What are the common symptoms?

Patients with dementia will have difficulty with one or more of the following cognitive functions:

• Retaining new information
• handling complex tasks such as managing bills and finances
• reasoning skills such as being unable to cope with unexpected events
• getting lost in familiar places

Memory loss

Trouble with memory can be an early symptom of dementia. But obviously not all memory loss means dementia. It affects short term memory more so than long term memory. For example, a person may be able to remember details of things that took place years ago but be unable to recall what they had done the day before. Other examples would be misplacing items or forgetting appointments. As memory function deteriorates patients may begin to confuse the past with the present or they all roll in to one. Also, when asked questions about what they did over the previous few days they may compensate by telling you about something that happened some time ago that they do have a recollection of as they may have no recollection of what happened yesterday or the day before.

Difficulty with day to day tasks

This is quite a common symptom of dementia that occurs as the disease progresses. In general, tasks that are done on autopilot seem to be maintained such as getting up and dressed in the morning but tasks that will require ongoing thinking and planning will become a challenge. The best example of this is planning of finances as this is something that may change day to day. Other daily tasks that may become challenging over time may be use of the remote control for the TV, use of household appliances or meal preparation.

Poor judgement

Patients with dementia have poor memory and often poor concentration and together these can lead to poor judgement. Driving is an example of an everyday skill that requires good judgement. Patients with dementia may find that this becomes a challenge for them. A simpler example of this would be judging whether or not you need to wear a coat on a cold day. As the disease progresses even decisions as straightforward as this can become a challenge.

Changes in mood

Apathy, depression and anxiety are all common symptoms that a patient with dementia may experience. Apathy is where there is loss of motivation and lack of interest in previously enjoyed activities. People with dementia are far more likely to suffer from this than those without dementia. It is quite difficult to treat with medication. Depression is a condition where people feel low or sad for prolonged periods of time. Previously enjoyed activities may no longer hold the same enjoyment for them. People with depression will often feel hopeless or have an irritable mood. They may have low self-esteem or feel worthless. Sleep is often interrupted in people with depression and there may also be symptoms such as difficulty with concentration or even memory function. Therefore, in people with dementia identifying and treating depression is very important. Anxiety often goes along with depression and this can range from worrying about every-day things to worrying about health issues for both the patient and also family members. Common symptoms of anxiety include constant worrying, difficulty concentrating, poor sleep, experiencing feelings of dread. Anxiety can also cause physical symptoms such as dizziness, palpitations, headaches and generalised aches and pains.

Behaviour changes

People with dementia struggle to communicate with the world in a normal sense and so often abnormal behaviour is their only way to communicate. For example, if a patient with dementia has pain they will not be able to simply say they have pain and would like a pain killer. Therefore, they may become distressed and agitated as a means of trying to communicate what they want. This applies also to the patient being constipated, bored or feeling unwell. Other types of abnormal behaviour that can occur in patients with dementia include restlessness and agitation, repetitive behaviour, shouting and screaming, walking, hiding, hoarding and losing things, accusing people of various things and losing inhibitions. It is important to note that any or all of these behaviours can be generated from very simple things such as having pain, needing to use the toilet, being too warm or too cold, being hungry and dehydrated or even being bored. It is important to consider all of these possibilities as they are all solvable issues that will help both the patient and carer feel a lot better.

Changes in personality

Some people with dementia experience changes in their personality. This can be a reflection of mood or behaviour changes (described above). Patients with the form of frontotemporal dementia that affects behaviour (see below) may be more susceptible to personality changes. This can be manifested as excessive emotion and emotional responses out of proportion to the situation. For example, watching a sad movie might make someone cry uncontrollably which would be a reaction considered out of keeping with the situation.

Sleep disorders

Patients with dementia often have disturbed sleep. This can take the form of just being unable to fall asleep at night or falling asleep and then awakening frequently during the night. The risk with both of these is that upon awakening the patient may get up and walk and without supervision and in the dark this may become dangerous. In the form of dementia called dementia with lewy bodies (discussed below) there can be a condition called “REM sleep behaviour disorder”. This is a condition where during REM (or dreaming) sleep loss of muscle tone that is supposed to happen does not and this can lead the patient to, in effect, act out their dreams. This can pose a danger to both themselves and bed partners.

Language and communication problems

People with dementia often have problems with language. This can include both understanding of language but also formation of words and sentences. When it begins the changes can be subtle and not even noticeable in regular day to day conversations. However if any details are sought it may become apparent. This can have a huge impact upon daily functioning. As the condition advances, understanding and responding to even the simplest of tasks can become challenging.

There are many forms of dementia and they all eventually lead to a similar constellation of symptoms- in that the patients will have difficulty with functioning as detailed above. However, there are some subtle differences and these have important implications for both treatment and prognosis.

Alzheimer’s dementia- this is the form of dementia with which people are most familiar. Memory impairment is the most prominent and often the earliest symptom of this type of dementia. The part of the brain that is involved in learning and memory function- called the hippocampus- is affected the earliest in Alzheimer’s dementia. An abnormal protein (called Beta-Amyloid) is deposited here and it prevents the nerve cells from performing their normal function and this manifests as memory loss.

Frontotemporal dementia- In this type of dementia either the frontal lobes (area behind your forehead) that are important for normal social interaction and behaviour become affected or the temporal lobes (area behind your ears), where language is perceived and understood, become affected. In the former a prominent symptom is behavioural issues. An example of this would be failure to act appropriately in social settings. Patients will often display a lack of understanding of other people’s feelings and a lack of interest or concern about how other people are feeling. People with this type of dementia may ignore personal hygiene and they may display a change in food preference in general with over-eating. Other behavioural changes that can occur include increased sexual behaviour as well as aggressive behaviour. In the type that affects the language centres patients will often present with difficulty in either forming words and sentences or in understanding the meaning of both familiar and less familiar words. This can cause huge problems with communication.

Vascular dementia- this is a form of dementia that is thought to be linked to vascular disease. This would apply to people who have had either big strokes or multiple very small strokes or TIAs (mini-strokes) over time. The vascular changes then affect memory and cognitive function in much the same way as the other forms of dementia- the big difference being the history of having had strokes in the past. In cases where there has been a big stroke there may be an immediate decline in cognition but for those who have suffered multiple small strokes over time (sometimes even without any knowledge that they may have had a small stroke) the change in cognition is much more gradual. This is thought to be the second most common type of dementia after Alzheimers disease.

Dementia with Lewy bodies- in this form of dementia an abnormal protein deposits in brain cells causing interruption of function. There is a close relationship between this type of dementia and Parkinson disease.

• Patients with this form of dementia can develop all of the symptoms described above but the following are considered to occur in this type of dementia more so than in the other types:
• Confusion and changes in level of alertness that can fluctuate day to day
• visual hallucinations
• difficulty with visual perception
• REM sleep behaviour disorder (mentioned above under sleep issues)

Mixed dementia- This is the case where there is more than one type of dementia contributing to memory problems. The symptoms may vary according to the areas of the brain involved. It is thought to be quite common but cannot really be diagnosed accurately until autopsy. It is thought also that the most common combination is vascular and Alzheimer’s dementia.