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the underlying cause, the confusion is reversible.

      ✔ Diabetes: One of the most common reasons for doctors seeing people who are acutely confused is that their blood sugar levels are either too low or too high. Neither situation is particularly good for people, but when their blood sugar is adjusted, their confusion quickly fades.

      ✔ Thyroid disease: Thyroxine is a hormone produced in the thyroid gland, which sits at the front of the neck. In simple terms, this hormone is involved in metabolism within the body: too much and everything in the body is in a rush (the heart races, diarrhoea develops and people become agitated); too little and everything slows down (pulse is slow, people gain weight, skin becomes dry, hair falls out and they can become constipated). Both an under- and over-active thyroid can cause confusion. In both cases, the confusion can again be reversed by treating the underlying cause.

      ✔ Hyperparathyroidism: The parathyroid glands are pea sized and sit just behind the thyroid gland in the neck. The hormone they produce – parathyroid hormone – is involved in controlling levels of calcium, phosphate and vitamin D. If the gland becomes overactive, levels of calcium in the blood shoot up. Too much calcium can affect personality and consciousness, cause disorientation and, if not corrected quickly enough, coma. Treatment is curative.

      ✔ Vitamin B12 deficiency: This vitamin, found in fish, poultry, eggs and dairy products, is absorbed in the gut during digestion with the help of a protein called intrinsic factor. Some people either don’t make enough of this protein or have a condition that destroys it. As a result, they don’t absorb vitamin B12. One of the roles of this vitamin is ensuring healthy nerve function. A lack can cause numbness and tingling in the hands and feet and, if significant, mood changes and poor memory. Treatment by injection of vitamin B12 avoids the problem of lack of stomach absorption and can improve symptoms.

       Alcohol-related causes

      Indulging in more than the advised levels of society’s favourite drug more often than recommended will reveal it to be the poisonous substance it truly is. The effects on the body are wide-ranging and it can wreak havoc on a number of our internal organs, but it’s the problems it can cause in the liver and brain that mimic dementia.

      ✔ Cirrhosis: Liver cells can be damaged by alcohol. The liver can also be affected by viruses such as hepatitis and an autoimmune condition in which the immune system, rather than an infection, attacks the body. Such damage stops the liver working as it should do, which, among other things, leads to the build-up of toxic waste products in the blood. When these toxins build up they can damage brain cells, leading to encephalopathy, which encompasses a collection of symptoms like confusion, poor memory, personality change and inappropriate behaviour. Occasionally, encephalopathy can be reversed by treating the liver damage, but it can prove fatal.

      ✔ Korsakoff’s syndrome: Another condition named after the doctor who discovered it, Korsakoff’s syndrome is most often seen in alcoholics in whom high alcohol intake stops the absorption of a B vitamin called thiamine. Thiamine is needed for normal nerve cell function, and insufficient levels commonly cause people to develop memory problems and changes in personality. This condition can be treated by quitting the booze and taking a thiamine supplement.

       Infectious causes

      Many infections can produce acute confusion, especially in the elderly. This confusion can be caused by the direct effect of viruses or bacteria on the brain, the toxins they produce in the blood stream, or the more general effects of infection on the body, from high temperature to dehydration. The most common infections that can cause confusion – or to give it its more glamorous-sounding, old-fashioned name, delirium – are

      ✔ Urinary tract infections such as cystitis (affecting the bladder) and pyelonephritis (affecting the kidneys)

      ✔ Chest infections, from bronchitis to full-on pneumonia

      ✔ Severe viral infections like influenza

      ✔ Infections that directly affect the brain, such as meningitis (which affects the meninges covering the central nervous system) or encephalitis (which affects brain cells)

       Prescription medication causes

      Although doctors try to follow the age-old dictum ‘first do no harm’, and medicines are designed to help people get better rather than make them worse, prescribing doesn’t always work as planned. We’re all different, and in an ideal world all treatment would be bespoke rather than off the peg.

      However, we don’t live in an ideal world and so, despite doctors’ best efforts, their prescriptions may make people, especially older people, feel more unwell than before they collected their pills from the pharmacy. The following medicines can potentially make people acutely confused:

      ✔ Benzodiazepines such as diazepam (valium)

      ✔ Strong painkillers such as tramadol, codeine and morphine

      ✔ Steroids like prednisolone (often used for chronic bronchitis and arthritis)

      ✔ Anticonvulsants such as carbamazepine and phenytoin

      ✔ Anticholinergics, including some hay-fever tablets and medicines used to treat an over-active bladder (such as oxybutynin)

      Chapter 2

      Spotting the Symptoms

       In This Chapter

      ▶ Spotting the early warning signs of dementia

      ▶ Identifying cognitive problems

      ▶ Understanding changes in emotional behaviour

      ▶ Looking at functional problems

      As doctors, we love to be able to categorise diseases and our ability to do our jobs properly depends on it. It’s important to know that set of symptoms A means a patient simply has a nasty dose of the common cold, while set of symptoms B means she’s more seriously ill with influenza. Without knowing what someone is up against, we can’t advise on treatments or tell her the likely outcome of what she’s going through.

      In this chapter I look in some detail at the symptoms that show that someone has dementia. And I describe the particular features that allow clinicians to tell people which type of dementia they are suffering from.

Identifying the Early Warning Signs

      While dementia affects everyone slightly differently, a few common symptoms can alert you to the fact that it may well be on its way. In the early stages, though, it’s important not to panic and see dementia lurking behind every forgetful or confused senior moment, because a failing memory is often simply a normal part of the ageing process. And it is important to bear in mind that there’s much more to all types of dementia than simply becoming forgetful.

       Differentiating between dementia and a few senior moments

      Many things can make all of us absentminded, from simple tiredness and poor concentration to a period of low mood or actual depression. How many of us, busily caught up in an engrossing task or conversation, have forgotten a dental appointment or burnt the dinner?

      Only when these symptoms become a regular feature of your behaviour, or that of someone you love, may they be a sign of something more serious. And the symptoms only really become significant when they start to interfere with a person’s ability to get on normally with everyday life.

      Also, it’s rare for memory issues alone to be enough to suggest that dementia is manifesting

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