Mailbox Response

The question was submitted 12/04/2008

Subject: mini strokes

At age fifty my husband started to forget things and seemed easily agitated (not at all his nature) After much coaxing he was referred to a Brain specialist. At first he was sent for and xray and we were told that he had the brain of a much older person. He was sent for and MRI and we were then told he has suffered from mini strokes. He is now on drugs for high blood pressure and cholesterol ( he has neither of these problems ) we are told this is a preventative action. All damage is in the front of the brain on one side. He has over the last five years become the nastiest man. His short term memory is almost non existent. Any thoughts on this nastiness. Is it normal? I get so many conflicting stories about mini strokes not causing any damage? Clearly this is not the man I used to live with.

Answer from DementiaNet

You describe a very sad situation. There are a number of causes of younger onset dementia and it is sometimes difficult to be certain of the diagnosis. Frontotemporal dementia commonly has a lot of behavioural type issues and can start at a younger age as is the case with your husband. However memory problems do not tend to come on as commonly at the early stages.

Multi-infarct dementia is the sort of dementia that is caused by strokes. These can be mini strokes as you describe or larger strokes. Their presentation is quite variable depending which part of the brain has had a stroke and at what time frame. The pattern with multi-infarct dementia tends to be more in a stepwise deterioration rather than a steady decline which you are describing. It can be associated with behavioural issues.

Alzheimer's disease uncommonly can also start in the younger age and tends to present in the first instance with memory problems whilst behavioural problems tend to come on at a later stage.

So you are describing a mixed pattern in the case of your husband. A progressive decline in memory over 5 years consistent with Alzheimer's disease coupled with the brain scan evidence of having had strokes. It is not uncommon for there to be a mixed picture with two different pathologies existing. This may well be the case with your husband.

Treating blood pressure and cholesterol and keeping these under good control hopefully will reduce further vascular episodes. It may be worth considering discussion with a specialist the possible introduction of one of the dementia drugs used for Alzheimer's disease because occasionally in this type of situation there may be some improvement seen.

Another point to be aware of in the setting of dementia, depression is often present as well, and is often not well recognized. The combination of depression and dementia may lead to unusual patterns of behaviour and consideration of whether a trial with an antidepressant it is worth considering.

Lastly, there is other medication is used to try to calm the patient or modify their behaviour. We call this antipsychotic medication which in small doses can be very effective.

If nothing is working and you are still struggling, it may be time to be referred to a Geriatrician or Psychogeriatrician. Whilst these specialists tend to see older patients they generally are very experienced in helping to manage difficult and challenging behaviour problems as you describe.

The answer was published on DementiaNet 18/04/2008