When Dementia is Treatable

Dementia: Common Signs and Symptoms

Before you or a loved one accepts a diagnosis of dementia, you might want to get a second opinion. Chances are, your doctor is right. But other neurological conditions—among them normal pressure hydrocephalus, epilepsy and essential tremor— often share symptoms with Alzheimer's or Parkinson's disease, especially in older patients. The signs of the lesser-known disorders exhibit themselves more subtly as people age, making it harder to distinguish among them. Other barriers to a correct diagnosis include the fact that some physicians are quicker to ascribe any memory loss in an older patient to dementia and any tremor to Parkinson's. Still other doctors, and often patients themselves, merely chalk up the problems to "old age." But there's a big bonus for families to avoid such resignation and make sure the diagnosis is precise: There are effective treatments for these three problems. 

1857 lithograph by Armand Gautier, showing personifications of dementiaCredit: wikimedia commons

Normal pressure hydrocephalus (NPH) is a slow collection of excess fluid in the brain, largely affecting people sixty or older. The buildup swells the brain's ventricles, which could stretch nerve tissue, resulting to symptoms of dementia. The cause normally can't be pinpointed. The most common symptoms are mild dementia, trouble walking and impaired bladder control. Granted," if you get in a nursing home, everybody will have one or all three of those things," said Mark Luciano, a neurosurgeon at the Cleveland Clinic who treats NPH. But NPH patients, he said, often appear as though "their machinery has slowed down. Their memory is worse, they don't start as much speech and they are slower and inattentive." In contrast, Alzheimer's patients "may seem pretty sharp, but they just don't recognize you." The best way to confirm an NPH diagnosis is a brain scan that shows the characteristically expanded ventricles." To treat NPH, a neurosurgeon usually implants a shunt, made from flexible plastic tubing, in the brain to divert excess fluid to a different part of the body. But shunting isn't a guaranteed success, and, especially in older patients, there's always the likelihood that they are suffering from NPH as well as another type of dementia. 

NPH isn't the sole treatable disorder masquerading as dementia. Epileptic seizures in older people can disguise themselves as gaps in conversation, confusion or blank stares. The image many people have of epileptic fits is one "of convulsions, where you're shaking throughout, falling down or biting your tongue," said R. Eugene Ramsay, professor of neurology and psychiatry and director of theInternationalCenterfor Epilepsy at the University of Miami. But seizures in older people can be much more elusive, with "periods where they stop what they do and stare off into the distance." Epilepsy is quite common among older people than was once believed—six to eight times as common in patients over age sixty as in any other age group. The primary difference between epilepsy and dementia is that epileptic seizures can cause confusion that lasts for a few hours or for a few days. Seizures are generally controlled, at least partially, with drugs. There is an older and a newer class of antiepileptic medication. The older type, which includes car-bamazepine, is more widely prescribed and has cheaper, generic versions. But the older medicines have more side effects in some patients. The newer type, which includes leve-tiracetam, is easily tolerated by some older patients. 

Essential tremor is a different common disorder, estimated to afflict 10 million people, normally starting around age forty-five. Once called senile tremor, it is usually mistaken for Parkinson's, especially in older patients. It's tough to distinguish the two diseases in their early stages. Parkinson's has become so common that a lot of family physicians are diagnosing it and treating it themselves instead of referring patients to a neurologist, noted Catherine Rice, executive director of the International Essential Tremor Foundation in Lenexa, Kansas. But as the tremors worsen, it's easier for a specialist to discern between the two conditions: With essential tremor, the person typically shakes—often in the hands-—while the body is active; with Parkinson's, the shaking often happens when the body is otherwise still. In essential tremor, the shaking can get worse over time, but the disorder does not progress into other debilitating conditions, as Parkinson's can. Treatments include prescription of beta blockers and anti-seizure medications or, in grave cases, a device implanted in the brain.

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