Researchers estimate that there are more than 10 million new cases of dementia each year – most of these being Alzheimer’s disease, which makes up approximately 60-80% of cases.
While common, especially in adults ages 55 and older, dementia isn’t a straightforward diagnosis. Landing on dementia often takes multiple tests and screenings, says geriatrician Hillary Lum, MD, PhD, professor of geriatric medicine at the University of Colorado Anschutz School of Medicine.
“Screenings are the starting point,” she says. “Many of us have an increased awareness of dementia — and there can be a lot of stigma and anxiety around a diagnosis — so it’s important to understand how we reach the point of saying ‘yes, your cognitive decline is the result of dementia.’”
Neither a brain scan nor a survey tells a patient’s whole story. Instead, Lum encourages patients and their clinicians to have a robust conversation about the patient’s experience and how their cognitive abilities are changing over time.
“Many people with cognitive impairment have trouble finding answers for why cognitive impairment is happening,” she says. “As people age and experience changes in their memory or thinking, it can be emotionally difficult to verbalize that, to bring that up to their clinician, to bring it up with family.”
That can lead to delays in evaluation of cognitive concerns, early diagnosis, and ultimately conversations about how to move forward when cognitive impairment is happening and why it’s happening.
Types of screenings
There is a range of screenings a clinician may deploy to better understand a patient’s cognitive function. Some of these are what Lum calls “paper and pencil” tests, which are common, often quick, and check for memory, problem-solving ability, and assess behavior.
However, other more intensive tests and physical exams help physicians make a diagnosis. Many of these tests can be used to rule out other conditions. A blood test, for example, can confirm hypothyroidism or B12 deficiency while imaging, such as an MRI or CT scan, might point out vascular issues in the brain, a tumor, or a stroke.
Lum underscores that there isn’t a single test that determines whether a person has Alzheimer’s or another form of dementia, and a clinician will likely use a combination of diagnostic tools to make a diagnosis.
“There are a lot of different reasons that a doctor may choose the test that they are using,” she says. “It's most important to remember that it's a screen, it isn't something that makes a diagnosis.”
A cognitive evaluation will also review a patient’s medications, other medical conditions, other symptoms, as well as review their quality of sleep, any mental health symptoms, alcohol and other substance use.
“There is a lot involved, so I hope that people don’t become too anxious or fixated on which particular paper and pencil screening their physician utilizes. The evaluation is quite involved and may happen over multiple clinic visits,” she says.
Starting the conversation
Stigma and shame often accompany declining cognitive function – but early diagnosis is a key element in maintaining quality of life.
“A diagnosis helps answer questions for the person who's experiencing changes and gives them opportunity to develop a care plan that fits them,” Lum says. “Knowing that you have an early diagnosis helps you with managing other chronic medical conditions. It potentially helps you with life planning, finances, transportation, living arrangements, and advance care planning.”
Starting the conversation with a clinician is an important step toward diagnosis and managing symptoms. It’s why Lum helps primary care teams and medical trainees ask questions that prompt discussion with their patients.
Common questions she encourages clinicians to ask include:
- Have you noticed that you forget things that just happened more often?
- Have you noticed that it’s difficult to finish a complex task that used to be easy for you?
- Have you noticed being unsure where you are in a place you’ve been to many times?
“These questions really get at how normal function is changing for a person. It's more than short term memory loss,” Lum says. “It's more than forgetting names or forgetting keys, because we hear often that people notice that they might have more difficulty with names or might walk into a room and forget why they came into the room. As a doctor, I'm wanting to press a little bit deeper and try to figure out if there are patterns to memory or thinking changes.”
For patients who are concerned they may be experiencing cognitive decline, Lum recommends writing down concerns before a clinic visit and bringing along a trusted person who can also share their perspective. This can help make the most of the visit with the clinician.
“Bring up concerns to your primary physician, and if you aren’t able to share everything that's happening, or, if you don't feel heard, ask for a follow up appointment,” she says. “Don’t wait until your next wellness visit in a year.”
