Alzheimer’s Disease is the most common form of dementia (also called a Neurocognitive Disorder), a disease of progressive decline in one or more areas of brain function. The primary early sign for this type of dementia is difficulty retaining newly learned information. This lies in contrast to older memories, which are preserved for much longer during the disease. Memory troubles appear in multiple behaviors, such as repeating the same questions, misplacing objects, word finding issues, and getting lost. A patient’s judgment may also falter, and they will have trouble making decisions. They can also seem listless and unmotivated to engage in their previous hobbies and pastimes. Memory problems are also frequently accompanied by changes in behavior and mood, such as depression, anxiety, and irritability. For many people, these are the most stressful parts of the disease.
As the disease progresses, patients will need more attention and help from caregivers. Memory loss worsens and communication skills become more impaired. People get lost during conversations, find it difficult to stay on track, and become frustrated more easily because of this. Actions that require several steps, such as paying a bill, cooking a meal, or getting dressed become increasingly difficult. People begin to have problems identifying family and friends who they have known for a long time. Their moods become more variable, and their behavior can be odd and unpredictable. Patients may start to hallucinate, seeing or hearing things that are not real, or become anxious because they forget where they are or who is taking care of them.
In the final stages of the Alzheimer’s Disease, people become progressively less mobile and often become bed-bound. This decreased mobility, combined with incontinence, leads to skin sores and infections. They have a lot of trouble communicating as their vocabulary and speech fully deteriorate. They have difficulty eating and progressively lose weight. Problems with eating and swallowing contribute the most common cause of death, pneumonia.
Causes and Risk Factors
Prevalence and age
Depending on how it is diagnosed, Alzheimer’s Disease accounts for between 60% and 90% of all dementia cases. Although dementia is not a normal part of aging, it is strongly associated with old age. Over 90% of cases of Alzheimer’s Disease appear in people over the age of 75, and between 1% and 3% of people over the age of 65 will be diagnosed each year. In the small percentage of patients in whom the disease starts before age 65, it is called “early onset”. Alzheimer’s Disease is the sixth most common cause of death in this country, and about 5 million Americans are currently dealing with the disease. Depending on the age of onset, life expectancy from diagnosis can range from 3 years for those diagnosed late in life to 10 or even 20 years for patients diagnosed at younger ages
Mild Cognitive Impairment
The very early symptoms of Alzheimer’s Disease are similar to those experienced in Mild Cognitive Impairment (MCI), except that those patients do not have personality changes and remain able to perform the common activities of daily living. MCI is a significant risk factor for symptoms to advance to Alzheimer’s Disease, and anyone diagnosed with MCI should have frequent check-ins with their physician to monitor for possible symptom progression.
Nerve cell death
The progressive death of nerve cells in the brain is the core of the destructive process of Alzheimer’s Disease. The death of these cells begins in areas of the brain important to memory and then slowly spreads to the rest of the brain. Although the cause is not known for certain, the prime suspects in the case are the accumulation of two proteins called “amyloid” and “tau”. Both of these proteins are found in healthy aging brains, too, but at much lower levels than in those of patients who had Alzheimer’s Disease. Amyloid protein collects between nerve cells and impairs communication between cells. Tau protein accumulates in disorganized “tangles” in nerve cells and inhibits many of the natural operations inside cells that are necessary for them to function normally.
Several genetic characteristics contribute partially to the development of Alzheimer’s Disease, and about 5% to 10% of cases are directly caused by certain genes. Variations of multiple genes, the most well studied called “APOE”, increase the risk of Alzheimer’s Disease but do not definitely mean that a person will develop it. Additionally, three other genes are known to virtually guarantee that those patients will get Alzheimer’s Disease. People with at least one of these three genes will begin to show signs of the disease as early as in their 30s and have what is known as early-onset familial Alzheimer’s Disease.
Most people with Down Syndrome will develop Alzheimer’s Disease if they live long enough. This is most likely because the gene for the damaging amyloid protein found in patients’ brains is located on chromosome 21, which is the extra copy chromosome that patients with Down Syndrome have.
Conditions that contribute to heart disease also appear to be related to the risk of developing Alzheimer’s Disease. Diabetes, obesity, high blood pressure, high cholesterol, and tobacco smoking may contribute to the kind of cognitive problems seen in dementia, though the exact mechanism for the connection is not completely clear yet. These afflictions also contribute to potential for strokes, which frequently occur alongside Alzheimer’s Disease.
Diagnosing Alzheimer’s Disease
Patients with this disease display a noticeable decrease of their cognitive abilities in at least one area (though often more). Care providers, friends, family, or even the patient may notice this first, but it should be confirmed by formal testing by a specialized physician. These changes affect patients’ ability to function in everyday life, at first only with more complex tasks, but they will need help with more basic skills as the disease progresses.
Alzheimer’s Disease is specifically marked by new found problems in learning and memory, usually accompanied by difficulties in at least one other cognitive domain. Problems with spatial memory and altered speech patterns often appear later in the disease as well, and people become progressively more disorganized. The disease follows a slow, constant decrease in these areas without any changes in course once it starts. Once the disease is recognized, family and friends who know the patient well often realize in retrospect that symptoms first appeared long before anyone originally noticed. Family history or genetic testing often point towards the diagnosis of Alzheimer’s Disease.
The severity of the disease is based on the number of different cognitive skills in which patients have difficulty. Problems in one area versus problems in multiple areas determine whether the status of the disease is considered “mild” or “major”.
Physicians who are considering whether a patient has Alzheimer’s Disease will want to perform some special imaging of the brain to help with the diagnosis and rule out other possibilities. Computerized Tomography (CT) scans are used to look for other possible causes of cognitive issues, like strokes, tumors, or consequences from traumatic brain injuries. Magnetic Resonance Imaging (MRI) and Positron Emission Tomography (PET) can both look for the areas of brain degeneration that are specific to Alzheimer’s Disease.
Treating Alzheimer’s Disease
Slowing disease progression
The medications Aricept (donepezil), Exelon (rivastigmine), and Razadyne (galantamine) help both in the early and late stages of Alzheimer’s Disease. These medications counteract the degenerative processes in the memory centers of the brain that are characteristic of the disease. These medications slow (but do not stop) the decreases in mental aptitude and the problems in performing the basic functions of daily life that patients naturally develop as part of the disease.
Namenda (memantine) helps treat more advanced Alzheimer’s Disease by preventing the nerve damage in the brain that is part of the disease process. Like the other medications, this one slows mental changes and preserves functioning. When Namenda is combined with one of the other three medications, patients are able to remain in their own homes (with assistance) longer before going to live in assisted care facilities.
Dealing with additional symptoms
Educating care providers about the behavioral changes that occur throughout the progression of Alzheimer’s Disease is the first step in addressing these issues. This includes learning to recognize situations that are particularly stressful to patients and how to best navigate them. Care givers also need to be on the lookout for the early signs of illness or side effects from medications that could lead to behavioral issues in these patients.
Antidepressant medications like Celexa (citalopram), Zoloft (sertraline), and Remeron (mirtazapine) are commonly prescribed to help manage the mood symptoms that frequently accompany Alzheimer’s Disease. Antidepressants are the safest medications that can address the depression, agitation, and anxiety that these patients often deal with.
Three other categories of medications that are used to manage behavior problems are prescribed sparingly and with caution. Medications like Ambien (zolpidem) and Lunesta (eszopiclone) can help patients with the sleep problems that commonly appear, and benzodiazepines such as Ativan (lorazepam) address anxiety. However, these need to be used with caution as they can lead to increased confusion and put patients at higher risk of falls. Antipsychotic medications are occasionally used to treat hallucinations and delusions that patients suffer. These medications come with an increased risk of stroke in these patients and are only used very rarely and under close supervision by an experienced physician.
Managing Alzheimer’s Disease
Dealing with change
Accepting the diagnosis of Alzheimer’s Disease and learning to manage the difficulties that come with it is stressful, to say the least. The most important coping strategies to learn focus on helping with organization and successfully completing the activities of daily life. Creating routines and developing systems for remembering important tasks are key. This might include getting a pill organizer for medications so the patient doesn’t miss medications or accidentally take them repeatedly. Make to-do lists for daily routines and then check things off to keep track. More complicated things like managing bills will eventually require the help of a spouse or other family member. Recognizing what to get help with and accepting that help is a difficult, but necessary, part of the process.
Every patient with Alzheimer’s Disease usually has one primary caregiver, most likely a family member, who provides most of the daily assistance that the patients need. This position is ultimately physically and emotionally stressful, as well as taking a financial toll by consuming time that might otherwise be spent working. Building a support network, such as joining a support group for families of patients with Alzheimer’s Disease, can be a good way to deal with emotions, share frustrations, and develop coping mechanisms for these trying times. It is important to get others to fill-in the care giving role on a regular basis so the primary caregiver can make time to care for him or herself, something that is often neglected.
Sundowning is a characteristic confusion that strikes patients with dementia in the evening and at night. Anxiety, irritability, and aggression can also appear during these times. Anything that disrupts the regular sleep/wake cycle can make sundowning more likely to occur. This includes napping during the day, lack of exposure to sunlight, late-night television, or consuming caffeine later in the day. Simmering sicknesses, like an undiagnosed urinary tract infection, can also contribute. The over the counter sleep aid, melatonin, may help, but check with the primary physician first.