retrieval starts early…….in one’s 30’s. Old memories last a life time, but what happened yesterday or the day before is quickly lost unless it is tied to some strong emotion. This is a normal part of aging and is not the same as the mild cognitive impairment that precedes dementia. You can improve your ability to remember information and names by making them important to you. One should focus and concentrate on information that is important (like where you park) and rehearse it a few times before turning attention to something else.

If your aunt is really worried, she can be easily tested by her doctor or mental health professional trained to administer simple cognitive tests. There are other ways to distinguish normal age-related forgetfulness from early expression of Alzheimer’s disease. How forgetful is she? Does she tell the same story to the same person more than two times in the course of a few days? Does she get disoriented in familiar places? Does she remember appointments and manage her money and medications well? Has there been a significant change in her personality or behavior?  These are all clues that something other than normal aging is going on and a thorough health assessment is needed. But this doesn’t seem to be the case with your aunt. I think you’re right in trying to reassure her, but getting a simple cognitive test, such as the Montreal Cognitive Assessment (takes 15 minutes) once a year will be time well spent in further reassurance.

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Len Kaye

About Len Kaye

Dr. Lenard W. Kaye is Professor of Social Work at the University of Maine School of Social Work and Director of the UMaine Center on Aging.