Recognition of Dementia: Discovering the Silent Epidemic

Is there an experienced clinician who has not been surprised by a patient who turned out to be demented? Most persons who see older patients will admit to having missed dementia more than once. I can still vividly recall an 81-year-old, relatively robust patient I had seen regularly for more than 10 years who developed persistent epigastric pain and weight loss. After an extensive negative evaluation focusing on the possibility of pancreatic cancer, I was surprised to discover after 2 months of frequent visits that the patient was disoriented, had probably been demented for at least 6 months, and most likely had been perseverating on this symptom. The experience of individual clinicians is reflected in a literature more than 2 decades old that emphasizes under-recognition of dementia.1 A paper by Roca and colleagues described underrecognition on a Johns Hopkins inpatient service and has been used to raise awareness in internal medicine.2 The paper by Froehlich et al.3 in this issue of JAGS cites more recent papers.4–6 That the phenomenon of underrecognition is widespread is evidenced by epidemiologic surveys. Investigators in the well known East Boston study7 stated that the vast majority of community-based cases were unrecognized.8 A more recent paper9 from the Honolulu Asia Aging Study emphasized the frequency and characteristics of silent dementia among older Japanese-American men. Among 101 noninstitutionalized men, 21% of family informants failed to recognized a problem with memory among subjects subsequently found to be demented, and 53% of the subjects whose family members did recognize a memory problem did not receive a medical evaluation for the problem. The Honolulu findings are similar in magnitude to those of Callahan et al.,10 who reported that 76% of subjects found at screening to have moderate to severe dementia were not noted be demented based on chart review. These and other papers confirm that as we approach the millennium, dementia in clinical practice remains, to a considerable extent, the silent epidemic. This phrase was used in 1982 by Peck, Benson et al.11 in a seminal paper that focused attention on dementing illnesses as common but largely unrecognized. The aging of our population then, and to an even greater extent now, has led to a growing public health burden, caused by the dementias, that can truly be characterized as a silent epidemic. The silence persists despite increased publicity about Alzheimer's Disease, including the public announcement of President Reagan's diagnosis of Alzheimer's Disease. Traditionally, medicine has focused on the importance of recognition of dementia primarily to allow prompt treatment of reversible causes.9,11 I believe this emphasis is misplaced, especially given the infrequency of truly reversible dementias.12,13 There are more immediate, practical considerations. For practitioners, failure to appreciate impairment in memory and judgment creates a barrier that makes effective patient care difficult, if not impossible. Compliance with treatments, even simple medication regimens, and follow-up will likely be difficult for patients with undetected dementia. Patients with dementia cannot be relied on to report symptoms and are thus at risk of having undetected (and treatable) medical problems.13 For patients and families, safety and security are always an issue. Accidents are almost certainly more common among demented older people. People with dementia are twice as likely as nondemented persons to have automobile accidents.14 Another problem is victimization. We do not have accurate estimates of the frequency with which unprotected older people with dementia fall prey to unscrupulous persons who take advantage of their vulnerability for financial gain. However, our own experience in community-based screening suggests that this is not infrequent. Finally, continued neglect of a progressive dementia in an isolated older person will often lead to a crisis situation characterized by devastation of a person's health and living situation. What is the solution, or why do we have such a problem? First, providers must realize that patients with cognitive impairment attributable to dementia cannot be expected to report their impairment.9 Although some persons do have insight, many persons with early symptoms do not. Memory complaints are more likely to correlate with depression than performance on tests of cognitive function.15 Second, the Honolulu study demonstrates that clinicians cannot rely on family members for reliable reports of symptoms of dementia.9 Although family members and informants may be very helpful when questioned specifically about cognitive dysfunction, many do not consider symptoms of early dementia abnormal, and most who recognize the symptoms do not seek medical care for them.9 See also p 1506 The solution then rests with the clinician. A clinician needs a good appreciation of how frequent dementia is. Although there is controversy about precise prevalence rates of dementia, and these rates likely vary in different populations, the syndrome of dementia becomes common in the late 70s and, by the mid-80s, likely affects about 30 to 35% of persons.16 Rates continue to increase into old age.17 Given these rates, all clinicians should probably begin to question routinely whether a person older than age 75 shows evidence of dementia. Simple screening tests are needed to allow clinicians to help answer the question of whether a person might be demented.3 The recent availability of symptomatic treatment for Alzheimer's Disease will likely increase interest in recognition of dementia. However, the ultimate responsibility will fall to the clinician. The results of improved recognition will predictably benefit patients and families. It will also make medical care more effective.