It was near the end of a routine office visit when my patient, Sam, told me he needed to talk to me about his wife. I closed his chart and gave him my full attention. “Ruth’s just not the same,” he said. “She tells me the same thing three times. She forgets when we have plans to go somewhere. I don’t know, but I think she might have that Alzheimer’s disease.” Concern and frustration were evident in his voice. “Can you check her out the next time she’s in here?” I shook his hand and promised I would.
I had known Sam and Ruth, both in their late seventies, for more than two decades, and apart from the usual infirmities of the golden years, they had managed to dodge serious illness. I saw them both regularly, and neither one had struck me as having suffered a significant decline in intellectual functioning. But it wouldn’t be unusual for early dementia to sneak in under the radar. Its first symptoms may be subtle and impossible to distinguish from the normal decline in memory that occurs with aging.
If you ask people over 60 what they dread most, dementia is almost always in the top three on their list of health concerns. After all, it is memory that makes us who we are; without it we are forever trapped in the moment, with no window on the past or the future.
There is some discussion among experts over what exactly constitutes early dementia, but they generally agree that it includes both a decline in memory (learning and recalling new information like “Where did I put those keys?” or “What did we do yesterday?”) and a decline in at least one other area of intellectual functioning. Among those areas are language (breadth of vocabulary, complexity of sentences), calculation (balancing a checkbook, figuring a tip), judgment (Is this a legitimate bill or a mail scam?), and visual-spatial orientation (becoming disoriented while walking or driving). Faulty memory alone is not enough to diagnose dementia, and the cognitive impairment must be a decline from a previously higher level of functioning.
Two weeks later as I entered the exam room and opened Ruth’s chart, I found the note I had written to remind myself to check her memory. Mindful of her husband’s concerns, I asked her how things were going.
“Dr. Kagan,” she said, “I’m worried about Sam.”
I waited for more and watched as she frowned.
“I think he might have Alzheimer’s.”
I couldn’t help smiling to myself. After 50 years, is this where marital bickering had brought them? “What makes you think that?” I asked.
“Well, I say things and he keeps correcting me. And then he gets angry. He’s so short-tempered lately. It’s not like him.”
I told her I would look into it the next time I saw her husband. After reviewing her vital signs and performing a basic physical exam, I proceeded to test her. Extensive formal testing tools exist to evaluate memory, but most clinicians rely on the Mini-Mental Status Exam (MMSE) in their offices to screen for dementia. The test takes just a few minutes and is commonly used for detecting cognitive impairment. It includes a series of questions that test orientation to place and time, recall, calculation, reading, and executive function—carrying out a complex task, such as copying a drawing of two overlapping pentagons.
Amused through much of the testing, Ruth offered an excuse or a dismissive laugh whenever she failed on some component of the exam. She was unable to recall any of three named objects after three minutes. She struggled with simple math and was unable to spell the word world backward. When we were done, her score was well below normal, placing her in the early dementia range. Depression in some cases may mimic dementia, especially when patients become withdrawn and disengaged, but Ruth showed no evidence of that melancholic state. A careful neurological examination disclosed no abnormalities to suggest prior strokes or other disorders, such as Parkinson’s disease, that may be associated with dementia.
I sent Ruth to have blood drawn and then walked over to my secretary, Carina. I asked her to schedule Ruth for an MRI of the brain.
“What’s the indication?” Carina asked. The radiologists would want to know what I was looking for.
“Put ‘Evaluate dementia’ on the request.”
She nodded and mumbled, “Oh, that explains her cookies.”
“Her cookies? What about her cookies?” I began to wonder if one of us was in need of a dementia workup, too.
Carina reminded me that for years Ruth, a kindhearted woman, had been bringing home-baked cookies to every appointment. Known among my staff as the Cookie Lady, she always made sure everyone got his or her own little bag. But for the past year, whenever Ruth came in the staff would politely wait for her to leave and then deposit the cookies in the trash. “They’re terrible,” she said, “but no one wants to say anything to her. Too bad. They used to be good.”
After Ruth left I tried one of her dry, tasteless cookies and agreed that they would not have earned anyone the affectionate nickname Cookie Lady. I saw it as one more example of how she had changed. I made sure that her MRI got scheduled.
Within a week I had all of Ruth’s results back. Her scan showed mild brain atrophy, or shrinkage, a common but very nonspecific finding in older people. There was no tumor, no evidence of a past stroke, and no fluid accumulation. Her lab tests showed no metabolic derangements or any deficiencies, such as inadequate amounts of thyroid hormone or vitamin B12, that can cause symptoms of dementia.
Based on her impaired cognitive functions and the absence of any other explanation, I concluded that, unfortunately, Sam was right. His wife had early Alzheimer’s disease. The diagnosis is a clinical one, meaning there is no specific test, either analyzing the blood or imaging the brain, that can identify the disease. Indeed, the only way to confirm Alzheimer’s conclusively is to biopsy the brain. But this invasive and risky test is seldom done because the diagnosis can be reliably established on clinical grounds alone.
That same week I saw Sam in my office and, as I had promised Ruth, evaluated him. He had no problem with the MMSE, and there were no neurological abnormalities. What he did have, however, was a wife of more than half a century who had begun to slip away from him mentally. It frightened him and left him feeling frustrated and helpless. He had responded by becoming short-tempered and demanding. But being short-tempered and demanding is not dementia.
Ruth had correctly observed a distinct change in her spouse, and with her limited capacities she had decided that the problem lay with him, speculating that he might have early dementia. “He keeps correcting me,” she had complained, demonstrating no insight into her own diminished mental faculties. Sam, in turn, was showing how Alzheimer’s disease affects more than the person who has it.
In fact, Ruth’s marked lack of insight into her deficits is characteristic of true dementia. Patients forget what they don’t know and so gain no self-awareness. The corollary is that patients who come to me worried that they might have Alzheimer’s generally do not. (There are exceptions, of course.) Alzheimer’s is the illness that is most often brought to a doctor’s attention by family members and friends rather than by the patients themselves.
There is currently no way to reverse Alzheimer’s disease. There are, however, drugs that can treat its symptoms. I prescribed these medications for Ruth after having a lengthy discussion with her and her husband about the nature of the illness and what they could expect down the road. I also suggested an Alzheimer’s support group for Sam to help him gain some understanding of how his wife’s disease was affecting him. There was no way to predict the tempo of Ruth’s illness, but her general health was good, and I told them that a program of physical activity and mental engagement would work in her favor.
They left my office hand in hand. I was confident that after 50 years they would find a way through this, too.
H. Lee Kagan is an internist in Los Angeles. The cases described in Vital Signs are real, but patients’ names and other details have been changed.
