The holidays are here and families are gathering to give thanks and celebrate. As relatives visit from near and far, some concerns may arise about older family members' memories. Perhaps your mother doesn't immediately recognize her cousin visiting from a few states away. Or Grandma confuses some of her grandchildren's' names. Maybe your elderly aunt tells you about her recent trip a few times without realizing that she's told you before.

I'm a geriatrician, and often these instances will result in a visit to my office. Here are some examples of concerns about patients I've seen, in their families' words:

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"We thought Mom was having some memory problems, but when we took her to her family doctor, he told us that her memory loss was just normal aging."

"My wife keeps asking me the same questions over and over. I took her to her doctor. He gave her some paper and pencil test and said she was fine."

"We thought Mom was fine until Dad died. Then we found that she wasn't eating enough or paying her bills. But her doctor won't refer her for an evaluation. We gave up on her doctor and set up this appointment."

By now you've realized I'm talking about the syndrome of dementia, the umbrella term for all the diseases that cause loss of cognitive abilities in adulthood. The most common causes are Alzheimer's disease and vascular dementia, resulting from multiple small strokes or one large one. Less common causes are frontotemporal dementia, Lewy body dementia and even rarer causes such as vitamin B12 deficiency, hypothyroidism and infections such as HIV.

Although the rarer causes of dementia pose a challenge for even an experienced practitioner, most patients present with typical symptoms that should not be difficult to diagnose. A typical patient with Alzheimer's disease will forget recent events, such as what they did yesterday, often called "short term memory loss." But as the disease progresses, longer term memories, such as their year of high school graduation, or the age they were when they married, will be lost. Affected persons may forget to pay bills; social graces may be lost as well. Demented patients' judgment is often affected, making them susceptible to scams and poor financial decisions. Unfortunately, almost always patients lack insight into their deficits and do not complain of memory loss. This can delay diagnosis, as relatives may be slow to recognize their problems.

But sometimes doctors present a barrier to diagnosis, as in the examples above. There are many causes, including lack of training and time to elicit the necessary history. Another is that, unlike most problems, the complaint of memory loss falls between specialties. Should the patient see their primary care physician, whose appointments may be limited to 15-minute slots? If a specialist's opinion is sought, which one is best? Should a neurologist see the patient? A psychiatrist? While physicians in both of these specialties have the necessary training, the typical neurologist and psychiatrist doesn't see a large number of patients with dementia and may miss it. Geriatricians are capable of evaluating memory loss, but frankly there aren't a lot of us.

If you have a family member with memory loss, how can you discover if the cause is dementia? Before seeing the doctor of your choice, I recommend that families complete a questionnaire that the Alzheimer's Association calls "10 Signs." The 10 Signs refer to the many cognitive domains affected in Alzheimer's disease and other causes of dementia, including calculation, problem solving, language and judgment. Not only does the form give examples of cognitive decline, but instances of normal aging as well. For example, a person with dementia may misplace items and may accuse others of stealing them. But misplacing objects occasionally and finding them later is normal. Families who complete this questionnaire will have the necessary information that should give a physician pause before dismissing a patient with dementia as having "normal aging."

There is now very good evidence that dementia appears to be decreasing in prevalence. But the diagnosis of dementia remains a clinical one, dependent on experienced physicians to nail down. While the right physician can pinpoint the diagnosis with 90 percent accuracy, it may take family members some effort to find that physician and convince him or her that their family member requires a thorough and appropriate evaluation.

Dr. James P. Richardson is chief of geriatric and palliative medicine at St. Agnes Hospital in Baltimore; his email is jrichard@stagnes.org.

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