Last week, the family of Miki Berkovich revealed that he is living with dementia with Lewy bodies. Alongside the pain prompted by the disclosure, it highlighted one of the central problems in the field: the gap between the moment changes begin to appear in memory, language, orientation or behavior and the point at which a person is evaluated.
That gap matters more today than ever because, in some diseases, it is now possible to identify the process at an early stage and begin treatment that may slow its progression.
The confusion begins with the terminology itself. Cognitive decline, mild cognitive impairment, dementia and Alzheimer’s are not different names for the same condition, though in everyday conversation they are often used interchangeably.
“The language here is very confusing,” says Dr. Debbie Shapira, head of the geriatric department and a physician at the memory clinic at Shaare Zedek Medical Center. “There is cognitive decline, there is dementia and there is Alzheimer’s.”
Cognitive decline, she says, can affect different areas of thinking. “It is not just memory. It can be language or orientation.”
When is it no longer normal aging?
The starting point is the brain’s natural aging process. “From around age 25, we all experience a gradual, natural and normal decline in some of our cognitive abilities,” explains Dr. Ithamar Ganmore, director of the Advanced Alzheimer’s Disease Treatments and Cognitive Neurology Service at Sheba Medical Center. “Over time, we become cognitively slower and may also have more difficulty learning new technologies. Still, the most important feature of ‘normal aging’ is that functional independence is preserved.”
Dr. Ithamar Ganmore, neurologist, Sheba Medical Center Photo: Sheba Medical CenterShapira points to the common difficulty of recalling names. “Often you know the name, but you just cannot retrieve it. Slowness in general is something that comes with age,” she says.
Processing information may also take longer, and the ability to multitask or divide attention between tasks can weaken.
“Not every forgotten name or word means the beginning of dementia. Many things are normal as a person ages, and there is no need to see a doctor because of them.”
What should raise a red flag is a new and persistent change compared with a person’s previous abilities.
One of the clearest examples is impaired short-term memory, which can appear as repetition that did not exist before.
“For example, say you are talking to your father and during the conversation he keeps asking the same questions again and again, or tells the same story within the same conversation,” Shapira says. “That repetition, that impairment in short-term memory, is no longer something considered normal with age.”
The story of Miki Berkovich put a spotlight on dementia and the challenges faced by patients' relatives
(Photo: Tal Shahar )
Even when a decline goes beyond normal aging, however, it does not necessarily mean a person already has dementia.
“When someone begins to experience cognitive decline, meaning there is a change compared with their previous level and a decline beyond the norm, that is the stage we call mild cognitive impairment, or MCI,” Ganmore says.
“At this stage, the person uses different strategies to cope with the difficulties, such as notes, lists, a calendar and so on. Despite the difficulties, however, the person still maintains functional independence.”
Dr. Debbie Shapira Photo: Shaare Zedek Medical CenterThe transition from mild cognitive impairment to dementia is defined by the loss of that functional independence.
When cognitive decline begins to disrupt everyday activities and creates dependence on another person, it falls under the definition of dementia.
“The impairment can appear, for example, as difficulty using a phone or remembering to take medication,” Shapira says.
Dementia, however, does not necessarily describe someone who has completely lost the ability to function.
“When people hear the word ‘dementia,’ they imagine the severe, advanced stage. But in its early stages, dementia can be mild, and beyond dependence in a particular cognitive area, these people can still be functional,” Ganmore says.
“For example, a person with mild dementia may still be able to work, but their functional independence is impaired if, for instance, they do not know which medications they need to take or whether they have already taken them, and they cannot solve the problem with a strategy. They depend on someone else.”
Not every cognitive impairment is defined as dementia
(Photo: Shutterstock)
Only after the cognitive condition has been defined does the question arise of what is causing it.
Alzheimer’s, Shapira stresses, is not synonymous with dementia. It is one of several diseases that can cause it. “There are different diseases that lead to dementia. One of them is Alzheimer’s disease.”
Other causes can include cerebrovascular disease, dementia with Lewy bodies, frontotemporal dementia and other conditions.
The distinction is not merely semantic. Different diseases may begin with different symptoms, require different diagnostic workups and sometimes respond differently to treatment.
The question, then, is not only whether cognitive decline has occurred, but also what is causing it and at what stage it was detected.
Sometimes it begins with a visual problem
The difficulty is that in their early stages, these diseases do not always look the way the public expects.
In about 25% of cases, the first symptoms of Alzheimer’s disease are not the typical ones, such as memory decline. When a symptom does not fit the familiar image of dementia, it is easier to miss, especially in people who are still working, driving and leading active lives.
“Diseases that cause cognitive or behavioral impairment do not have to begin with a memory problem,” Ganmore says. “It can begin, as was described in Miki Berkovich’s case, with some type of visual disturbance, both in Alzheimer’s disease and in other conditions.
“In others, it can begin with a language disorder, such as difficulty retrieving words, constructing sentences or understanding what is being said. In some cases, the first change can be difficulty with calculations, trouble understanding how to get dressed or difficulty operating devices the person previously knew how to use, such as a cellphone, computer or other equipment.”
Sometimes, the first sign is not cognitive at all, but behavioral or related to personality.
“It can be newly inappropriate, impulsive or aggressive behavior that was not there before, or the opposite: withdrawal, reduced initiative or other features of apathy,” he says.
Emotional and behavioral changes such as depression, anxiety, impulsivity or indifference may appear alongside cognitive decline and can sometimes dominate the picture. But the person experiencing them is not always aware of what others have already noticed.
These “atypical” symptoms can appear in patients of any age, but they are more common among younger patients.
Alzheimer’s disease that develops before age 65 is defined as young-onset Alzheimer’s. In this group, presentations that begin with language, vision, orientation or executive-function problems are more common.
Ganmore says clinics are now seeing more people in their 50s and early 60s coming in for evaluation.
“That does not necessarily mean the disease has become more common at those ages,” he says. “We think the main reason is that people are reaching diagnosis at an earlier stage, one at which they would not have come in for evaluation in the past.”
He adds: “The current recommendation is that from age 50 onward, if the beginning of cognitive decline or new behavioral changes is noticed, people should see specialists in the field for diagnosis.
“Unlike in the past, today we have options for the early stages of Alzheimer’s disease. Because the new medications are intended for early-stage disease, it is important to reach diagnosis when symptoms begin.”
Looking for the disease’s fingerprint
Symptoms can indicate that something has changed, but they do not always reveal exactly what is happening in the brain.
Two people may arrive at a clinic with similar memory problems and still receive different diagnoses. The difference may lie, among other things, in the biological process occurring in the brain and the proteins accumulating there abnormally.
In Alzheimer’s disease, one of the key hallmarks is the buildup of a protein called amyloid-beta.
“One of the diagnostic revolutions is that we now know how to measure the protein that accumulates abnormally in the brain in Alzheimer’s disease,” Ganmore says.
“Diagnosis of Alzheimer’s biomarkers, reflecting abnormal levels of amyloid-beta in the brain, can now be performed using brain imaging, cerebrospinal fluid sampling or blood tests.”
The imaging he refers to is a dedicated amyloid PET scan, which can detect amyloid-beta accumulation in the brain. Cerebrospinal fluid testing looks for a characteristic pattern of proteins associated with the disease, while newer blood tests attempt to identify the same biological signature using a standard blood sample.
In May 2025, the U.S. Food and Drug Administration approved the first blood test intended to help diagnose Alzheimer’s disease. About a week ago, the FDA approved a second blood test for the disease, and this week approved a third.
“It is important to emphasize that Alzheimer’s biomarker tests are currently intended only for people with symptoms of cognitive decline at the level of MCI or dementia,” Ganmore says. “They are not intended as screening tests for people without symptoms or with only minimal symptoms.”
In dementia with Lewy bodies, the main protein that accumulates in the brain is alpha-synuclein.
In recent years, tests have been developed to detect tiny amounts of abnormally folded alpha-synuclein, including in cerebrospinal fluid, but their use is still largely in the research and development stage.
“This innovative alpha-synuclein test is still in its infancy and, unfortunately, is not available in Israel for routine clinical use,” Ganmore says.
When the family notices first
The decision to seek diagnosis is not always in the hands of the person experiencing the change.
Sometimes it is a spouse, children or other close relatives who first notice repetition, confusion, behavioral changes or difficulty performing tasks that were once routine.
“In principle, in our field, the process almost always includes both the patient and the family,” Ganmore says.
“In addition to the fact that functional impairment in patients also affects those around them, over time the patient gradually loses abilities and requires outside support — initially from the family and later, sometimes, from other caregivers or services.”
Lack of awareness of the change is not unusual and can itself be part of the medical condition.
“It is a very familiar problem,” Shapira says. “Family members often call me and say, ‘I see something happening with my husband and I’m worried.’ There are situations in which the patient has no awareness of the illness. Sometimes they do, but there are definitely cases in which they do not.”
In such situations, she says, direct confrontation or presenting the person with a list of mistakes can make them defensive and push them away from evaluation.
A better approach is to gently describe a concrete change that has been observed, express concern and suggest an evaluation without deciding in advance that it is dementia.
“Say gently: ‘I feel there has been a bit of a change. We often argue about whether I told you something and you did not notice, and I have noticed that maybe you missed something, and I’m a little worried,’” she suggests. “‘There may be a problem. Let’s check it out. Let’s try to see a doctor.’”
There should also be room for the possibility that the concern turns out to be unfounded.
“I say: It is worth getting checked. There are things we can do today, treatments we can try. Let’s do an evaluation and see what is going on. Maybe I’m wrong and there is no problem at all,” Shapira says.
The message is not “something is wrong with you,” but rather “we noticed a change and it is worth understanding what is behind it.”
Don't force the issue or get into a confrontation — instead, ask them to get checked to determine whether there is a problem
(Photo: Shutterstock)
When even that approach meets resistance, the evaluation can be framed as a family matter rather than something that singles out one person as ill.
“I have had families bring in both partners because one of them refused to come,” she says. “They told him: We have reached an age when we should be checked, and we are doing it together. That was a way to get the partner who needed the evaluation more than the other one to come in.”
At the clinic itself, family testimony does not replace assessment of the patient, but it can fill in details the patient does not remember or is unaware of.
“I first speak with the patient and then, in parallel, try to get information from the family member as well,” Shapira says.
Objective tests are then conducted to determine whether the difficulties described at home are also reflected in cognitive assessment.
The goal is not to win an argument or convince someone that they are ill, but to open the door to evaluation at a point when it is still possible to understand the source of the change and act.
Not a cure, but valuable time
The diagnostic revolution has not happened in isolation. It has developed alongside the arrival of the first drugs aimed at affecting the biological process of Alzheimer’s disease rather than merely easing symptoms.
It is important to stress that these drugs are intended only for early-stage Alzheimer’s disease after the presence of amyloid in the brain has been confirmed.
They are not intended for all types of dementia and are not treatments for dementia with Lewy bodies. Therefore, the discussion of these drugs should not be taken to mean that they are relevant to Berkovich’s condition.
“In terms of Alzheimer’s disease, there has been a revolution in drug treatment in recent years, with two medications: lecanemab and donanemab,” Ganmore says.
“These are drugs intended for the early stages of Alzheimer’s disease. They are antibodies that reach the brain and help clear amyloid-beta. This is a disease-modifying treatment, but only for Alzheimer’s disease.”
In the pivotal trial of lecanemab, the drug slowed cognitive and functional decline by about 27% over 18 months.
In the pivotal donanemab trial, decline was slowed by about 35% among patients with low or intermediate levels of tau protein and by about 22% across the study population as a whole.
Because the studies examined different populations and used different outcome measures, those figures should not be viewed as a direct comparison between the two drugs.
Medications can slow the progression of the disease, but they cannot cure it
(Photo: Shutterstock)
Ganmore does not dismiss the debate over the magnitude of the benefit.
“In most cases, the drugs do not cure or stop the disease, but slow its worsening. There is debate over whether the degree of slowing is sufficient,” he says.
“Still, because this involves severe functional impairment, to the point of loss of independence, affecting the patient, the family and ultimately the health system, every slowing and every delay in progression to the severe stages is meaningful.”
Both drugs reduced by 55% the progression from the early stages of the disease — MCI and mild dementia — to more advanced and severe stages, including moderate and severe dementia.
The treatments are not risk-free. They can cause swelling and tiny bleeds in the brain, a phenomenon that in most cases is detected on imaging and does not cause symptoms, but in rare cases can be serious. Careful patient selection, preliminary testing and MRI monitoring are therefore required.
What is still in our hands?
Early diagnosis and the new drugs are relevant to people who have already developed symptoms and meet the criteria for treatment.
But alongside the question of how to treat disease is a broader one: Can the risk of dementia be reduced in advance, or at least can its onset be delayed? The answer is not a guarantee, but there is certainly room for action.
According to a 2024 report by the Lancet Commission, addressing 14 modifiable risk factors could prevent or delay nearly half of dementia cases at the population level.
That does not mean that someone who follows every recommendation will be protected from the disease, but it does mean that risk is not determined solely by age and genetics.
“We now know of a fairly long list of risk factors that preventive medicine can address in order to delay the age at which dementia appears,” Shapira says. “These are things that are in our hands.”
At the top of her list is physical activity. “The more physically active you are, the greater your chances of delaying dementia,” she says.
There is no need to become a professional athlete. The recommendation is to reduce inactivity as much as possible and incorporate regular movement into daily life, according to age and health status.
Many dementia risk factors are also familiar from cardiovascular medicine.
“Everything that helps prevent a heart attack or stroke also helps prevent dementia,” Shapira says. “That includes controlling blood pressure, cholesterol and blood sugar and maintaining a healthy weight. Smoking, of course, is also a factor.”
In other words, what protects the blood vessels over the years may also help preserve cognitive function.
But brain health is not limited to medical measurements. Loneliness, the level of social engagement and continued mental activity throughout life also play a role.
“When you are lonely, not in contact with anyone and only with yourself, the likelihood that dementia will appear earlier is higher,” Shapira says.
Learning and engaging in activities that challenge the mind, she says, may contribute to “cognitive reserve,” meaning the brain’s ability to cope over time with changes and damage.
Decline in the senses is also not something that should necessarily be accepted as an unavoidable part of aging.
“Hearing loss can cause dementia to appear at an earlier age,” Shapira says. “Vision is also discussed today, and it is important to preserve visual acuity as much as possible.”
Accordingly, World Health Organization guidance includes treatment of hearing impairment, maintaining social connections and managing cardiovascular risk factors.
Shapira also stresses the importance of recognizing and treating depression. “The chance that dementia will appear at a younger age is higher in someone who suffers from depression and is untreated than in someone receiving psychological or drug treatment,” she says.
The relationship between depression and dementia is complex. Sometimes depression may be a risk factor, while at other times it may be one of the early signs of a process that has already begun. Either way, there is no reason to ignore it.
Berkovich’s story, involving one of Israel’s greatest athletes, also illustrates the limits of prevention.
“Even if there is already damage in the brain that can cause dementia, all these things can delay the age at which it appears,” Shapira says.
“If you delay it from age 70 to 80, and from 80 to 90, that is an advantage, and you never know at what age dementia might have appeared had you not exercised.
“With dementia, that kind of delay is not just a number on a timeline. It can mean additional years of independence, relationships and the ability to manage your own life.”
A revolution that still does not reach everyone
Even after all the progress made over the years, access to early diagnosis and treatment is still not available to everyone.
“Early diagnosis requires access to specialist physicians and advanced testing, and the new treatments require careful patient selection and prolonged monitoring,” Ganmore says.
In Israel’s public health system, he says, those resources remain limited. “There is a shortage of specialists in the field, who are essential both at the diagnosis stage and during treatment,” he says.
“There is also a shortage of allied health professionals who are so important in helping patients and families cope with these conditions — psychologists, occupational therapists, speech therapists, social workers, specialized nursing teams, day centers and more.
“Because of the limited availability of resources, along with insufficient public and government support, access to treatment is severely lacking and the burden on families is increasing.”
The gap is particularly striking with the new Alzheimer’s drugs. “We very much hope they will be included in the national health basket. Right now, they are not covered and they are expensive,” Ganmore says.
“Most people receiving them today have private insurance with coverage for medications not included in the basket. Even patients with private insurance still have to pay significant sums for the day-hospital admissions and MRI scans needed for treatment, and those are usually not covered by private insurance.”
Most of the tests required to determine eligibility for lecanemab and to monitor treatment are also currently not covered by the national health basket.
In Israel, resources for early diagnosis and treatment remain limited; illustration
(Photo: Shutterstock)
The result is a situation in which the therapeutic window has opened, but not everyone who may be eligible for treatment can pass through it.
For Ganmore, expanding access is not only a question of equality between patients, but also a public interest.
“This is a very common condition that affects many patients,” he says. “We believe increasing access would benefit everyone: patients, families and the health system.”
The shortage goes beyond medication. Dementia is a medical, emotional, functional and financial challenge that can last for years, and family members are often required to gradually become the primary caregivers.
In the absence of sufficient public support, some of that assistance is currently provided by nonprofit organizations.
“There are various organizations that today fill the vacuum created by the lack of public services,” Ganmore says.
Among them are EMDA, which provides counseling, guidance and support groups for families; Ezer Mizion’s Tzipora Fried Center, which assists with emotional coping and access to rights and benefits; and Melabev, which provides community services for people living with dementia and their families.
Their work is essential, but it cannot replace a broad, equitable and accessible public system.