Dementia Misdiagnosis and Hearing Loss

By Bonnie O'Leary

July 2009

Editor: It's that time of year again! The start of Hearing Loss Convention Season! As is normally the case, HLAA kicks off the activity in June. Char and I didn't attend this year, but super reporters extraordinaire Cheryl Heppner and Bonnie O'Leary from NVRC will be providing detailed coverage of the activities.

More coverage of this great convention is at: http://www.hearinglossweb.com/res/hlorg/shhh/cn/2009/2009.htm

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I was especially interested in this educational session because of my own outreach work in retirement homes and assisted living facilities. Not long ago two former senior care executive directors told me, in confidence, that their communities had admitted residents diagnosed with dementia when, in fact, further evaluation revealed that they were profoundly hard of hearing. I continually wonder how often this happens around the country.

This presentation was given by Ms. Michael Bower, BA, ACC, who has spent 23 years in the field of long term care, primarily in nursing homes. She is known as a "Life Enrichment Consultant" which, in everyday parlance, is more widely known as an "Activity Director." Activity Directors are responsible for planning and providing leisure services and recreation to residents and/or participants in facilities for seniors.

What is Dementia?

The first part of Ms. Bower's program focused on dementia, citing some of the causes. Dementia is a symptom, not a diagnosis. It involves diminished cognitive capacity and can affect various kinds of cognition. It is caused by several diseases or conditions and, depending on the cause, can be progressive or reversible.

The most prevalent form, affecting 50% of those with dementia, is Alzheimer's. This disease is progressive and terminal. Currently there are medications such as Aricept and Lamenda that can slow it down, but there is no cure. The hereditary form of Alzheimer's can start in people who are in their 20s (pre-senile) and takes as little as 15 months to three years to become terminal. Late-onset Alzheimer's starts after the age of 60 (senile) and can last ten to 15 years. Many of us were surprised to learn that the term "senile" refers to age range, "pre-senile" being any age before 60.

What is Alzheimer's?

In Alzheimer's Disease, the brain forms plaques and tangles and it shrinks. There is a decrease in neurotransmitters. The disease progresses over time through various stages, including memory loss; loss of abstract thinking; poor judgment; lack of inhibitions; impaired decision-making; language and communication problems; behavior issues; disorientation to place, time, situation and people; mobility and movement disorders; altered reality; progressive inability to perform activities of daily living; eventual total dependence; withdrawal; and finally, death.

Ms. Bower explained that Alzheimer's Disease is "human development in reverse." During the course of the disease, the short-term memory is the first to go. The patient may not remember what happened in recent days or weeks. Immediate memory loss is the next stage, when the patient can't remember what happened in the last five minutes. Long-term memory is the last to go, at which point the patient becomes totally disoriented and entirely dependent. Often, patients withdraw to the fetal position before they die.

Lewy Body Disease

Often mistaken for Alzheimer's Disease, Lewy Body Disease frequently occurs as the dementia component associated with Parkinson's Disease. It is caused by proteins the brain which were discovered by Frederick Lewy in 1912 when he was examining brains of Parkinson's patients. This disease causes movement disorders and facial masking, it has negative reactions to psychoactive medications, and patients have more spontaneous aggressive behaviors. Also common are hallucinations and delusions. Lewy Body Disease is progressive and terminal.

Vascular Dementia

This form of dementia is caused by strokes or TIAs, Transient Ischemic Attacks which we refer to as "mini strokes." The progression of this dementia can be halted by preventing further TIA/stroke incidents. It may not respond well to psychotropic medications, and how it manifests itself depends on the areas of the brain that have been damaged.

Other Dementias

Other dementias include Human Mad Cow, Pick's Disease, HIV/AIDs dementia, alcohol and drug-abuse, Progressive Supranuclear Palsy (rare), Huntington's Chorea-Dominant Genetic, Ernicki-Korsakoff's Disease, vitamin deficiency-related disorders, and thyroid deficiency.

The Three "Ds" to Consider

Ms. Bower emphasized the importance of understanding the difference between the "Three Ds." These are: 1) Dementia, which is usually a slow, steady progression that's non-reversible; 2) Depression, which is usually related to a life circumstance, has ups and downs, and is generally treatable; and 3) Delirium, which has a rapid onset, fluctuates, is the result of physical illness, and needs immediate treatment.

Why People with Hearing Loss are at Risk for Misdiagnosis

In medical crisis situations, there can be a lot of pain, illness and fear, all of which lessen the hearing ability and can result in decreased ability to focus. If the onset of the medical condition is sudden, hearing aids can be left behind, and there are no assistive listening devices in an ambulance or the ER. If the medical condition renders the person unable to speak, the staff and EMTs won't know about the hearing loss. It is very possible for people with hearing loss to become frightened in these medical situations, be confused because they don't understand what is being said around them, respond (if they can) inappropriately to what is being asked of them or said to them, seem disoriented and "not with it." Many of these behaviors can be confused with cognitive decline. Ageism is also often a factor in medical situations where the assumption is if a person is older and confused, he or she has dementia, and there is a lot of ignorance among medical professionals about hearing loss.

Mini-Mental State Exam (MMSE)

When a patient seems confused or disoriented, the MMSE is given as a screening tool to establish level of cognition. It is well established and reliable, easy to administer, and often given without the knowledge of the patient. The MMSE includes many simple questions such as "What is the year?", "What is the date?", "What is the day?", "What town are we in?", "What is this building?" But successfully passing this exam depends on being able to hear and understand language. (Bonnie's note - I remember being asked very similar questions when coming out of anesthesia years ago, but I could answer them with my eyes closed because I could hear then. I could not do it now, it would all sound like gobbledegook.) Ms. Bower pointed out how easy it would be to fail the MMSE if the instructions and questions aren't understood and the patient has been so overwhelmed with his medical circumstances that he or she has not been able to communicate about his hearing loss.

Before it's an Emergency

Ms. Bower concluded her presentation by giving some recommendations about how to prepare for a possible medical emergency. First, educate your emergency personnel and your doctors. Ask your HLAA chapter to create or acquire personal hospital kits. Put signage INSIDE your home (e.g. "I'm hard of hearing") so EMTs can read it. Keep your family and friends informed. If you use assistive listening devices and hearing aids, keep them close by and in plain sight if you can. Otherwise be sure someone knows where you keep them. Let your neighbors know you have a hearing loss, and consider using a Medic Alert/Life Line ensuring that your hearing loss is on their records.

Ms. Bower has written a book which she hopes will be of use to Activities Directors across the country, alerting them to the possibilities of confusing dementia with hearing loss, and stressing the importance of providing good acoustical environments for seniors so they can participate more fully in the activities available to them. Social contact is vital to mental health, and "sensory deprivation" can actually lead to a form of dementia.

For more information, you can contact MABower@earthlink.net.

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