Early Dementia

My father passed away from dementia in 2022. My mother is still alive and in the early stages of it. Most likely Alzheimer’s for both, as that is the most common form of dementia. There are others, but that type accounts for the majority of cases.

I see a lot of dementia in the ER and virtually never actually diagnose it.

Things like episodes of confusion, short-term memory loss, forgetfulness, wandering away from home, getting lost while driving, forgetting how to do something, difficulty with simple tasks, poor judgment, changes in mood, and trouble with communication… These are all signs of dementia. And most often they are not the result of any other acute condition.

It’s often the adult children of elderly parents who voice these concerns. Most often, these issues have not been discussed with any medical provider. Despite dementia being very common in the elderly, no one in the room besides myself seems to have considered it a possibility. The patient is usually there for something else that actually may be an acute problem — a fall, a possible stroke, or a heart condition. Those are things we can address in the ER. Dementia? Not so much.

There is no lab test or imaging, including CT or MRI, that will diagnose dementia. Patient symptoms, reported history from the family, physical and neurologic exams, cognitive testing, and so on can help arrive at a “possible” or “probable” diagnosis. Some of this is done in the ER, such as gathering a history from the patient and family. The patient will get a physical exam, but the goal of that is to rule out acute problems like a stroke. A brief ER visit will not confirm the diagnosis of dementia. It requires follow-up with primary care.

Episodes of confusion or memory loss seem to be some of the most common complaints that I hear about. They are obviously concerning to the family, sometimes not so much for the patient. Rarely, when these complaints occur in isolation, are they also an acute problem. These are particularly challenging when the episodes happened some days or weeks in the past but are only brought up during the ER visit. There is no test I can do to prove that the episode was related to dementia.

I think ER providers are often reluctant to mention dementia as a possibility because we are only seeing a snapshot in time. It’s all a guess based on experience, and once you open that can of worms, who knows what the reaction might be. Patients are often reluctant to admit it’s a possibility. Sometimes the family has been suspecting it, but sometimes they are also reluctant to consider it or even hostile to the idea. Some insist there must be something else going on.

In general, elderly patients get a bigger workup in the ER, so lab tests, an EKG, or CTs/MRIs may or may not happen depending on the exact complaint that brought them in. Those tests are not for diagnosing dementia — they are for making sure there is not something more acute going on. If dementia is the most likely underlying cause, the rest of that workup will usually be relatively normal.

It’s certainly okay to bring up these concerns in the ER, but don’t expect a definitive answer.