Dementia Stages Explained: What Families Should Expect at Every Step

Did you know that difficulties with memory and cognition are nearly as ubiquitous as the experience of aging itself? Research has shown that nearly two-thirds of adults over the age of 70 will experience some degree of cognitive decline during elderhood. Yet only about 10-15% of this cohort experiences dementia. There is, in fact, quite a broad spectrum of cognitive concerns, which extends from changes associated with normal aging, to “mild cognitive impairment,” all the way to dementia of varying stages. The breadth of this spectrum can lead to confusion among older adults, caregivers, and families alike. When should cognitive symptoms concern us? At what point should I worry about myself or my loved one?

How Dementia and Cognitive Impairment Are Diagnosed

Unlike many if not most medical conditions and diagnoses, there is no simple blood test or imaging study that provides a definitive diagnosis of cognitive impairment. It takes time and expertise to offer what in medical language is often referred to as a “clinical diagnosis,” that is, a diagnosis made through clinical judgment (not just using medical technologies), taking all possible information into account. Therefore, if there is concern for memory or cognitive changes, the first step is to go see your primary care provider (PCP).

What to Expect at a Cognitive Evaluation

It is important to know that some PCPs are comfortable diagnosing cognitive impairment, but not all are. There may be some variation in what a PCP has to offer in their clinic, and some may prefer a more extensive visit with a geriatrician or a memory neurologist. At minimum, you or your loved one should have:

1. An extended discussion about memory and cognitive symptoms, as well as any mood symptoms that might be present. Sometimes, mood symptoms can masquerade as a memory problem, and a thorough assessment of mood and sleep is therefore essential.
2. A cognitive screening test. This is typically either a Mini Mental Status Exam (MMSE) or a Montreal Cognitive Assessment (MoCA). These tests often take about 10 minutes to administer in the clinic.
3. An assessment of “global function.” This involves evaluating how independently someone can perform daily activities like managing finances, managing medications, driving, using the telephone, or managing their own hygiene (to name a few).

Your PCP, geriatrician, or neurologist may feel that additional evaluations are necessary, for example imaging of the brain, or some basic lab work. These must, however, be interpreted against the background of the above three components.

The Key Questions That Determine Dementia Stage

There is a lot of misinformation out there about cognitive impairment and dementia. It can be challenging to sort out what is happening. But here are the key questions that your health care team must answer:

• Is there objective evidence of impairment on a screening cognitive test – to match the patient’s subjective concerns?
• Are significant mood or sleep issues, medications, or other medical problems impacting the patient’s cognition?
• Is the patient’s global function impacted by this impairment?

Understanding the Spectrum: Normal Aging, MCI, and Dementia

Understanding where our loved ones are along the spectrum of cognitive decline can help us build and maintain strong care networks around them. Below is a table that outlines the basic differences between normal cognitive aging, mild cognitive impairment, and dementia.