Evaluation Of Seniors

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Dementia is not a physical illness or condition. Rather, it is a symptom that can result from a variety of illnesses, some of which are reversible and some of which are not. The term dementia refers to a decline in one’s cognitive functioning (that is memory, attention, reasoning, visual perception, language functioning, and so on) which is significant enough to disrupt the individual’s ability to function in their everyday life and/or which lead to significant negative changes in one’s emotional and behavioural functioning.

The most common cause of irreversible dementia is Dementia of the Alzheimer’s Type or DAT. DAT occurs in approximately 5% of the population over 65 years old. The risk of developing DAT increases with age so that the proportion of people who have DAT double by the age of 70, and again by the age of 75 and so on. By the age of 85 or older, it is estimated that between 25% and 50% of individuals will have developed the disease.

People with a parent or sibling who had DAT, especially if it onset at an early age, are at more risk of developing the disease. There are several other factors that increase the risk of DAT and other illnesses leading to dementia. These include, but are not limited to, problems with circulation arising from high cholesterol and/or high blood pressure, diabetes mellitus, and a history of moderate or severe traumatic brain injury.

There are several disorders that can lead to dementia. DAT is the most common and accounts for approximately 70% of all people diagnosed with dementia. Here is a general description of the most common types of dementia.

Dementia-Alzheimer’s Type (DAT). The human brain has tens of billions of neurons each of which is connected to thousands of other neurons. Unlike muscle, bone or skin cells, neurons are not ever replaced so throughout our lives we have fewer and fewer neurons as neurons die and are not replaced. Because we have so many neurons these losses only start to become noticeable as we move into old age. In DAT, this gradual loss of these neurons and their connections accelerates. In recent years it has been discovered that there is also a progressive accumulation of different types of proteins (amyloid and tau) in the brain which may account for the accelerated cell death. In the early stage of the disease, these changes generally affect parts of the brain that are associated with our ability to learn and retain new information. Therefore, the first symptoms generally consist of memory problems or rapid forgetfulness. As the disease progress, the pathology in the brain spread to other regions, which leads to other changes in thinking skills, behaviour, and in personality. These may include increased apathy and/or irritability, word finding difficulties, social withdrawal, socially inappropriate behaviour, and increased difficulty managing finances.

Vascular Dementia. Vascular dementia consists of cognitive decline that occurs because of problems with our vascular or circulatory system in the brain. This may result from a single event, such as a major stroke or the gradual accumulative effects of dozens or even hundreds of very mild strokes. A person with vascular dementia tends to show a more rapid onset of symptoms compared to what is seen in DAT. How quickly it progresses depends in part on when it is identified and whether contributing factors to the strokes, such as high blood pressure, can be controlled. The cognitive deficits associated with vascular dementia largely depend on which area of the brain was affected by the disease or the event, and hence are more variable in nature than those seen in DAT.

Frontotemporal Dementia or Frontal-Temporal Lobar Degeneration (FTLD). The term FTLD refers to the regions of the brain that are mostly affected by the disease (the frontal and temporal lobes of the brain). It is estimated that Frontotemporal dementia-spectrum disorders account for up to 20% of all pts with degenerative dementias. The condition typically presents between the age of 45 and 65 years old. Genetics factors remain at this time the only known cause for FTLD. We also know that there is a certain amount of overlap between patients with FTLD and patients with motor disorders, such as motor neuron disease (MND) or Amyotrophic Lateral Sclerosis (ALS). It can be difficult to distinguish between DAT and FTLD as both diseases share a number of similarities, such as insidious onset and progressive difficulties with memory and language. Personality changes, such as appearing more indifferent or depressed or being more socially inappropriate or careless can also occur in both DAT and FTLD, but in DAT these changes usually occur at a later stage in the disease compared to FTLD. There are several types of FTLD, which essentially depend on the regions in the brain that are predominantly affected. The most common type of FTLD is called the Behavioral variant of FTLD and involves primarily personality and behavioural changes. It accounts for approximately 56% of all FTLD and progresses relatively rapidly (an estimated time of 3.4 years from diagnosis to death). Other variants of FTLD start with a decline in a person’s language skills or a person’s ability to express himself/herself and/or to understand what other people are saying.

Physicians have various tools that are useful in diagnosing dementia and in particular DAT. Typically, the diagnostic workup will include imaging of the brain, which will show what the brain “looks like.” Such scans may reveal atrophy or lesions in the brain which are beyond age-expected changes. Blood tests and other procedures are also useful in ruling out other disorders that might account for the symptoms. Recent research has identified a variant of a gene known as Apolipoprotein E or ApoE, that is associated with an increased risk of developing DAT. That variant, known as ApoE4, increases one’s risk of developing DAT as much as thirty-fold. However, despite this and other breakthroughs we are still a long way from having a physical test for DAT. There are, for example, many people who show significant brain atrophy but no evidence of dementia or, on the other hand, significant dementia without any abnormal brain scan findings. Rather, the condition is diagnosed by the onset of symptoms. Neuropsychological assessment has been shown to be one of the most sensitive tools available to detect mild cognitive impairment as well as early stages of DAT and other dementias. It has also been shown to be very helpful in differentiating between the various types of dementia which, in turn, can lead to earlier diagnosis and treatment.

Like all of the rest of our body, our cognitive functions, senses, and motor functions decrease with age. We all know that as we age our vision, hearing and motor strength diminish. In the same way, when we are in our 70’s or 80’s we may not process information as quickly or remember the details of a conversation that they had a few days ago as well as we might have done when we were 20. Many such changes are considered as normal, but if excessive may also be early warning signs of dementia. Whenever these changes are of concern for an individual or his/her family, even if they are not causing major disruptions in the person’s life, a neuropsychological assessment can be helpful in determining whether they are greater than what should be expected given the person’s age. If they are, the individual is said to have MCI. The thinking skills that are impaired in MCI might make it more difficult for the person to complete complex or unfamiliar tasks but do not yet prevent a person from going about his/her activities of daily living and therefore do not meet the criteria for a diagnosis of dementia.

There are different subtypes of MCI, depending on the kind of cognitive impairment the person has. For example, some people have specific difficulty memorizing new information while other thinking skills, such as their ability to focus their attention or express themselves will remain intact, whereas someone else may experience significant problems finding words and so on.

Not everyone with MCI will develop DAT or another form of dementia. Every year, approximately 10% of people diagnosed with MCI go on to develop dementia.

Early diagnosis is important for two reasons.

First, although there is no “cure” for DAT or many other dementias there may be things that can be done to slow or reverse the progress of the dementia, such as reducing high blood pressure in vascular dementia. There are medications, such as Aricept or Exelon that are used to potentially delay the progression of dementia. Although these medications are of limited effectiveness, ongoing research is likely to lead to their improvement in the future. In addition, leading a healthy lifestyle by controlling your cholesterol level, keeping a normal blood pressure, avoiding smoking or maintaining normal blood sugar levels can help lower the risk of developing dementia. Physical exercise and mental stimulation are also increasingly considered to be protective factors for our cognitive health.

Second, if the individual does have a progressive dementia an early diagnosis gives that person and his or her family more time to come to grips with this reality and make decisions about how it will be dealt with by all involved. Likewise, even if the dementia can’t be reversed or slowed there are treatments that can reduce some symptoms that accompany dementia and thus improve the patients’ and their families’ overall quality of life. Psychotropic medication for example may be used to treat depressive or anxiety symptoms. Likewise, behavioural therapy with the patient and his or her caregivers may help them to better manage behavioural problems.

DAT and most other illnesses that lead to dementia are considered as neurodegenerative disorders, which means that they typically show a course of gradual deterioration over time, ultimately ending in death. The rate of the progression largely depends on the type of dementia as well as other medical factors, such as co-existing diabetes or heart disease, that are known to also contribute to cognitive and functional difficulties. In DAT, the length of illness is considered to average 7 years, but can range between 5 to 15 years. People with a strong family history of DAT and develop the condition themselves tend to show symptoms earlier in life (between 40 to 60 years of age) and also tend to decline more rapidly. More generally DAT tends to progress more slowly in people who develop it at a later time in their life.

A wide variety of treatments have been touted as slowing or even reversing the course of dementia. With respect to such approaches, although we know of no studies that show that they are harmful to people in any way, there are likewise no well-controlled studies that clearly demonstrate that they slow down or reverses the progression of the disease. The bottom line is that if one wants to invest the time and money to try such methods they probably won’t be harmed in the process; however, there’s also a good chance that they won’t experience any meaningful improvement.

Our Seniors’ Neurocognitive Assessment Program (SNAP)

It is a service that we offer for seniors who have concerns about their cognitive functions, such as memory difficulties.

The term cognitive functions refers to a group of skills or abilities that our brains use to make sense of information, analyze that information and decide what to do about it. In everyday language, these functions include our use of, seeing, hearing, and other senses to tell us what’s going on in the world, our use of concentration, memory and reasoning to make sense of it, and our use of judgment to develop plans to act on it.

As we age, our cognitive functions, just like our senses of sight and hearing, become less acute. This is perfectly normal. However, as we age we also become more susceptible to illnesses that can impair our cognitive functions. Some, like drug side effects, hypertension or depression can be treated and others, like some forms of dementia, cannot.

Many of these illnesses are not identifiable by standard medical tests like blood tests or x-rays. Instead, the earliest warning sign of many of these disorders is what is known as Mild Cognitive Impairment or MCI. MCI is the disruption of these cognitive functions that is over and above what is due to normal aging but is still fairly mild. Simply put, as we age, we and/or those around us are often quite aware that we don’t remember things or think through decisions as well as we used to. The question is, how do we tell if that’s just normal aging or MCI? One of the most effective ways to differentiate normal aging from MCI is to perform a Neurocognitive Assessment.

One of the best ways to see whether any organ of your body is working properly is to get it to do its job and see how it does, like when you are asked to walk on a treadmill while your heart is being monitored. Neurocognitive assessment does this with your brain. Your brain is put to work using a series of neuropsychological tests that require you to remember things like lists of words or numbers, figure out problems and so on. Some of these tests are often affected by MCI and others aren’t. By examining how you do on these tests, we get a good indication of whether you have MCI and, if you do, we can find some suggestions which might help guide your physician in exploring possible causes of this condition, and determining what forms of treatment or management are best for you.

The amount of time the assessment takes varies, depending on several factors.   However, you will be scheduled for an initial 3 ½ hour session.  You might be done early or you may need to come back for second brief session.

Although most health care services are billed on an hourly basis, because cost is a significant issue for people our program involves a flat fee of $1,999.00 so you won’t have any unpleasant surprises at the end of the process. MSP does not cover psychological services, but part or all of the cost may be covered by extended health insurance.

This cost includes our review of your doctor’s referral letter and an information form that you will complete before coming in, your visit with us which includes an interview and the testing, a follow-up session with you to go over our findings and a written report which we will send to your doctor.

You will be asked to complete and return an information form before your first visit.  We also recommend that you be well-rested for the session and avoid use of alcohol or recreational drugs for 24 hours before the visit.  However, you should continue to take any prescription medications as instructed by your doctor, and bring any eyeglasses and/or hearing aids you use.

Although referral from a physician is not mandatory for this program, we strongly recommend that you discuss this program with your doctor to be sure that he or she believes that this will be of benefit to you.  We will also ask your permission to speak with your treating physician.  In this way, we can share information with your doctor which will give us a more complete picture of your situation and also assure that our findings and recommendations are as helpful as possible.

All testing is done or overseen by Dr. James Schmidt, Ph.D.

Dr. Schmidt is board certified in clinical neuropsychology and clinical psychology (ABPP) and has practiced neuropsychology for over 40 years in a variety of hospital, rehabilitation, and private practice settings.