One of the most common concerns and complaints of older individuals, and often the focus of concern of families, comes under the heading of “confusion and forgetfulness.” These two terms are often used together, but this is a misnomer that may lead to problems in terms of understanding what might be happening and how to do a proper and necessary assessment.
By Dr. Michael Gordon
All of us at some point in our lives experience what might be called confusion, which is to say that we “mix up” one experience or set of facts with another, or mistake one person for another or one event with another. Getting lost while driving might be construed as an experience of confusion, depending on the circumstances. Believing that a destination is east of a street rather than west could occur even in the most cognitively intact person under certain conditions.
When individuals and their families talk about confusion, this is worrisome. It usually means that, in what would otherwise be normal and familiar situations, the person of concern—often a spouse or a parent—is constantly mixing up very ordinary and fairly self-evident processes or activities. Usually the person is not able to self-correct, or does not have real insight as to what is happening. People could be considered truly “confused” if they can no longer use a telephone or the stove they have been using for years, or have problems identifying people very close to them, or get easily lost in places of great familiarity.
Forgetfulness is somewhat different. It does not mean occasionally forgetting where one left one’s keys or purse. Many forget whether we locked the car when we left it and so we end up going back to check, or confirm that someone else locked it, or use the remote automobile door lock, which has been a boon.
The kind of forgetfulness that is of concern is that which results in a person being unable to recall something that happened even moments before. It is the forgetfulness that has someone often asking the same question over and over again. It is the missing of important appointments, of constantly looking to another source to confirm what they were supposed to do or where they were supposed to be. The person in question is often unaware of this
growing deficiency which often leads to conflicts with their loved ones.
When the symptoms become profound enough, usually a family member seeks advice from a physician. This should entail a proper assessment of the person’s total medical condition as well as what is often called a cognitive assessment: a series of questions that assess different domains of cognition including memory, spatial skills, basic calculations, word generation and clock drawing. For all of these activities, there is a long-established basis of what is within the normal range for people at different ages with different degrees of education.
If problems are found, it is then the professional role of the physician to try and define the nature of the cognitive problem and then decide on potential possibilities for therapeutic intervention. These could range from eliminating medications that might be promoting the symptoms (such as sleeping medications), or treating underlying medical conditions that might aggravate the symptoms (for example, clinical depression). Medications are available that in some individuals have been shown to ameliorate, even if not cure, the causative medical condition; these may be administered and the impact evaluated over a period of time.
The physician may ultimately categorize the condition within the wide definition of dementia, which among other conditions includes Alzheimer’s, or blood vessel disease affecting the brain. It may not always be possible to define the exact cause, but the likely causes are usually evident from a thorough medical evaluation.
Dr. Michael Gordon is a geriatric medicine consultant to Palliative Care at Baycrest Geriatric Health Care System.