What are the early signs of dementia? Things to look for in loved ones and yourself

This is the 84th instalment in a series on dementia, including the research into its causes and treatment, advice for carers, and stories of hope. I did not recognise the signs of dementia developing in mum – the changes in her walking, her frequent need to urinate, her difficulty in swallowing – until quite late. Looking back, I see how they developed one after another. Nearly 80 per cent of all dementias are caused by Alzheimer’s disease. The hallmark of this is the abnormal deposit of proteins – amyloid plaques and neurofibrillary tangles – in the brain. These proteins act like roadblocks, disrupting communication between brain cells. In the beginning, the hippocampal regions of the brain are affected; the hippocampus is responsible for memory and learning. As these proteins continue to affect other parts of the brain, more bodily functions are affected. Here is what to look for in a loved one, or even in yourself. Changes in walking and balance When my mother stumbled and fell from a garden step, our chief concern was that she had split her head open. It was bleeding. It might have needed sutures. We worried about injury to her brain because of the fall. It never occurred to us that there was already injury to her brain – and that it was probably what had caused her to lose her balance in the first place. According to Timothy Kwok, a professor of geriatric medicine at the Chinese University of Hong Kong, walking and balancing are two of the major strengths and abilities humans have – despite most of us taking our mobility for granted and performing it mostly subconsciously. These abilities are entirely dependent on healthy brain function. “When dementia sets in, steps become uneven and smaller, thus increasing the risk of falling,” he adds. That describes my mother’s steps the day she fell. The risk of falls and resulting fractures is several times higher in people with dementia than in healthy older people. Similarly, a sufferer’s ability to adapt the way they walk when faced with obstacles – such as a child or an animal running in front of them, or a bump in the road – is also impaired. They do not respond with the same accuracy and speed as they once would have done. That can lead to trips and falls. Often, though, these are blamed on frailty, failing eyesight, or dodgy hips or knees – not dementia. Words are not enough Often, when clinics test an older person’s cognition, they focus on memory and verbal responses. Research suggests we need to consider a person’s whole health when trying to ascertain their brain health. When my mother’s failing memory caused concern, we took her to her doctor. She was asked her name, the date and her place of birth, what day it was and who she lived with. She could have answered many of these queries right up until the end of her life, when her Alzheimer’s was quite advanced. She always knew her name and could confidently tell you she was born in Bombay – now called Mumbai – in June 1941, even in the days before her death. This focus on spoken answers is not enough. Women often have stronger verbal skills than men, and this can hide early dementia symptoms. They are better able to talk around gaps in memory and score normally on word-based tests, even when their brains show significant changes associated with Alzheimer’s. Eating and drinking can be hazardous I was not aware my mother was aspirating when she was eating; some food, liquid or saliva was going down the wrong way, entering the airway and lungs instead of the stomach. A doctor friend we were having lunch with noticed this and quietly voiced her concern. I had not even heard the term used before. Swallowing is a complex motor skill managed by the brainstem and cortical networks. Kwok says that in moderate to late stages of dementia, chewing and swallowing become problematic, a condition known as dysphagia. “Initially, people with dementia chew less and may spit food out instead of swallowing it. Later, swallowing becomes difficult and uncoordinated. Liquid is more difficult to swallow than solids,” he says. Although it sounds counterintuitive, using a thickening agent in food can sometimes help. As the disease progresses, puréed food is usually recommended, which comes with a downside. “This limits food choices and the enjoyment from eating,” Kwok says. I observed this in my mum. Loss of bladder control is a wake-up call When I recall my mother’s bladder problems, I realise how long her dementia symptoms had been evident before we recognised them as such. She had complained of an irritable bladder for years before a dementia diagnosis was confirmed. She always felt an urgent need to use the toilet, but urinating never seemed to alleviate that feeling. She saw her doctor time and time again. Sometimes a urinary tract infection (UTI) was diagnosed, which is not uncommon in the elderly; sometimes antibiotics were prescribed. She drank cranberry juice, which is meant to alleviate cystitis, or bladder inflammation. She was finally prescribed a medication specific to irritable bladder, which – we discovered too late – probably hastened her cognitive decline. Many bladder-control pills work by blocking a brain chemical crucial for memory and attention. In older people, especially those at risk of dementia, this “anticholinergic” effect can cloud thinking in the short term and, when used for years, is linked with a higher risk of cognitive decline and dementia. There are safer alternatives. When my sister and I discovered that mum had begun wetting herself, we gently encouraged her to use incontinence pads and realised the problem was not cystitis or a leaky bladder. Bladder function – like all our bodily functions – is controlled by the brain. When dementia sets in, the bladder becomes irritable, Kwok says, resulting in urinary frequency and nocturia – needing to urinate often at night. As the disease advances and dulls the sensation, it becomes less noticeable and the ability to hold in urine is impaired. Urinary incontinence follows and later faecal incontinence too. Impaired sleep worsens dementia Mum had never been able to reliably sleep for eight hours per night. Depression had disrupted it for years. But fitful sleep can be an early marker of dementia, and it can get progressively worse as the disease advances and upsets the circadian rhythm. Eventually, it can turn time on its head so that day becomes night and night becomes day. Dementia impairs one’s ability to fall asleep and to maintain sleep, Kwok says. Poor sleep will cause further cognitive decline, as sleep is crucial for the brain to remove toxic waste, such as beta-amyloid protein, and to consolidate memory. On the other hand, some dementia leads to excessive sleep. Keep an eye on your older loved ones. If you notice them having trouble walking, swallowing, needing to use the toilet more frequently or not sleeping well, have them visit a doctor. While there is no cure for dementia, early diagnosis and symptom treatment may help slow its advance, keep a patient more comfortable and may help start a difficult conversation. Like what you read? Follow SCMP Lifestyle on Facebook, X and Instagram. You can also sign up for our eNewsletter here.

What are the early signs of dementia? Things to look for in loved ones and yourself

.css-1c6uqr6{color:inherit;font-weight:inherit;font-size:inherit;font-family:inherit;line-height:inherit;overflow-wrap:break-word;}Verbal tests don’t always pick up Alzheimer’s disease. Falls, problems swallowing, bladder issues and other symptoms can be better signs

Changes in walking and balance

Verbal tests don’t always pick up Alzheimer’s disease. Falls, problems swallowing, bladder issues and other symptoms can be better signs