Are you dealing with a diagnosis of dementia?
If so, you might be wondering what type of dementia you are dealing with. Or, perhaps you’ve heard someone say it’s important to find out what type of dementia it is.
It’s true that there certainly are different types of dementia, and it’s often said that the most common one is Alzheimer’s disease.
But actually, especially as people get to be age 80 or older, by far the most common type of dementia is mixed dementia. Meaning, the dementia symptoms are caused by a mix of types.
If you are dealing with memory loss or other forms of cognitive decline, it’s a good idea to know the basics about the different types of dementia.
In this article, I’ll cover:
What is dementia and what’s the difference between Alzheimer’s and dementia
The most common types of dementia in older adults
When it might be important to find out what type of dementia it is
My usual approach to using dementia type to help patients
What is dementia?
Dementia (also known as major neurocognitive disorder) is an umbrella term and a clinical syndrome. Having dementia essentially means having developed chronic cognitive impairments that are bad enough to interfere with independence in daily life activities.
To be diagnosed with dementia, these five things must be true:
A person is having difficulty with one or more types of mental function. Although it’s common for memory to be affected, other parts of thinking function can be impaired.
The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) lists these six types of cognitive function to consider: learning and memory, language, executive function, complex attention, perceptual-motor function, and social cognition.
The difficulties are a decline from the person’s prior level of ability. These can’t be lifelong problems with reading or math or even social graces. These problems should represent a decline, compared to the person’s usual abilities as an adult.
The problems are bad enough to impair daily life function. It’s not enough for a person to have an abnormal result on an office-based cognitive test. The problems also have to be substantial enough to affect how the person manages usual life, such as work, family responsibilities, or Instrumental Activities of Daily Living (IADLs).
The problems are not due to a reversible condition, such as delirium, or another reversible illness. Common conditions that can cause — or worsen — dementia-like symptoms include hypothyroidism and medication side-effects.
The problems aren’t better accounted for by another mental disorder, such as major depression or schizophrenia.
Dementia usually develops over time, as brain cells become damaged and die, due to one or more underlying causes (such as Alzheimer’s disease, or one of the other types of dementia).
For more on how dementia is diagnosed, see How We Diagnose Dementia: The Practical Basics to Know.
What is the difference between Alzheimer’s and dementia?
Alzheimer’s disease is the most common underlying cause of dementia.
It is a slowly progressing neurodegenerative condition that causes the brain to develop amyloid plaques and tangles made of tau protein. As the brain changes progress, brain cells initially malfunction and later die.
Cognitive symptoms of Alzheimer’s disease usually emerge after 10-15 years of brain changes, and often involve short-term memory.
Given enough time, people with Alzheimer’s disease in their brains usually first develop mild cognitive impairment, and then eventually dementia.
(Note: Mild cognitive impairment is another syndrome that can have several underlying causes. Learn more here.)
In short: Alzheimer’s can be considered a type — or underlying cause — of dementia.
4 common types of dementia
Most dementia is caused by neurodegenerative disease. Below are the four most common causes of dementia that affect older adults, along with their more typical early symptoms. (Note that for each type of dementia, there can be a lot of variability in the symptoms.)
1. Mixed dementia
Research has shown that the most common types of dementia in older adults is actually mixed dementia, meaning there is more than one disease process affecting brain cells and causing dementia symptoms.
Before I tell you more about mixed dementia, let me cover the other common types of dementia in older adults, as most mixed dementia is a mix of the conditions listed below.
2. Alzheimer’s disease
How it harms the brain: Alzheimer’s is characterized by the development of abnormal amyloid plaques and tau tangles in the brain, and by slow neurodegeneration of brain cells. These brain changes start 10-15 years before symptoms become apparent. Researchers are still trying to figure out just what are the factors that start and accelerate the Alzheimer’s neurodegeneration process.
How common it is: Experts estimate that Alzheimer’s disease is involved in 60-80% of dementia cases.
Typical early symptoms: The most common early symptoms are problems with short-term memory and with executive function. Reduced insight into one’s problems (technically called anosognosia) is also common.
Other early symptoms can include problems with visualspatial processing, language problems, delusions, paranoia, and apathy.
3. Vascular dementia
How it harms the brain: Vascular dementia is usually caused by the accumulation of problems related to the small blood vessels of the brain. These can include small blockages and small bleeds, and tend to leave small scars behind in the brain. (On brain imaging, these problems often cause “white matter hyperintensities.” Learn more about this type of damage here: Cerebral Small Vessel Disease: What to Know & What to Do.)
How common it is: Experts estimate that cerebrovascular disease is a contributor to 50% of dementia cases.
Typical early symptoms: The most common early symptoms are impaired executive function and slower processing speed. Many people with vascular dementia also have problems with short-term memory.
Researchers believe that some forms of apathy and late-life depression may be related to small vessel vascular damage as well.
4. Lewy body disease
How it harms the brain: Neurons in the brain accumulate abnormal aggregations of alpha-synuclein protein. These are called Lewy bodies. When they accumulate in a certain part of the midbrain that regulates movement, this causes Parkinson’s disease, but in Lewy body dementia, the Lewy bodies have accumulated in other parts of the brain.
How common it is: Experts estimate that Lewy body dementia is involved in 20% of dementia cases.
Typical early symptoms: To be diagnosed with probable Lewy body dementia, a person must have at least two of the following “core clinical features” of dementia with Lewy bodies:
Visual hallucinations
These can involve well-formed images of children, people, or small animals, or just might be shapes and colors
REM sleep behavior disorder
This is a condition in which the person becomes able to physically vocalize or act out dreams during REM sleep (usually the body is not moving during REM sleep and dreaming)
Parkinsonism
This means showing some of the typical signs associated with Parkinson’s disease, which include slowed movements, a tremor at rest, stiffness, or problems with balance and walking.
Note: Parkinsonism signs are motor symptoms (meaning, symptoms related to movement) that are associated with problems in a part of the brain that coordinates movement. Parkinson’s disease is the best-known condition associated with these symptoms, but there are related conditions (including Lewy dementia) that can cause parkinsonism. Parkinsonism can also be caused by medications, such as antipsychotics and other drugs that block dopamine.
Cognitive fluctuations
This means experiencing a significant change in cognition, attention, or arousal. People might seem to zone out, or get very sleepy, or get very confused, but at other times might seem almost normal.
Note: Dementia with Lewy bodies is related to Parkinson’s disease dementia. In Parkinson’s disease dementia, the dementia comes on after the person has had the motor symptoms of Parkinson’s for at least one year. Whereas in Lewy body dementia, the cognitive problems start before or at the same time as the parkinsonism motor symptoms.
Also: Frontotemporal degeneration (FTD)
Frontotemporal dementia is actually not all that common in older adults, but I’m including a little information here, as people ask me about it often. FTD is a more common cause of dementia in people younger than age 65.
How it harms the brain: Neurons degenerate in the front and/or sides of the brain. (The reasons for this are varied, and depend on the subtype of FTD.)
Degeneration in the front of the brain affects behavior in particular, and is associated with behavioral variant FTD. Degeneration in the sides of the brain (the temporal areas) is associated with a variant called primary progressive aphasia, which involves language problems.
How common it is: FTD is a more common cause of early-onset dementia (i.e. occuring before age 65); it’s been estimated to account for 10% of early-onset dementia cases. FTD becomes less common as people get older and is estimated to account for about 3% of dementia cases in people over age 65. Most people diagnosed with FTD are less than 65 years old.
Typical early symptoms: Early symptoms depend on the variant of FTD:
Behavioral variant:
Early symptoms may include becoming disinhibited in speech or behavior, developing apathy or loss of empathy, or developing “personality changes.” Symptoms are often mistaken for a psychiatric illness. Memory is usually not particularly affected early on.
Primary progressive aphasia:
Early symptoms involve language and may include difficulty finding words, articulating words, naming objects, or understanding words or sentences.
Other causes of dementia in aging
There are many other conditions that can cause dementia. In older adults, conditions I might consider include:
Parkinson’s disease dementia (which is related to Lewy body dementia, as explained above)
Alcohol-related dementia (which includes Korsakoff’s syndrome)
Chronic subdural hematoma
Normal-pressure hydrocephalus (which can sometimes be treated with a shunt)
There are also some newer types of dementia pathology that are relevant to older adults. (Dementia pathology means brain changes that are associated with clinical dementia symptoms.) These include:
Limbic-predominant age-related TDP-43 encephalopathy (LATE)
LATE is a recently identified neurodegenerative condition that is relatively common in older adults. It involves abnormal amounts of TDP-43 protein. On autopsy, it has been found in roughly half of the brains of persons with clinical dementia, often in combination with Alzheimer’s disease pathology and vascular disease.
This condition is also common, especially as people reach age 90+, and involves a particular loss of neurons in the hippocampus, a brain structure that is involved in short-term memory.
Cerebral amyloid angiopathy (CAA)
In this common condition, amyloid protein builds up in the walls of the small blood vessels of the brain. This can lead to small bleeds and cognitive decline. Many people with Alzheimer’s disease also have evidence of CAA in their brains.
For those who want to really dig into the science of different dementia pathologies, here is a resource: Neuropathology of Dementia Disorders.
Less common causes of dementia
There are some other less common causes of dementia that you might hear about, most of which are likely to affect people younger than 80. They include:
Progressive supranuclear palsy
Corticobasal degeneration
Multisystem atrophy
Huntington disease
Chronic traumatic encephalopathy
HIV-associated dementia
Creutzfeldt-Jakob disease
Unfortunately, other than HIV-associated dementia, these rare causes of dementia cannot be cured or slowed down. For these conditions, medical care focuses on managing symptoms and quality of life.
The most common type of dementia in geriatrics
Given all the different things that can cause dementia, you might think that in geriatrics, we’d be spending a lot of time trying to sort out what type of dementia our patients have.
But we usually don’t. That’s because there is one type of dementia that is by far the most common in older adults, and that is mixed dementia.
For instance, an autopsy analysis of 2695 participants found that 91% of them had more than one of six key neuropathologies, and 41% had three or more. Studies of older adults who died at age 80 or older with clinical dementia have shown that it’s uncommon for them to have only a single type of dementia pathology in their brains.
(Interestingly, research done by the Religious Orders Study and Rush Memory and Aging Project found that Alzheimer’s pathology was also present in one third of decedents who didn’t not have outward signs of mild cognitive impairment or dementia. In other words, neuropathology is NOT destiny.)
The most common mix is Alzheimer’s disease and cerebral vascular disease.
The Alzheimer’s Association has a good overview of mixed dementia here: Mixed Dementia.
Does identifying the type of dementia matter?
It depends who you ask.
Personally, I find that most of the time it doesn’t matter all that much, especially once a person is aged 80 or older.
Now, I have heard various “experts” recommend getting the type of dementia identified, “so that you can get the right type of treatment” or an “appropriate, specific treatment.”
I find myself wondering in response to this: what “specific” treatment??
Surely these experts must know that we essentially have no treatment that works reliably for the most common types of dementia (with the possible exception of anti-amyloid antibodies such as lecanumab, which have been studied mostly in younger Alzheimer’s patients with mild cognitive impairment or early dementia). So it is not clear to me why it’s valuable to try to identify the type of dementia, unless one is participating in a research study.
Furthermore, once people are in their 80s, they are very likely to have mixed dementia.
That said, if you are dealing with dementia, chances are that someone will recommend further evaluation to get the type diagnosed. Now, it’s true that with more specialized brain imaging and detailed neuropsychological testing, it is often possible for experienced clinicians to identify the likely type of dementia.
But since it doesn’t really change management, it seems to me that it’s usually not a good use of time and effort, if you are dealing with dementia, especially in those aged 80+.
My usual approach to types of dementia
So from a practical perspective, when considering dementia treatment, my main priority is usually to check and consider whether the person has any symptoms of Lewy body dementia. This is important to know because those people can be very sensitive to drugs that block dopamine, and many antipsychotics and other drugs do this.
Otherwise, I feel it’s best to focus on what types of difficulties and symptoms the person is having, and try to find ways to manage those. So for instance, if the main problem is related to memory, then we need to find ways to work around that. If a key problem is processing or expressing language, then we need to see what we can do to improve communication.
The best ways to treat Alzheimer’s and other types of dementia
The truth is that the best care for Alzheimer’s, mixed dementia, or other types of dementia does not really depend on the underlying type of dementia.
Instead, the best treatment comes from doing things like:
Learning better dementia communication strategies
Learning to focus on optimizing current skills, abilities, and quality of life
Learning strategies to manage any challenging behaviors or difficulties
Finding support groups
Talking to experts and fellow travelers to learn more about what to expect
Planning appropriately when you can
Practicing self-care and acceptance
(Note: if you are concerned about an aging parent with dementia, learn more about my Helping Older Parents with Memory Loss program here.)
Medications do sometimes have a role in managing dementia. But the medications FDA-approved for dementia usually have only a small effect. And the medications used for sundowning and difficult behaviors tend to be problematic.
And again, aside from lecanumab (Leqembi), most medications for dementia are not really specific for a type of dementia.
Key take-aways about types of dementia
In short, here’s what’s most important to know about Alzheimer’s and other types of dementia in older adults:
In older adults, mixed dementia is the most common types of dementia.
Alzheimer’s disease and cerebral vascular disease are the most common mix.
It’s useful to check for Lewy-body dementia symptoms (e.g. hallucinations, REM sleep behavior disorder, Parkinsonism, cognitive fluctuations).
So that you can then be very careful about medications that affect dopamine.
Unless there are unusual symptoms, extensive evaluation to identify the type of dementia usually doesn’t change management much
The most important forms of dementia treatment, when it comes to quality of life and wellbeing, are non-medical and do not depend on the type of dementia.
I do know it’s very hard to be dealing with Alzheimer’s and other forms of dementia. I do think it’s good to be informed about the most common types, and hope this article has helped you with this.
