The Echoes of Memory Lane

When forgetfulness requires intervention

BY KRYSTEN GODFREY MADDOCKS / ILLUSTRATIONS BY WILDPIXEL

Occasionally, we lose our keys, forget an acquaintance’s name, or miscalculate restaurant tips. While we might attribute some of these blunders to stress or aging, paying attention to them is essential — especially if it limits our ability to complete tasks we once found easy.

The Centers for Disease Control estimates that 5.8 million people in the United States live with Alzheimer’s disease and related dementias. By 2060, that number is expected to grow to an estimated 14 million people.

Not everyone experiencing mild cognitive impairment will get diagnosed with dementia (an umbrella term for the loss of cognitive functioning) or Alzheimer’s disease. Still, we shouldn’t accept it as a natural part of aging, according to Dr. Dax Volle, a geriatric psychiatrist with Dartmouth Health.

“It’s been a pretty long-held belief that older people become senile, but losing the ability to function and do the things that are important to you — that’s not a normal part of aging,” he says.

Volle saw his aunt experience cognitive changes in her early to mid-60s after she retired from teaching. Her inability to receive an accurate diagnosis before her death led him to pursue geriatric psychiatry.

What is Dementia, Anyway?

Dementia refers to a loss of cognitive functioning — including deficiencies in thinking, remembering and reasoning — to such an extent that it interferes with a person’s daily life and activities. While Alzheimer’s disease is the most commonly diagnosed form of dementia, there are others, including frontotemporal, vascular and Lewy Body dementia. Each of these dementia subtypes presents differently. For example, someone with frontotemporal dementia might remember things correctly but have trouble with executive functioning and social interaction, Volle says.

Recognizing the Subtle Signs

Some of the early signs of dementia don’t necessarily present as absentmindedness. The disease also affects a person’s language ability, personality and mood. In the beginning stages of cognitive impairment, loved ones might not recognize subtle signs, according to Dr. Alexandra Filippakis, a neurologist with Wentworth Health Partners Coastal Neurology Services.

However, changes in behavior usually signal someone could be struggling. People experiencing mild cognitive impairment often avoid undertaking tasks that involve calculations, she says.

“I’ll often ask, ‘Who does the finances or balances the checkbook?’ Often it will be the spouse who does that, not the patient,” she says. “When I ask why they no longer do those tasks, I might hear, ‘He took over five years ago because I bounced a couple of checks or forgot to pay the bills.’ As objective diagnosticians, these are the little details we pay attention to give us some hints,” Filippakis says.

Other signs a loved one might be struggling with impairment include falling prey to costly phone or computer scams.

“I had a patient come in last week that said, ‘I’m not an unintelligent person, but I got scammed on the phone, and I’m filing for bankruptcy now,” she says.

It can be challenging for families to evaluate a loved one’s memory decline objectively. Getting a proper evaluation and diagnosis is an important next step.

Getting the Correct Diagnosis

If you’re concerned about your own memory loss or think a loved one might be experiencing cognitive impairment, you should first make an appointment with a primary care provider, who can rule out other health concerns or medicines that might be causing confusion.

• From there, patients are often referred to a geriatrician, a provider who specializes in caring for older adults. They could also be referred to a psychiatrist, cognitive neurologist or geriatric psychiatrist.

• Certain neuropsychological screenings, such as the Montreal Cognitive Assessment for Dementia (MoCA), can help doctors assess patients’ performance in particular cognitive domains, such as naming, attention span, language and spatial relationships.

• Blood tests can screen patients’ electrolyte, hormone, and vitamin levels — which all impact cognition.

• Imaging tests, such as MRIs or CAT scans, can look at the structure of the brain and indicate whether a patient experienced a stroke, a brain bleed or a tumor. They can also show certain types of brain shrinkage or atrophy.

The testing process takes time, but it helps doctors give patients and families a clearer diagnosis, which can help them pursue specific courses of treatment, Volle says.

“There are a lot of question marks when it comes to dementia and what to expect when, and how to plan for the future,” he says. “A good diagnosis can really shape the trajectory of somebody’s health care experience.”

It’s critical to evaluate memory concerns because there’s a chance symptoms might not be permanent. When Filippakis examines patients, she sometimes discovers they have undiagnosed Attention Deficit Hyperactivity Disorder (ADHD) or thyroid diseases. Even untreated depression can masquerade as memory loss or dementia.

“Seeing the right doctor can help families get closer to answering the big question, ‘Is this going to get worse over time?’” she says.

Dealing with Denial

Getting your loved one to agree to attend appointments, take cognitive tests and undergo diagnostic imaging can all prove to be challenging, especially if they don’t think anything is wrong.

Even though you may not want to rock the boat, ignoring symptoms or assuming there’s nothing you can do might keep family and friends from treatments or care that can help them live a better life.

“Denial does run quite deep with patients and within families. Many people attribute symptoms to something else — she’s absent-minded or getting older,” Filippakis says. It can be difficult to tell someone that it’s something more than that.

New Treatment Options

The correct diagnosis can help patients access treatments that boost their memory and thinking. A class of medications called cholinesterase inhibitors can help improve symptoms for people with Alzheimer’s disease. They don’t stop or fix damage to the brain, but can help people function a little better for a little longer, Volle says.

In the brains of people who have been diagnosed with Alzheimer’s disease, a protein called amyloid builds up into plaques that damage brain cells. Emerging treatments, including immunotherapy drugs such as donanemab, can help the body’s immune system remove these plaques from the brain, reversing the disease. While promising and exciting, Volle says it’s still not a cure for the disease.

“The actual clinical trials show that after being on the trial for 18 months, those who received the medication were doing about 30% better on cognitive testing compared to the people who were not getting medication during the trial,” he says.

In March 2024, the Food and Drug Administration delayed the approval of donanemab. However, the FDA accelerated the approval of two other similar monoclonal antibody treatments, aducanumab and lecanemab, following promising trial results. Lecanamab is the currently approved and available monoclonal antibody treatment.

Dr. Filippakis says that it’s still unknown whether reducing amyloid directly results in slowing the progression of Alzheimer’s disease. A protein called tau, or the interplay between these two proteins, might be a better target. The benefits shown in clinical trials has been modest and uncovered risks such as brain swelling or bleeding in patients.

Also, many people are not candidates for these therapies. If people show microhemorrhages on brain MRIs, take blood-thinning medications, are homozygous for the ApoE4 gene, or are too far along in the disease course, they won’t be eligible, she says.

“A big problem is that the new anti-amyloid therapies are being overhyped in the media, and patients are asking for them often, only to be disappointed by the data when discussed,” Filippakis says.

An Ounce of Prevention

While you can’t necessarily prevent dementia, there are things you can do to reduce your likelihood of getting it. Regular hearing and eye exams can help you get hearing aids or eyeglass prescriptions you need. The symptoms of sight and hearing loss can be similar to some of the early signs of dementia.

It’s crucial to stay physically, cognitively and socially active and manage your blood pressure, cholesterol, and diabetes. Quitting smoking, reducing alcohol use, and eating a Mediterranean-style diet all help your body — and brain — stay healthier longer.

“Lifestyle changes are the biggest factor in reducing the risk of who’s going to go on to develop memory loss and dementia later in life,” Volle says.

Many believe that they are doomed to inherit Alzheimer’s disease if their parents or grandparents had it. There are genetic susceptibilities, but it doesn’t mean that every generation will be affected, particularly if family members were diagnosed in their 80s, Filippakis says.

“Your risk is more than someone whose family didn’t have it,” she says. “It’s just something to be aware of so you can try to control the risk factors you’re able to.”

Getting Support

In addition to working with their health care providers, families can get support from organizations as they pursue dementia diagnosis, treatment and caregiving assistance.

Visit the New Hampshire/ Massachusetts chapter of the Alzheimer’s Association at https://www.alz.org/manh to access resources, including a 24-hour helpline.

Get connected to local services by visiting ServiceLink, an aging and disability resources center run by the New Hampshire Department of Health and Human Services.

Anyone can tap into support groups, classes, and free materials by visiting the Aging Resource Center at Dartmouth Health.