Signs of Dementia: When Patients Should Seek Specialist Assessment

Dementia, by contrast, involves a progressive decline in one or more cognitive domains, including:

• Memory
• Language
• Attention
• Executive function
• Visuospatial ability or social cognition, that is severe enough to represent a meaningful departure from the person’s previous level of functioning and affects their ability to manage daily activities [6].

The distinction is not always sharp in the earliest stages, which is precisely why specialist assessment is valuable, because it provides the clinical rigour needed to determine whether what is being experienced falls within normal variation or represents something that warrants further investigation and monitoring. It is also important to understand that cognitive decline is not always dementia. Conditions like anxiety, thyroid dysfunction, vitamin B12 deficiency, sleep apnoea, urinary tract infections and medication side effects can all produce symptoms that closely resemble dementia. Many of those are entirely treatable [7].

A thorough specialist assessment will systematically consider and exclude these alternatives before arriving at a diagnosis, which means that seeking assessment is not the same as receiving a dementia diagnosis, and the fear of one should never be allowed to prevent the other.

Memory and Learning Difficulties

Memory impairment is the most widely recognised early sign of dementia, and in Alzheimer’s disease, the most common form, it is typically the first domain to be affected [8]. However, not all memory difficulties are the same, and understanding the distinction between the kinds of forgetting that are part of normal life and those that may signal something more serious is important.

The type of memory most commonly affected in early Alzheimer’s disease is episodic memory, the ability to store and retrieve specific recent experiences and events [9]. A person in the early stages may forget conversations that took place earlier the same day, repeatedly ask the same questions without awareness of having asked them before, lose track of recent news or events that would previously have registered clearly, or struggle to recall what they did yesterday in any meaningful detail.

This is distinctively different from forgetting where the car keys are, occasionally losing the thread of a conversation, or being unable to recall the name of a friend. These are familiar experiences for most people across a wide age range and, in isolation, are not cause for clinical concern. The distinguishing features of dementia-related memory impairment are its consistency, its progressiveness and the degree to which it affects functioning, rather than the simple fact of forgetting.

In some forms of dementia, memory may be relatively preserved in the early stages while other cognitive domains are primarily affected. This is particularly true of frontotemporal dementia, posterior cortical atrophy and the primary progressive aphasias, which is why memory difficulty alone neither confirms nor excludes a dementia diagnosis, and why comprehensive assessment across multiple cognitive domains is essential [10].

Language and Communication Changes

Difficulties with language are among the most important and sometimes the most distressing early signs of dementia, particularly in conditions that primarily affect the language networks of the brain. Word-finding difficulty is a common early symptom across several dementia subtypes. A person may pause mid-sentence while searching for a word that was previously automatic, substitute a related but incorrect word, describe objects by their function rather than their name, or use increasingly vague language [11].

In the primary progressive aphasias, language difficulties are the defining early feature, emerging before memory or other cognitive domains are significantly affected. Changes in written communication may also be noticed, with emails or messages becoming shorter, less coherent or more error-prone than previously. Difficulties following complex conversations, keeping up with television programmes that require sustained attention to plot, or understanding humour and figurative language may also emerge [12]. 

For people who work in roles requiring high levels of verbal or written communication, these changes may be noticed by colleagues before the individual themselves fully acknowledges them.

Personality and Behavioural Changes

Changes in personality and behaviour are among the most diagnostically significant early signs of dementia, and among the most difficult for families to make sense of. This is because they can appear without any obvious cognitive explanation and may initially be attributed to stress, relationship difficulties or mood disorders. Frontotemporal dementia, in particular, frequently presents with behavioural changes as the primary early feature. A person who was previously warm, considerate and socially aware may become disinhibited, making inappropriate comments or acting impulsively in social situations [13].

Empathy may diminish noticeably, with the individual appearing less responsive to the emotional needs of those around them. Apathy is another common early feature, presenting as a marked reduction in motivation, initiative and engagement with activities and relationships that were previously important. These changes are driven by neurodegeneration in the frontal and temporal lobes, which govern social behaviour, emotional regulation and personality, rather than by a deliberate shift in character [14].

Understanding this distinction is important both for families trying to make sense of what they are observing and for clinicians who may otherwise attribute behavioural changes to psychiatric causes without exploring neurological ones. Increased anxiety, irritability or emotional lability may also emerge in early dementia across several subtypes, sometimes representing a psychological response to the experience of cognitive change, and sometimes reflecting the neurological changes directly [15].

Executive Function and Everyday Difficulties

Executive function, the set of higher-order cognitive processes that govern planning, organisation, problem-solving, decision-making and cognitive flexibility, is affected in the majority of dementia syndromes and often represents one of the earliest areas of practical difficulty in daily life [16]. A person experiencing executive dysfunction may struggle to manage tasks that were previously automatic, such as planning and cooking a meal, managing household finances, organising a schedule or following a complex set of instructions. 

They may find it increasingly difficult to adapt when plans change unexpectedly, to manage competing demands simultaneously, or to make decisions that previously required little conscious effort. In a working context, these difficulties often manifest as declining performance in roles that previously presented no challenge. Projects may be left incomplete, errors may increase, and the ability to manage complex or multi-stage tasks may deteriorate noticeably [17]. 

As with other early dementia signs, these changes are most clinically significant when they represent a clear departure from the individual’s previous level of functioning and persist or worsen over time.

Disorientation and Visuospatial Difficulties

Becoming confused about time, date or place is a well-recognised feature of dementia that tends to become more pronounced as the condition progresses, but can emerge in subtle ways in the early stages [18]. A person may lose track of what day it is with unusual frequency, become confused about the sequence of recent events, or find that familiar environments feel less intuitively navigable than they previously did.

Visuospatial difficulties, which affect the ability to perceive and interpret spatial relationships, are particularly associated with posterior cortical atrophy, a variant of Alzheimer’s disease with a younger average age of onset [19]. A person affected may find driving increasingly difficult, struggle to judge distances when parking or navigating junctions, become lost in environments they know well, or experience difficulty with tasks such as reading, recognising faces or interpreting complex visual scenes.

These difficulties are sometimes the first sign that something has changed, and yet they are among the least likely to be connected to dementia by either the individual or those around them, making them particularly important to include in any comprehensive assessment.

When to Seek Assessment

If you or someone close to you has noticed a change in cognitive function, personality, behaviour, language or everyday ability that represents a departure from previous baseline, is persisting over time and is not explained by an obvious cause such as acute illness or bereavement, that warrants a specialist assessment.

Waiting to see whether things improve, or reassuring oneself that the changes are simply ageing, is understandable but carries real risk.  In fact, a systematic review published in Alzheimer’s and Dementia found that earlier diagnosis was independently associated with better access to treatment, more effective advance care planning and significantly improved quality of life outcomes for both individuals and their families, regardless of the underlying dementia subtype [20].

An assessment is not a diagnosis. It is the beginning of a structured, careful process of clinical evaluation that may result in reassurance, the identification of a treatable cause, a diagnosis of mild cognitive impairment warranting monitoring, or a dementia diagnosis with the treatment and support planning that follows from it. All of these outcomes are better served by seeking assessment promptly than by deferring it.