Personality Change May Be Early Sign of Dementia, Experts Say
“Has the person become agitated, aggressive, irritable, or temperamental?” the questionnaire asks. “Does she/he have unrealistic beliefs about her/his power, wealth or skills?”
Or maybe another kind of personality change has happened: “Does she/he no longer care about anything?”
If the answer is yes to one of these questions — or others on a new checklist — and the personality or behavior change has lasted for months, it could indicate a very early stage of dementia, according to a group of neuropsychiatrists and Alzheimer’s experts.
They are proposing the creation of a new diagnosis: mild behavioral impairment. The idea is to recognize and measure something that some experts say is often overlooked: Sharp changes in mood and behavior may precede the memory and thinking problems of dementia.
这些学者在提倡一种新的诊断类别——轻度行为障碍(mild behavioral impairment, M.B.I.)，旨在辨认与测量某些专家认为常遭忽视的面向：心情与行为的急剧变化，可能在失智症造成的记忆与思考困难之前出现。
The group made the proposal on Sunday at the Alzheimer’s Association International Conference in Toronto, and presented a 34-question checklist that may one day be used to identify people at greater risk for Alzheimer’s.
该研究团队上周日于多伦多的阿尔茨海默氏症国际年会(Alzheimer's Association International Conference)发表了这份提案，并提出一个列有34个问题的检查清单。或许这份清单有天能用来识别较易罹患阿尔茨海默氏症的人。
“I think we do need something like this,” said Nina Silverberg, the director of the Alzheimer’s Disease Centers program at the National Institute on Aging, who was not involved in creating the checklist or the proposed new diagnosis.
“我认为这样的诊断工具确实有需要，”在美国国家老龄化研究所(National Institute on Aging)主持阿尔茨海默氏症中心计划(Alzheimer's Disease Centers program)的妮娜‧席维伯格(Nina Silverberg)表示。她并未参与这份检查清单的设计或提出这个新诊断类别。
“Most people think of Alzheimer’s as primarily a memory disorder, but we do know from years of research that it also can start as a behavioral issue.”
Under the proposal, mild behavioral impairment (M.B.I.) would be a clinical designation preceding mild cognitive impairment (M.C.I.), a diagnosis created more than a decade ago to describe people experiencing some cognitive problems but who can still perform most daily functions.
这份提案指出，临床上应该先进行轻度行为障碍诊断，再进行轻度认知障碍(mild cognitive impairment, M.C.I.)诊断。轻度认知障碍是十多年前创造出来的诊断类别，用来描述有些人有点认知问题，但日常生活功能大抵正常。
Dr. Zahinoor Ismail, a neuropsychiatrist at the University of Calgary and member of the group proposing the new diagnosis, said studies and anecdotes suggested that emotional and behavioral changes were “a stealth symptom,” part of the dementia disease process, not separate from it.
札希努‧伊斯梅尔(Zahinoor Ismail)博士是加拿大卡尔加里大学(University of Calgary)的神经心理学家，也是提出这个新诊断类别的研究团队成员。他表示，各项研究与生活轶事都表明，情绪与行为的转变是”神不知鬼不觉的征候”，属于失智症发展过程，不应与失智症分开视之。
Whatever is eroding memory and thinking skills in the dementia process may also affect the brain’s systems of emotional regulation and self-control, he said.
If two people have mild cognitive impairment, the one with mood or behavior changes develops full-blown dementia faster, he said. Alzheimer’s patients with those symptoms “do much worse over time”; after death, autopsies have shown they had more brain damage.
Of course, not everyone experiencing mood swings with age is suffering warning signs of dementia. Dr. Ismail emphasized that, to be considered M.B.I., a symptom should have lasted for at least six months and be “not just a blip in behavior, but a fundamental change.”
Still, some experts worry that naming and screening for such an early-stage syndrome might end up categorizing large numbers of people, making some of them concerned they will develop Alzheimer’s when there are not yet effective treatments for the disease.
“There’s the potential benefit of early diagnosis, identifying people more likely to decline,” said Dr. Kenneth Langa, a professor of internal medicine at the University of Michigan. But “the flip side is overdiagnosis, labeling someone and getting people in the clinical cascade, where you start doing the test and people start doing more brain imaging and being at the doctor’s more and getting more concerned.
“早期诊断、辨认出那些更可能患病的人或许有好处，”芝加哥大学(University of Michigan)内科教授肯尼斯‧兰加(Kenneth Langa)博士表示。不过“从另一面来看，这也是过度诊断、给人贴标签、让人陷入没完没了的临床程序。当你开始做检测，民众就要开始做更多脑部显影扫描、更常看医生，也会产生更多担心”。
“If it becomes a routine practice, that’s a huge amount of dollars.”
Dr. Langa, who has written about M.C.I., cited the experience with that designation. Many people given an M.C.I. diagnosis do not develop full-blown dementia even a decade later, and as many as 20 percent have later been deemed cognitively normal, he said.
That could be because on the day they were screened, their cognitive function was lower than usual, possibly a result of stress or medications they were taking for other conditions.
“That’s one of the things that makes me think twice” about creating M.B.I., said Dr. Langa, who recommended the checklist be tested by researchers before doctors began using it.
Others are more enthusiastic.
“We have to improve our ability to identify people at risk,” said Arthur Toga, a neuroscientist at University of Southern California. Eventually “there will be an effective treatment,” he said, “and there’s too much unknown about this disease anyway.”
“我们必须提升辨识风险族群的能力，”南加州大学(University of Southern California)的神经学家阿瑟‧托加(Arthur Toga)表示。假以时日，“一定会出现有效治疗手段，”他说道。“毕竟，这种病有太多未知之处了。”
Dr. Toga said that his mother exhibited frustration and other emotional changes in her 70s, years before she developed Alzheimer’s. He believes her moods stemmed from dismay felt by his mother, a retired teacher, while trying to hide something family members had not yet noticed: “her ever decreasing cognitive capacity with words.”
Indeed, Dr. Langa and others said, memory tests are not always able to detect early problems because some people, especially highly educated ones, may be skilled enough at taking tests that their scores do not reflect the full extent of their cognitive slippage.
Dr. Mary Ganguli, a professor of psychiatry, neurology and epidemiology at the University of Pittsburgh, said people often came in reporting that they or a family member had stopped doing something they always enjoyed, like baking a certain Thanksgiving dessert or tinkering with the lawn mower in springtime.
玛莉‧冈古力(Mary Ganguli)博士是匹兹堡大学(University of Pittsburgh)的精神病学、神经病学和流行病学教授，她表示人们常在就诊时表示，自己或某位家人不再从事他们向来喜爱的某项活动了，像是烘焙某种感恩节点心，或是春天的时候对除草机修修弄弄。
Even the patient may not know why, she said. They may be uninterested in the activity because “they couldn’t figure out how to do it anymore.”
Usually, when Dr. Ganguli asks if the patient is having trouble remembering things, “They will say, ‘Yes, but it’s not the biggest problem,’” she said. “But if I assess them, I find memory problems.”
Some experts supporting the new diagnosis said that unlike most cognitive problems, some mood and behavior symptoms could be treated with therapy and medication. “We can make them sleep better, we can take the edge off depression, we can help the family learn how to manage the problems,” Dr. Ganguli said.
Dr. Ismail said apathy was a common symptom, but he has seen starker changes. One patient in her 70s became so sexually uninhibited, she “went from prude to promiscuous,” he said. Another, a law-abiding 67-year-old woman, suddenly “started smoking crack.” Both later developed dementia.
Mood and behavior changes have long been recognized as early-warning signs of frontotemporal dementia, which accounts for about 10 percent of dementias.
Palmer Posvar, a patient of Dr. Ganguli’s, was in her 50s when she started taking food off other people’s plates, asking to borrow money from friends and trying to pawn heirloom jewelry, said her husband, Wesley. At 54, she was found to have frontotemporal dementia. Now 64, Mrs. Posvar can no longer speak and she falls so frequently that she was recently moved from their house in Fox Chapel, Pa., to a nursing home.
Still, “early diagnosis is a double-edged sword,” Mr. Posvar said when asked about creating a mild behavioral impairment category.
The upside is that “there are medications which help manage mood and behavior,” and clinical trials that these patients might qualify for, he said. But “does that become part of your health record that’s accessible by insurance companies” or employers, he wondered.
“And do you really want to know? Because there’s no cure yet.”
Some experts said they believed the benefits of the new diagnosis outweighed the drawbacks.
“We should not be ignoring them, waiting for the cognitive manifestations to appear,” Dr. Ganguli said, “because we may be missing the opportunity.”