Asked by Jan, United Kingdom
My mum is 67 and has suffered depression on and off all her life. She is just coming off medication from which she was having side effects: excessive sweating, and most disturbing, a shocking loss of short-term memory. She knows that she can't remember but she is extremely worried that she may have the beginning of Alzheimer's disease. She has episodes of being excessively high in her mood swings and appears confused and does not seem to be aware of her surroundings and what she is saying or doing. She then seems to come around and the next day she seems perfectly normal but says she can't remember anything about the episode. I wonder if she is suffering from some form of dementia.
Mental Health Expert
Dr. Charles Raison
Emory University Medical School
Dear Jan, I am also worried about your mom's situation, for two primary reasons. First, she is older and one of the bad things about being older is that any symptom is much more likely to signal a serious medical problem than when the same symptom appears in young people. Second, her story doesn't clearly point to one simple solution. Whenever a story doesn't make sense, I also worry.
Actually, much of your story does make sense. For example, excessive sweating is a frequent side effect of antidepressants that affect the neurotransmitter serotonin, because serotonin is much involved in regulating body temperature, and sweating is a very important body-temperature regulation mechanism. It also makes sense that your mother is having trouble remembering things. To a certain degree this is normal as we age. Although we don't have much data on it, I also know from clinical experience that antidepressants can occasionally cause people to complain of forgetfulness.
The part of your mom's story that doesn't make clear sense is the business about the high-mood episodes that last a day and which she doesn't remember. This is very unusual. It doesn't fit a classic bipolar story and isn't a very good story for Alzheimer's dementia either. Daylong episodes with alterations of consciousness, bizarrely elevated mood and poor memory are extremely rare. If she was a young person I'd think first of unrecognized drug or alcohol abuse or some type of dissociative condition.
But your mom, being older, is at significantly increased risk for having a clear medical cause for her problem, especially if she has never had these types of symptoms before. Because her symptoms are episodic, I would first want to rule out some type of episodic physical problem. The classic episodic event that can radically change people's behavior and ability to think is a seizure. When we think of a seizure most of us think of someone falling over and violently jerking. While this often happens, many seizures only manifest as changes in behavior, level of awareness and ability to think.
So I might think about having your mom get an electroencephalogram (EEG) and a magnetic resonance imaging (MRI) study. If they are negative that does not rule out the possibility your mom is having a seizure problem, but if they are positive then you know what is going on. The EEG would show changes consistent with -- or associated with - -seizure activity and the MRI might show a cause such as a recent small stroke or a brain tumor.
If these tests are normal, I might look more closely at the medications she is taking. As people age they become more and more sensitive to medication-induced side effects, including the types of symptoms your mother is having. But medication usage wouldn't easily explain why the symptoms are coming and going to such a pronounced degree.
If your mother has had episodes of being high and somewhat disoriented for many years she almost certainly has bipolar disorder. I have taken care of patients who spent months in extreme mania and were unable to remember any of it, so this is certainly a possibility. However, the fact that your mother's episodes last for only a day make this possibility less likely.
Finally, it is possible that your mother is developing a dementia -- of which Alzheimer's disease is the most common. People with dementia will show times when they are better and times when they are worse -- especially early in the illness. Throughout the illness, demented patients tend to be mentally sharper, less confused and less agitated in the morning than in the evening. This is so common that it has a name --"sundowning." If your mother's memory is grossly abnormal even when she is having a "normal" day, then dementia becomes more likely. Unfortunately, chronic depression is a risk factor for developing dementia, so your mother is at some increased risk for dementia from that factor alone.
I hope you are not frustrated by the fact that I'm not able to provide a single, simple, crystal-clear diagnosis to account for your mother's difficulties. What I have done in my answer is walk you through various possibilities the way a doctor would walk the situation through his or her own mind. Many times we never do really figure out exactly what is wrong, or only know a certain answer when the problem is so serious that it is difficult to do anything about it. Be this as it may, the most important practical advice I can give you is to heed your own sense of worry and get your mother a full work-up as quickly as possible.
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