Forgetting a name or where the car keys are is often described as "it must be dementia," and that is how most people perceive the neurodegenerative process, but as a psychiatrist, I know the secret. The Diagnostic and Statistical Manual of Mental Disorders – DSM-5, in its latest edition, says loss of memory is just part of the story of dementia and is sometimes not even its earliest or most noticeable symptom. According to the DSM, dementia can be diagnosed according to other symptoms such as behavioral changes.
Dementia's early symptoms can exhibit in unexpected ways that are sometimes mistakenly explained and therefore lead to a wrong diagnosis and delayed intervention.
An article recently published in the New York Times highlighted symptoms other than memory loss, including unexplained personality changes and disturbed sleep patterns. These appear often years before a decline in memory is observed. From the psychiatric perspective, they are easily mistaken for depression, anxiety or even late bipolar disorder.
Early symptoms of dementia can appear as common psychiatric conditions such as short temper, impulsiveness or social isolation and therefore are misinterpreted. Patients with frontotemporal degeneration (FTD), especially, may exhibit inappropriate social behavior, like the uncle who suddenly hits on the girls in the family or the grandmother who uncharacteristically and inappropriately begins to tell rude jokes.
Those patients may also present with a loss of empathy that could lead to offensive behavior toward others or rash financial decisions.
During my years in practice, I encountered patients who were diagnosed with depression after withdrawing from social interaction or exhibiting indifference to others. But further inspection revealed that their executive function was impaired, and they struggled with planning and decision making. These cognitive difficulties indicated a neurodegenerative process as the primary cause of the condition.
Disrupted sleep
Disruption to sleep is another red flag. While sleep disorders are common in advanced age, dramatic changes to sleep patterns, such as waking up repeatedly at 3 a.m. or feeling overly fatigued during the day, could indicate neurological changes.
For example, Dementia with Lewy bodies (DLB) is notorious for its impact on REM sleep, causing patients to act out their dreams often by violent means. This is often mistaken for Post-Traumatic Stress Disorder (PTSD).
Financial mistakes
The wrong financial decisions can be early warning signs of cognitive decline, even before significant memory loss appears. Patients can begin missing payments, may begin impulsive shopping, or be susceptible to fraud that in the past would have been easily detected by them. This happens when the dementia affects areas of the brain responsible for judgment, risk assessments and impulse control.
Dr. Oren Tene Photo: Tal GivoniBehind the wheel
Driving is a cognitive task that can also indicate early signs of dementia. Missing red lights, sudden stops, or disorientation even in familiar settings could indicate a decline in executive function or in motor perception. While older drivers are usually more careful, patients with dementia may take more risks.
I recommend that families pay attention to near-miss accidents, excessive hesitation or difficulty in night driving that could be early warning signs of a cognitive decline.
Early detection
The challenge in an early diagnosis of dementia is that the signs are often subtle and attributed to old age, stress or other mental states. As a psychiatrist, I try to maintain a holistic approach that considers cognitive, emotional and behavioral changes rather than focusing just on memory loss.
Errors in judgment, changing sleep patterns, changes in personality and behavior are all reasons to seek medical evaluation. Early detection allows for better planning, access to new treatments and the ability to maintain a safe quality of life for more extensive periods of time.
Dementia is more than memory loss; it is a gradual decline in the brain's ability to regulate emotions, control behavior and make proper decisions. Early signs are the key to an early diagnosis and treatment.
Dr. Oren Tene is chair of the Psychiatric Wing at the Tel Aviv Sourasky Medical Center – Ichilov Hospital