When it comes to mudslinging politicians, there’s been a lot of recent talk about who has dementia and who’s too old to be in office. Aside from the usual politicking, our current crop of elder statesmen has prompted a lot of buzz about who should be ineligible to hold office.

As a geriatrician, I’ve found that it’s the wealthy and the powerful who won’t give up their positions without a fight. That said, it’s not always because they’re megalomaniacs. The changes of dementia are often subtle at first, and often overlooked.

First, a brain primer.

There are the frontal lobes that regulate judgment, risk assessment and inhibition of impulses. Symptoms of problems in this part of the brain can manifest as apathy, quick anger, sexually inappropriate behavior, loss of speaking ability and poor judgment.

The parietal lobes regulate sequencing. Think: Putting on socks before shoes, putting toothpaste on the toothbrush before brushing, and so forth. Symptoms of problems here can include an inability to get dressed, can’t eat at the table, can’t use the phone.

Occipital lobes regulate our ability to understand position in space and movement. Problems in this part of the brain can manifest as an inability to locate objects, difficulty identifying colors, vision problems, etc.

Dementia incidence is about 10% in those over 65. It’s about 40% in those over 85. Alzheimer’s is the most common form of dementia, representing about 70% of all cases. It usually starts with decline in memory, mood and awareness. People can have mood swings, paranoia and delusions.

The second most common form is vascular (litte strokes) dementia, and this represents around 30% of all cases. It’s difficult to identify early. Short-term memory is usually affected, people can become paranoid, they can lose things, they sometimes blame others for stealing. Interestingly, social grace and conversational ability often remain intact. General testing might not reveal deficits, and in-depth neuropsychological testing may be needed.

Alcoholic dementia is more common in heavy drinkers, even after just a few years, and especially if there have been head injuries in the past. There will likely be poor judgment, poor risk assessment, poor memory — and they’ll often make up stories to fill in what they don’t remember. This type of dementia can’t be diagnosed until someone has been dry for about six months.

Lewy body dementia is often associated with Parkinson’s disease. People with LBD often will seem sociable, but then have mood swings and become delusional, aggressive or paranoid. These symptoms are often made worse by Parkinson’s disease medications. A good first step is to minimize medications that worsen psychosis. I talk about this in my book, Living in the Moment. Watch out for low blood pressure, as well!

With frontal dementia, memory is often fine at first, but there’s a loss of judgment and inhibition. People with front dementia may be sexually inappropriate, or undergo a severe change in personality. This, too, can be treated, just not with the usual sedative behavioral meds used for dementia. A neuropsychological exam will likely be needed to determine capacity. With front dementia, there’s a high risk for financial abuse and susceptibility to scammers

Regardless of the type of dementia, a lot of these symptoms can be nebulous if you don’t know exactly what to look for. Let’s do a quick recap with some examples: 

Change in empathy: The person with early dementia may no longer care about the affairs and daily lives of friends or family members.

Apathy: The elder may no longer be interested in things they once loved, such as church, a club, spending time with family, etc.

Loss of judgment: They may take risks they never took before, and they may fall victim to swindles. Red flags can include a new “friend” or new (often younger) romantic partner who isolates the elder from friends and family.

Mood swings: This is common if they get easily angered about small things. Perhaps they cry or laugh very easily. This may lead to divorce if the dementia isn’t diagnosed.

Inability to perform tasks of daily living: This can manifest in a lot of different ways, such as not paying bills, not getting groceries, missing appointments, and so forth.

Getting lost in conversation: This is another symptom that can present in a number of different ways — mixing up important points in a presentation or rambling during phone calls are two examples. We all jumble our words from time to time, but doing so and being unaware of it is a different matter. It can be an early sign of dementia and shouldn’t be overlooked.

And, finally, back to politicians. I think we can all agree that politicians need to listen to their constituents, produce useful policies, follow through with their campaign promises, and get the work done. For most people, aging might mean forgetfulness. It might mean muddling our words  from time to time or a little less vigor in our step. There’s no shame in any of these things, but when you’re in a position of power (like a politician is!) and you refuse to step down despite diminished capacity, it affects far more people than, say, only your spouse or close friends.

I’ll say this: When I can no longer understand the needs of my patients, pay attention, address the problems presented and follow through to make sure treatment is effective…then it’s time to hang up my stethoscope. Politicians should do the same.