A 72-year-old woman had gone to see a specialist with a complaint of having experienced memory problems for about the last seven months.
Her daughter reported that the family had noticed she was frequently losing items around the house and struggling to order food through a delivery app.
Upon conducting an objective cognitive test, the specialist noted that the senior citizen scored slightly lower than expected for her age.
Routine scanning and blood tests did not reveal any significant abnormality.
On more detailed history-taking, it was revealed that the patient had lost her husband 10 months earlier and was going through bereavement.
There were mild depressive features, common during bereavement.
The specialist concluded that the subjective memory complaints were likely due to her being in mourning.
The memory issues were from minor cognitive difficulties experienced due to mild depression and the patient was referred for counselling.
Six months later, her repeat cognitive test revealed an improved score.
The patient was in a brighter mood, having had the chance to receive treatment for her depressive episode.
Her family reported that she was no longer experiencing memory difficulties, apart from very minor lapses.
Many causes
Many people often associate memory loss with dementia.
But not many know that dementia affects more than just the memory, or that what appears to be dementia is sometimes just forgetfulness.
Dementia is a lifelong, incurable and progressively deteriorating condition.
Stigma surrounds the disease and many people fear to acknowledge that they may have the condition.
In 2015, there were approximately 125,000 people with dementia in Malaysia.
This number is projected to rise to about 260,000 by 2030 and to 590,000 in 2050, in tandem with the increase in the number of elderly people.
In the West, geriatric psychiatrists are often the first port of referral for cognitive disorders.
This is as geriatric psychiatrists commonly deal with disturbances of mental health disorders in the elderly.
According to a 2014 review in the Annals of Indian Academy of Neurology, 15-20% of patients with memory problems actually have a diagnosable depressive disorder or anxiety.
Therefore, some subjective memory issues may not be dementia at all, and are easily reversed with talk therapy or medications to treat depression.
Some patients that come to see the doctor with subjective memory complaints are at times dealing with stressful life events, bereavements or stress from a caregiver role.
As demonstrated in the vignette at the start, these causes can be treated and reversed.
Other causes of memory issues include:
Some medications, especially ones with “anticholinergic burden” can affect the memory.
Acetylcholine is a neurotransmitter (a chemical message released by nerve cells to send signals to other cells).
Medications with anticholinergic properties block the effects of acetylcholine in the body.
“Anticholinergic burden” refers to the cumulative effect of using one or several medications with anticholinergic effects.
By blocking the effects of acetylcholine, these medications can cause confusion and cognitive difficulties as a side effect.
Commonly prescribed medications with anticholinergic burden include amitriptyline, a common pain medication, and chlorpheniramine, which is used for allergies.
An underactive thyroid gland (hypothyroidism) can not only reduce metabolism, but also affect thinking and mood.
Symptoms include lethargy, weight gain and difficulty tolerating cold environments.
Stress, anxiety or depression can cause forgetfulness, confusion, difficulty concentrating and other problems that disrupt daily activities.
Excessive intake of alcohol can interfere with brain functioning and affect cognition.
Vitamin B12 helps maintain healthy nerve cells and red blood cells, so insufficient levels of this vitamin, whether due to diet or absorption, can cause memory difficulties.
A tumour or infection in the brain can cause cognitive difficulties and changes in personality.
A brain scan can help rule this out.
A decreased number of red blood cells can cause tiredness, slowed thinking and reduced mood, which in turn may manifest as memory difficulties.
MCI causes a slight, but noticeable and measurable, decline in cognitive abilities, including memory and thinking skills.
However, those experiencing it are still able to function well and perform their activities of daily living.
The added problem is that MCI raises the risk of a person developing dementia in the future.
More acute and sudden changes in cognition could also be related to delirium – a transient, usually reversible, cause of mental dysfunction, which can occur alongside a wide range of neuropsychiatric abnormalities.
It can be caused by infection, stroke, electrolyte imbalances and a whole host of other conditions that need to be ascertained and treated.
Complex processes
Diagnosing memory difficulties is a complex and delicate process.
Careful history-taking is paramount to avoid misdiagnosis.
The specialist needs to be well-trained and gather the appropriate information before making a conclusion.
Often, further or repeat testing may be necessary to form a diagnosis.
On-the-spot diagnosis based on limited evidence and short cognitive testing should be avoided whenever possible.
However, diagnosis is only a small part of managing the condition.
Treatment can also be complex, with limited options available.
Medications, such as cholinesterase inhibitors (donepezil, rivastigmine and galantamine) and NMDA (N-methyl-M-aspartate) receptor blockers (memantine) can help reduce the rate of memory decline.
In some patients, they may even modestly improve some symptoms.
Cholinesterase inhibitors prevent the breakdown of acetylcholine, hence raising its availability for binding to the brain receptors.
While useful, these medications can also come with side effects.
However, they come in many types of preparations and the doctor can help the patient choose the right treatment and dose.
For dementia, psychoeducation remains key, as patients and caregivers want help in dealing with day-to-day activities, such as personal care, diet, memory aids and household tasks.
This is as dementia comes with a whole host of complications.
Aside from forgetfulness and disorientation, patients may also develop anxiety, obsessive behaviours, agitation, restlessness, constant wandering, depression, and even psychosis.
Treatment can be extremely complex, ranging from use of skilled behavioural techniques to medication.
The use of medication itself in this patient group requires skill, knowledge and training, as age, frailty and multiple illnesses need to be carefully balanced.
Too much medication can cause sedation and too little would have no effect.
From quiet to aggressive
Dementia can happen in many forms.
Sometimes, a patient can be quiet and placid. This is sometimes termed as being “pleasantly confused”.
On the surface, they live quietly in their own world, oblivious to their surroundings.
They tend to be quite settled and are easy to manage, with only the occasional mild outburst.
Sadly, some dementia cases can be more complicated.
Patients can have what is called “behavioural and psychological symptoms of dementia (BPSD)”.
In such instances, they suffer from low mood, aggressive outbursts, verbal and physical aggression, restlessness, agitation and psychosis.
These are the people who usually need the assistance of secondary healthcare services, as the patients themselves are frequently at high risk of either hurting themselves or others.
In addition, caregiver stress can be enormous under these circumstances.
Many caregivers have to seek help for their own mental health issues, as they struggle to juggle work, care for children, and a parent with dementia whose needs are incredibly complex.
Unfortunately, caregivers are often left unsure as to where to seek help or support groups as they try their best to navigate a complex condition with limited understanding and resources.
The mental health of the elderly cannot be ignored.
Stigma continues to remain a barrier in seeking help and treating dementia, which could lead to improved quality of life.
Until science can come up with a cure or some way of halting the progression of this most cruel disease that robs people of their lives, it is vital to make things as bearable as possible for those suffering from this devastating condition, as well as their loved ones who have taken on the difficult role as caregiver.
And even when there’s nothing left to be done, listening with no judgement and no agenda can still make a difference.
Indeed, this can sometimes be the most valuable treatment one can offer to both patient and caregiver.
Dr Wan Izwin Wan Hassan is a consultant geriatric psychiatrist. For more information, email starhealth@thestar.com.my. The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
Already a subscriber? Log in
Get 20% OFF The Star Digital Access
Cancel anytime. Ad-free. Unlimited access with perks.
