Accurate diagnosis of an illness depends to about 60 percent on what the patient tells the doctor and what questions the doctor asks. A good physician also hears what is not being said and pursues it. If patient and doctor don’t speak the same language, misdiagnosis increases exponentially.
An area of medicine that concerns me in the older, ex-pat community is the assessment of cognitive impairment or dementia. This is one area of medical assessment that absolutely demands that doctor and patient are native speakers of the same language. Diagnosis of the dementias depends largely on both understanding and production of accurate language and its nuances. For example, in early Alzheimer disease, one of the signs is naming difficulty and a person may call a pencil a pen, or a jug a cup. These belong to the same semantic category, things you use for writing or things that hold liquids, but are not correct. Someone without a command of English, will miss these typical errors.
The Baby Boomers are now reaching the age at which there is a growing concern with the possible development of various diseases, among them, one of the dementias. It’s almost impossible to pick up a newspaper or magazine without reading about the “tidal wave” of dementia bearing down on us, in particular, Alzheimer disease. Well, the truth is this. Between 50 and 60 percent of people diagnosed as having Alzheimer disease, don’t have it. They may have some form of cognitive impairment, a different type of dementia, a condition that mimics dementia or a completely reversible condition and this occurs when both doctor and patient speak the same language. If they don’t, there is no hope for an accurate diagnosis.
The first category of misdiagnosis is conditions that can mimic dementia. The vital aspect of assessment of cognition most often omitted is a complete physical examination, including full assessment of vision and hearing. The reasons for this will become obvious.
One of the common conditions that mimic dementia is hypothyroidism or a sluggish thyroid. If the thyroid isn’t producing enough thyroid hormone, if affects multiple areas, including the brain. The person may be forgetful, feel depressed, irritable and appear to be in the early stages of a dementia. The warning here is that thyroid function can be regularized but it must be done by a qualified endocrinologist. The reason is that replacement of thyroid hormone is a very delicate process with a small variance between too much and not enough. The wrong dosage has been shown to actually promote the development of dementia so great care is required with close, ongoing monitoring. The same issues apply to people with an overactive thyroid and even more so when the parathyroid glands produce too much calcium. This last is so often missed as to be an outstanding danger for misdiagnosis, the tragedy being that all thyroid and parathyroid problems are treatable and the “dementias” reversible.
The next great imitator is hearing loss. A significant number of older individuals have impaired hearing and may either not be aware of it or deny it. It can look like a dementia. Research shows there are good reasons to seek hearing loss treatment sooner rather than later. People with uncorrected hearing loss report feelings of being anxious, depressed, paranoid, angry and insecure. They miss important information and find themselves isolated from family and friends.
Reduced stimulation to the ears and brain can actually impair the brain’s ability to recognize speech adequately. Once speech recognition deteriorates, it is only partially recoverable once hearing aids are in place, so it’s important to seek help before the secondary effects of hearing loss occur.
It’s the old “use it or lose it” concept. When you can’t hear what’s going on around you, it contributes to reduced mental sharpness and communication abilities. Using hearing aids early can help prevent other effects of hearing loss. But it’s unfortunately the case that many reject hearing aids because When I am assessing a patient for cognitive impairment, and I either know or suspect a hearing loss, I always use a voice amplifier so that I can be sure that the patient hears me accurately.
It’s not hard to identify when someone is having trouble hearing if he or she is constantly asking others to speak up or repeat themselves. Speaking in a very loud voice is an early clue. Turning up the volume until the windows rattle is pretty clearly due to hearing loss. .Forgetfulness is sometimes a symptom.. When the ability to communicate is disrupted by hearing loss, more of a person’s mental energy is spent trying to hear—leaving less mental energy available for other tasks—such as memory.
A hearing test is the first step in identifying hearing loss or ruling it out as a contributing cause to other behavioral changes. A qualified audiologist is the person to see for a full and complete hearing assessment.
Normal pressure hydrocephalus (NPH) is a rise in cerebrospinal fluid (CSF) in the brain that affects brain function. However, the pressure of the fluid is usually normal. Symptoms of NPH often begin slowly. There are three main symptoms of NPH :Changes in the way a person walks: difficulty when beginning to walk , feet held wider apart than normal, shuffling of the feet, unsteadiness. Slowing of mental function: forgetfulness, difficulty paying attention, apathy or low mood. These are also found in Parkinson disease but if we add problems controlling urine (urinary incontinence), and sometimes controlling stools (fecal incontinence) it is probably NPH which is treatable by surgery.
A few screening tests by a GP are completely inadequate for accurate identification of the true dementias and the false dementias. Expert assessment is essential although not always available but the absolute minimum requirement is that both patient and doctor speak the same language.