Why So Many New Cases?
The next time you are in a physician's waiting room, look around. Can you identify which patients need to be screened for dementia? Would you tend to pick out the frail octogenarians? They fit the profile. But don't overlook the 37-year old veteran who was a sports hero in high school before going off to war--or the 48-year-old farm mom who struggles with diabetes and hypertension.
The recent awareness of a dramatic increase in dementia in younger patients is changing the picture of who is at risk and when physicians need to begin monitoring patients for early signs of cognitive decline.
A study sponsored by BlueCross BlueShield showed a 373 percent increase in cognitive decline in excess of normal aging in people age 30 to 44. Increases in people 64 and under told a similar story.
What is behind these troubling new numbers? Are we simply getting better at diagnosing these problems? Are epigenetic factors related to diet, lifestyle and environmental exposures triggering genes early in people predisposed to Alzheimer's? Or is something else in play?
"Alzheimer's is the disease we tend to think of first, and its incidence is increasing," neurologist David B. O'Neal, MD, of the BBH Specialty Care Network in Shelby Medical Plaza, said. "It's also true that lifestyle factors like poorly controlled blood sugar seem to have a role in how it develops. However, there are many other conditions that have a serious impact on cognition."
Whether from sports or work injuries, traffic accidents or battle trauma, brain injuries have become more common in younger people. Hypertension and lipid issues, even in middle age, can lead to vascular dementia and strokes or a series of mini-strokes.
"Metabolic conditions and autoimmune diseases like MS can have an effect," O'Neal said. "We are also seeing more Parkinson's Disease in younger patients. Injuries and exposure to farm chemicals and other environmental factors may be involved. Lewy Body Disease, the rapidly progressive illness linked to Robin Williams' suicide, is another devastating possibility. Brain tumors and other neurological conditions can also have cognitive effects.
"During a neurological workup, there are also several types of pseudodementias we have to rule out or evaluate. For example, memory problems may be linked to something as simple as low levels of B12. Serious depression can sometimes mimic dementia, and hospitalization itself can create a temporary delirium or disorientation. Sleep problems affect alertness. Sleep apnea, in fact, not only causes fatigue that inhibits brain function--the lack of oxygen can actually damage brain cells.
"Drug interactions or a bad response to a medication can seriously affect thought processes. We also have to consider the patient's overall health. Underlying conditions such as thyroid disorders and uncontrolled diabetes can also affect brain function."
Through imaging, neurologists look for tumors and changes in tissue such as a build-up of plaques that might indicate developing Alzheimer's. Images may also show evidence of injuries or damage from stokes or an autoimmune disorder.
When early signs of developing dementia are detected in younger patients, what can be done to prevent or slow the damage?
"We have several medications that may be able to ease symptoms and could possibly halt or slow progression, depending on the diagnosis," O'Neal said. "That's why it is so important for physicians to watch for signs of cognitive changes in younger patients, as well as those who are older. This is especially true in patients at high risk due to their family history or underlying health conditions."
Although memory problems are the hallmark of Alzheimer's disease in older patients, forgetfulness may not be the first sign of mental decline in younger patients.
"They may be having more difficulty in planning and decision making. They may report having problems with concentration or attention span, or more difficulty doing tasks they could normally do before." O'Neal said.
Although stress can contribute to confusion, the mental symptoms and confusion that may be mistakenly attributed to stress could actually be caused by cognitive decline. In some cases, there also may be changes in movement, balance, mood and temperament, especially if new limitations are causing frustration.
Demographics can also play a role in predicting which patients are most at risk.
"There is a greater incidence of early onset dementia in rural areas than in urban, and in patients whose education ended in high school or before," O'Neal said. "Women and African-Americans are also at greater risk. Lifestyle and occupations with more repetitive activities, greater exposure to toxins and head injuries, and fewer opportunities to learn new things can be factors.
"A college education and a habit of life-long learning seem to have a protective effect. Reading, solving puzzles and other activities that keep neurons firing and building new pathways also seem to help. In addition to physical activity, mental activity has a healthy effect. It's like physical therapy for the brain."