Memory disorders

Normal forgetfulness, mild cognitive impairment and dementia

Everyone occasionally forgets names, where the keys are, or an appointment, and this increases slightly with age, stress and lack of sleep. It is not a disease. The key difference is the effect on daily functioning:

• Ordinary forgetfulness: temporary, remembered later, with no effect on independence.
• Mild cognitive impairment (MCI): a noticeable and measurable decline in memory or other mental functions, but the patient still carries out daily activities independently. Some patients progress to dementia over time (about 10–15% a year), but others remain stable or improve.
• Dementia: a decline in cognition sufficient to impair independence (finances, medicines, orientation, self-care). It is a syndrome that can have different causes: Alzheimer’s disease (the most common cause, about 60–70% of cases), vascular dementia (from disease of the brain’s vessels), dementia with Lewy bodies, frontotemporal dementia and mixed forms.

Which changes need a check-up

• Frequently repeating the same questions or stories within a short time.
• Forgetting recent events, appointments or conversations, while memory for distant events is preserved longer.
• Difficulty managing medicines, bills or finances, or following a familiar recipe.
• Losing one’s way in familiar places or mistakes about date and time.
• Difficulty finding words, changes in speech, impaired judgment or changes in behavior and personality.

Forgetfulness that affects safety or independence (for example forgetting a gas flame left on, getting lost on the way) needs assessment without delay. It is often a family member who notices first; the patient may not recognize the problem, which is itself a feature of the disease.

What the possible causes are

Before speaking of a neurodegenerative disease, treatable and reversible causes are looked for:

• depression and anxiety (which can present as “forgetfulness”), insomnia and sleep apnea;
• drugs: anticholinergics, benzodiazepines, some antihistamines, opioids, sleeping pills, polypharmacy in older people;
• alcohol;
• metabolic disorders: hypothyroidism, vitamin B12 or folate deficiency, calcium or sodium disturbances, kidney or liver failure, hypoglycemia;
• infections (for example urinary tract infections in the elderly can cause acute confusion, called delirium);
• structural causes: normal pressure hydrocephalus, chronic subdural hematoma, tumors.

In other cases the cause is a neurodegenerative disease (Alzheimer’s, Lewy body, frontotemporal) or a vascular one (repeated small infarcts, hypertension, diabetes, high cholesterol). Causes can coexist. A single poor result on a test does not make the diagnosis.

How the assessment is done

The doctor reviews the onset and course of the changes (slow or fast), sleep, mood, medicines and the ability to carry out daily activities. When possible, a family member or close person can bring useful observations, with the patient’s knowledge. Standard tests of memory and other cognitive functions (for example MoCA or MMSE) are used, which assess memory, attention, language, orientation and executive functions; they are a screening instrument, not a diagnosis in themselves, and are interpreted according to age and schooling.

Blood tests usually include blood count, glucose, thyroid function, B12 and folate, calcium, kidney and liver function. Brain imaging (MRI or CT) is recommended at another center to exclude structural causes and to assess vascular disease or atrophy; in particular cases specialized examinations are performed. There is no single test that diagnoses dementia; the diagnosis rests on the clinical picture as a whole.

How they are treated and followed

Treatment depends on the cause. Reversible causes are corrected: treating depression, replacing B12 when it is deficient, correcting the thyroid, reviewing drugs, treating sleep apnea. In mild to moderate Alzheimer’s disease, drugs that slow symptoms can be used (cholinesterase inhibitors such as donepezil, rivastigmine, galantamine; memantine in more advanced stages). They do not cure the disease. The newer anti-amyloid antibodies are reserved for selected patients at a very early stage and require monitoring in specialized centers.

Prevention and risk reduction are a real part of treatment. Studies show that about 45% of dementia cases are linked to modifiable factors: untreated hearing and vision loss, hypertension, high LDL cholesterol, diabetes, obesity, smoking, excess alcohol, physical inactivity, depression, social isolation, head injury and air pollution. Control of blood pressure (target usually below 130/80 mmHg, i.e. “tension 13 over 8”, according to the case), of diabetes and lipids, regular physical activity, good sleep and social ties are the most concrete measures. There is no supplement that treats every memory disorder. Do not change medication without consultation.

What helps the family

Keep a clear daily routine, reminders for appointments (calendar, notes, alarms), and suitable supervision of medicines (weekly pill box) when needed. Discuss safety at home (gas, doors, getting up at night) and driving, which should be reviewed with the doctor. Physical activity, sleep and control of vascular factors are part of care. It is important to plan legal and financial matters early, while the patient can take part in decisions. Carers should also seek support for themselves. Regular check-ups, every 6 months to a year or sooner when the doctor considers it reasonable, follow the course.

Care at Tirana Polyclinic: we offer neurology consultation and interpretation of tests and imaging performed at other clinics. The assessment is coordinated with other specialties according to the cause.