A NEW SIGN OF DEMENTIA?
Some experts say to look out for sharp, lengthy changes in mood or behavior
“Has the person become agitated, aggressive, irritable, or temperamental?” the questionnaire asks. “Does she/he have unrealistic beliefs about her/his power, wealth or skills?”
Or maybe another kind of personality change has happened: “Does she/he no longer care about anything?”
If the answer is yes to one of these questions — or others on a new checklist — and the personality or behavior change has lasted for months, it could indicate an early stage of dementia, according to a group of neuropsychiatrists and Alzheimer’s experts.
They are proposing the creation of a new diagnosis: mild behavioral impairment. The idea is to recognize and measure something that some experts say is often overlooked: Sharp changes in mood and behavior may precede the memory and thinking problems of dementia.
The group made the proposal Sunday at the Alzheimer’s Association International Conference in Toronto and presented a 34-question checklist that may one day be used to identify people at greater risk for Alzheimer’s.
“I think we do need something like this,” said Nina Silverberg, director of the Alzheimer’s Disease Centers program at the National Institute on Aging, who was not involved in creating the checklist or the proposed new diagnosis.
“Most people think of Alzheimer’s as primarily a memory disorder, but we do know from years of research that it also can start as a behavioral issue.”
Under the proposal, mild behavioral impairment (MBI) would be a clinical designation preceding mild cognitive impairment (MCI), a diagnosis created more than a decade ago to describe people experiencing some cognitive problems but who can still perform most daily functions.
Dr. Zahinoor Ismail, a neuropsychiatrist at the University of Calgary and a member of the group proposing the new diagnosis, said studies and anecdotes suggested that emotional and behavioral changes were “a stealth symptom,” part of the dementia disease process, not separate from it.
Whatever is eroding memory and thinking skills in the dementia process may also affect the brain’s systems of emotional regulation and self-control, he said.
If two people have mild cognitive impairment, the one with mood or behavior changes develops full-blown dementia faster, he said.
Alzheimer’s patients with those symptoms “do much worse over time”; after death, autopsies have shown they had more brain damage.
Of course, not everyone experiencing mood swings with age is suffering warning signs of dementia. Ismail emphasized that, to be considered MBI, a symptom should have lasted for at least six months and be “not just a blip in behavior, but a fundamental change.” Still, some experts worry that naming and screening for such an early-stage syndrome might end up categorizing large numbers of people, making some concerned they will develop Alzheimer’s when there are not yet effective treatments for the disease.
“There’s the potential benefit of early diagnosis, identifying people more likely to decline,” said Dr. Kenneth Langa, a professor of internal medicine at the University of Michigan. But “the flip side is overdiagnosis, labeling someone and getting people in the clinical cascade, where you start doing the test and people start doing more brain imaging and being at the doctor’s more and getting more concerned.”
“If it becomes a routine practice, that’s a huge amount of dollars,”
he added. Langa, who has written about MCI, cited the experience with that designation. Many people given an MCI diagnosis do not develop full-blown dementia even a decade later, and as many as 20 percent have later been deemed cognitively normal, he said. That could be because on the day they were screened, their cognitive function was lower than usual, possibly a result of stress or medications they were taking for other conditions. “That’s one of the things that makes me think twice” about creating MBI, said Langa, who recommended the checklist be tested by researchers before doctors began using it.
Others are more enthusiastic. “We have to improve our ability to identify people at risk,” said Arthur Toga, a neuroscientist at University of Southern California. Eventually “there will be an effective treatment,” he said, “and there’s too much unknown about this disease anyway.”
Toga said his mother exhibited frustration and other emotional changes in her 70s, years before she developed Alzheimer’s. He believes her moods stemmed from dismay felt by his mother, a retired teacher, while trying to hide something family members had not yet noticed: “her ever decreasing cognitive capacity with words.”
Indeed, Langa and others said, memory tests are not always able to detect early problems because some people, especially highly educated ones, may be skilled enough at taking tests that their scores do not reflect the full extent of their cognitive slippage.
Dr. Mary Ganguli, a professor of psychiatry, neurology and epidemiology at the University of Pittsburgh, said people often came in reporting that they or a family member had stopped doing something they always enjoyed, like baking a certain Thanksgiving dessert or tinkering with the lawn mower in springtime.
Even the patient may not know why, she said. They may be uninterested in the activity because “they couldn’t figure out how to do it anymore.”
Usually, when Ganguli asks if the patient is having trouble remembering things, “They will say, ‘Yes, but it’s not the biggest problem,’” she said. “But if I assess them, I find memory problems.”
Some experts supporting the new diagnosis said that unlike most cognitive problems, some mood and behavior symptoms could be treated with therapy and medication. “We can make them sleep better, we can take the edge off depression, we can help the family learn how to manage the problems,” Ganguli said.
Ismail said apathy was a common symptom, but he has seen starker changes. One patient in her 70s became so sexually uninhibited, she “went from prude to promiscuous,” he said. Another, a law-abiding 67-year-old woman, suddenly “started smoking crack.” Both later developed dementia.
Mood and behavior changes have long been recognized as early-warning signs of frontotemporal dementia, which accounts for about 10 percent of dementias.
Palmer Posvar, a patient of Ganguli’s, was in her 50s when she started taking food off other people’s plates, asking to borrow money from friends and trying to pawn heirloom jewelry, said her husband, Wesley. At 54, she was found to have frontotemporal dementia. Now 64, Posvar can no longer speak and she falls so frequently that she was recently moved from their house in Fox Chapel, Pennsylvania, to a nursing home.
Still, “early diagnosis is a doubleedged sword,” Wesley Posvar said when asked about creating a mild behavioral impairment category.
The upside is that “there are medications which help manage mood and behavior,” and clinical trials that these patients might qualify for, he said. But “does that become part of your health record that’s accessible by insurance companies” or employers, he wondered. “And do you really want to know? Because there’s no cure yet.” Some experts said they believed the benefits of the new diagnosis outweighed the drawbacks.
“We should not be ignoring them, waiting for the cognitive manifestations to appear,” Ganguli said, “because we may be missing the opportunity.”