- Alzheimer’s disease is an illness denoted by the gradual deterioration of brain cells, resulting in cognitive impairment, which is referred to as dementia
- A typical diagnosis of Alzheimer’s includes: medical history, mental status evaluation, physical examination, neurological examination and genetic testing
- The symptoms of Alzheimer’s disease are different across the stages: Preclinical-Stage, Early-Stage, Mid-Stage and Late-Stage
- There are no known cures for Alzheimer’s disease, but palliative measures exist to aid with the quality of life of people with Alzheimer’s
- The risk factors for Alzheimer’s disease include age, genetic, environmental, vascular disease and head trauma
Here is how Terry Pratchett defined his Alzheimer’s Disease: “It occurred to me that at one point it was like I had two diseases – one was Alzheimer’s, and the other was knowing I had Alzheimer’s.”
Alzheimer’s Disease, the most common form of dementia, is a progressive and degenerative illness characterized by the gradual deterioration of brain cells, resulting in progressive cognitive impairment. The degrading of nerve cells is thought to be caused by the accumulation of abnormally folded proteins leading to atrophy, or shrinkage, in affected brain regions. This process is responsible for the numerous behavioral, cognitive, and physiological impairments that grow in severity as the dementia advances.
As Alzheimer’s disease spreads throughout the brain, function in diseased areas is diminished.
- Cerebrum: memory, problem solving, reasoning, movement, and sensory processing
- Cerebellum: coordination, balance, auditory and visual perception
- Brainstem: cardiovascular functions and digestion
Though Alzheimer’s is more likely to impact those sixty-five and older, younger demographics can be affected by the disease as well. Those afflicted by early onset Alzheimer’s account for about five to ten percent of Alzheimer’s cases. Early onset Alzheimer’s tends to affect people in their fifties, although the disease has been found in those as young as in their thirties. The symptoms and progression of early onset Alzheimer’s Disease (EOAD) are similar to LOAD (late onset Alzheimer’s Disease).
As we age, some changes are common to most of us: our wit dulls, our bodies slow, our hair greys, and our senses decline. If all of these things take place in healthy populations, is it possible to distinguish the symptoms of Alzheimer’s or other forms of dementia from normal aging? The difference is, while intermittent memory lapses can be mildly annoying, daily performance is not seriously impeded.
Signs of normal aging are:
- Sometimes misplacing items
- Forgetting names of acquaintances or calling people from time to time by the wrong name
- Failing to remember appointments or the reason individuals walked into a room
- Finding it more difficult to concentrate or unable to remember something that they recently read or a discussion that they recently had
- Occasionally having issues with word recall.
It can be difficult to delineate one form of dementia from another, given that they can occur in tandem, but there are tests that can increase the accuracy of a diagnosis. Those typically include the following:
- Medical history: this will help a physician to determine if an issue may be the result of some prior condition
- Mental status evaluation: this is done by interviewing the person and those close to them, to determine the extent their mental status has altered
- Physical examination: the physician asks about person’s diet, medications, collects samples, checks vitals
- Neurological examination: the doctor tests coordination, eye movement, reflexes, speech, sensation, muscle tone & strength, and performs neuro-imaging scans to find anomalies in the brain consistent with Alzheimer’s disease
- Genetic testing: genetic tests can determine if certain genes associated with an increased risk of developing Alzheimer’s, are present
The average life expectancy of individuals with Alzheimer’s disease is 4 to 8 years, but some live with the disease for over 20 years. Deaths are usually caused by infection, malnutrition or dehydration but, in the absence of these secondary conditions, AD will eventually cause the body to shut down.
MCI is characterized by issues with processing and retaining information that go beyond what are generally thought of as normal age-related impairments, but are not severe enough to significantly impede one’s normal routine.
Symptoms of MCI are as follows:
- Occasionally forgetting things
- Minor difficulty concentrating
- Trouble making plans or completing tasks
- Increased disorientation
- Reduced impulse control
- Loved ones often notice these changes
MCI can also result in changes to a person’s mood or temperament, including:
- Irritability and aggression
My wife had noticed that I would sometimes get lost when running errands and forget appointments. This news was particularly disconcerting due to my family’s history with dementia.
The described symptoms of forgetfulness and disorientation are consistent with mild cognitive impairment, and it is not uncommon for close friends and family to become aware of these setbacks before the person, as it was for the above individual.
This is a newly defined stage of Alzheimer’s disease (AD) where changes in the brain begin to occur before memory, cognition, mood, or behavior is measurably or severely impacted.
Individuals in this state may never develop the disease, but possess some of the known biological markers. People affected cover the gamut from being entirely asymptomatic to presenting early signs of cognitive decline that do not qualify as what is referred to as mild cognitive impairment(MCI).
Signs and symptoms of preclinical AD are:
- Beta-amyloid accumulation, detectable by PET imaging or cerebrospinal fluid testing
- Tau protein found in cerebrospinal fluid(CSF)
- Grey matter reduction
- Reduced activity levels in areas of the brain typically affected by Alzheimer’s
- Slight cognitive decline, though not significant enough to meet MCI criteria
The goddesses of forgetfulness and memory, Lethe and Mnemosyne, are a capricious pair. At their whim, we can be propelled to the heights of wisdom or the depths of madness. Following an Alzheimer’s diagnosis, I now found myself at their mercy, which was often absent for those they would wantonly dement. As time carried on, my grasp on reality was slipping. Days would blend together, things would disappear, and obligations would be forgotten. The mind I had cultivated over a lifetime, was now slowly waning. Those unaware of my illness tended to disregard my behavior as simple products of thoughtlessness and discourtesy.
I was ill equipped to face the beasts that loomed ever nearer, threatening to take all that I am. Despite knowing that I could not last forever, I would dedicate everything to staving off its procession.
My daughter came by often. When talking about the implications of my illness she would usually provide some platitude to placate my fears, but despite their naivete, her words heartened me. I knew that no matter how much the disease changed me, she would be by my side.
Early-stage Alzheimer’s disease is diagnosed when issues with memory and thinking become more apparent, such that daily functions are hindered. The person is still capable of independent activities in this stage.
Those afflicted with Alzheimer’s disease in this stage may experience some of the following symptoms:
- Trouble applying words/names to appropriate people or objects
- Difficulty remembering recently acquired information
- Carrying out tasks with reduced proficiency
- Losing or misplacing a valuable object
- Problems staying organized
- Changes in mood
My mother had started to see things and keep odd hour, often spending the night yelling profanities at the illusory dogs that harassed her. Once the dawn came, the incorporeal canines would leave her be and she would return to her normal self; a kind, god-fearing woman who would sooner die than utter a lick of profanity. I loved her dearly, in spite of what she had become, but I would be lying if I said that watching her slowly dwindle before my eyes didn’t bring me pain.
The disease progression now causes a number of behavioral and neuro-psychological changes. People lose much of their ability to carry out basic activities and their long-term memory is impacted, typically becoming more dependent on caregiving.
Here are this stage’s symptoms:
- Short-term memory loss increases and long-term memory loss begins to occur, causing people to forget friends and family members. It is normal for them to make up stories to fill in these gaps.
- Diminished coordination and muscle tone: as brain cells continue to die, strength and dexterity are reduced, increasing risk of fall and injury.
- Decreased vocabulary: as a result of neuro-degradation, individuals will have less language fluency.
- Delusions: i.e. strongly held, false beliefs that are held in the face of evidence to the contrary. 30 percent of those affected by AD experience delusions and often paranoia as well.
- Hallucinations: perceiving things that are not present or occurring.
- Sundowning: increased confusion and agitation coinciding with changes in light, particularly during at sundown in late afternoon or early evening.
- Incontinence: decreased ability to control one’s bladder or bowels.
- Emotional outbursts: these include uncharacteristic irritability, crying, and aggression.
- Wandering: confusion and memory loss can lead to patients roaming aimlessly and getting lost.
- Decreased inhibitions: they are more willing to engage in actions that have been deemed by their former selves or society as unacceptable.
My aunt had been incapable of self-care or speech for a while, and the nurses informed me that she was no longer able to walk. I found her sitting in her favorite red wicker chair, gazing idly with her lips pursed as she hummed some broken tune. “Hello, Mara! Have you been well?” To which she provided no response, as had been the norm for quite some time. I continued, “So, what colors would you like today?”, again, came no reply. I found a jar of periwinkle and began painting, though faint tremble in her hands made the task slightly more difficult. I noticed her eyes staring blankly into my own. The moments of lucidity that once filled me with hope were now little more than cruel taunts of a disease that had all but destroyed the woman for whom I cared dearly. I knew that her dwindling flame would shortly fade, but instead of heartache, I almost felt relief.
In this stage of the disease, individuals with dementia are almost entirely reliant upon caregivers as a result of their worsening condition.
This stage’s symptoms include:
- Limited or no capacity for communication: People with dementia display an increased level of difficulty when attempting to speak or are nonverbal. They may not be able to communicate pain or discomfort once they reach this stage.
- Fading cognitive skills: They grow less aware of their environment and may often be incoherent.
- Loss of coordination: They become unable to control muscle movements. At this point, it is common for patients to no longer be ambulatory.
- Major personality changes: There may seem like there is very little left of their personality.
- Loss of appetite: They may lose their appetite and ability to feed themselves, putting them at risk for malnutrition.
There are no known cures, nor means of significantly slowing the illness, but palliative measures exist and are intended to aid with quality of life on this difficult journey.
A number of medications are used to maintain mental function, but these only provide a temporary fix that may or may not be useful for limited periods of time.
- Acetylcholinesterase inhibitors, like Rivastigmine, Galantamine and Donepezil, are used to improve cognitive function in those suffering from mild to moderate symptoms, but have shown little efficacy when used in the late stages of AD.
- When the symptoms increase in severity, an NMDA (N-Methyl-D-aspartate) receptor antagonist called Memantine is utilized.
- Antidepressants: used to control low mood and irritability that occur in most dementia cases. These include Citalopram, Fluoxetine, Paroxetine, Sertraline, and Trazodone.
- Anxiolytics: Lorazepam and Oxazepam are examples of medication used to treat anxiety and associated issues.
- Atypical antipsychotics: employed to treat hallucinations, delusions, and aggression that occur as AD gains ground. Haloperidol, Aripiprazole, Olanzapine, Quetiapine, Risperidone, and Ziprasidone.
There are techniques to help those with AD cope with their illness and symptoms in a more positive manner. While there are a number of approaches that have little to no scientific evidence supporting their efficacy, many can be used to reduce stress, ease social interaction, and comfort individuals with AD.
- Behavioral: Interventions meant to reduce behavioral issues in the person with dementia and improve mood and well-being. Activities have been designed to enhance quality of life through engagement, social interaction, and opportunities for self-expression and autonomy.
- Cognitive: Attempts to decrease deficits in a person’s cognitive function and capacity using cognitive retraining and reality orientation. Cognitive retraining attempts to improve cognition by having the person perform tasks that retrain extant neural pathways or attempt to create new ones. Reality orientation involves regularly putting forth information regarding time, place, or person, so that confusion may be reduced and understanding be engendered. It has been demonstrated that both can increase cognition, though the extent of improvement remains in question.
- Emotional: Attending to the subjective perceptions and experiences of the individual with AD. Some studies suggest that doing so may lead to a reduction in behavioral problems and improve cognition. Simulated presence therapy (SPT) and Reminiscence therapy (RT) are two such approaches. In SPT, recordings of loved ones are played, with the idea that the sense of comfort and familiarity might reduce behavioral problems. In RT, past experiences are discussed with the aid of mementos such as photos and familiar items, a process that is believed to jog long term memories and improve mood and cognition.
- Stimulation: Using art, music, pets, exercise, and other leisurely pursuits to boost mood, behavior, and functional abilities, appeal to prior interests, and reduce monotony.
There are a number of characteristics and conditions that can increase one’s chances of developing Alzheimer’s; however, It should be noted that the presence of one or more of the following factors does not necessarily mean that the disease will manifest.
The likelihood of developing AD doubles every 5 years after reaching the age of 65, a point of major concern, as this age group is the fastest growing with the increase in longevity and the shift of the Baby Boomer generation into older age.
Exposure to high amounts of certain metals, air pollutants, nutrition, various pesticides, and stress have been linked to AD.
Individuals with one or more relatives with AD are more likely to develop the disease, due to heredity and/or environment.
There are genes that increase one’s risk of developing Alzheimer’s by facilitating the formation of longer- form amyloid beta peptide plaque clusters between nerve cells, the presence of which is believed to result in neurodegeneration. The genes are as follows; Apolipoprotein E 4 (ApoE-ε4), Amyloid precursor protein (APP), Presenilin-1 and 2 (PS-1 and PS-2).
Those with a history of head trauma are 4.5 times more likely to suffer from AD than those without. This has to do to with the chemical changes that may occur as a result of brain injury.
Hypertension, high cholesterol, stroke, heart disease, and many other medical issues that negatively impact the circulatory system significantly raise one’s chances of AD. Reasons for this include strokes or extant damage to the brain’s vessels, which raise the likelihood of Alzheimer’s symptoms appearing once tangles and plaques arise in their brains.
Most people would naturally prefer to avoid the prospect of facing Alzheimer’s. It is said the people fear losing their memory as much or more than they fear death. As daunting as this possibility may be, it is important to not let our own fear and biases negatively affect those who are experiencing the disease. Knowledge about Alzheimer’s symptoms and progression of the disease can allow for sound medical and legal planning and decisions to be made as soon as possible. A diagnosis can also provide the family some relief, knowing the reason for worrisome symptoms and making a plan for how to move forward.
- Scales, K., Zimmerman, S., & Miller, S. J. (2018). Evidence-Based Nonpharmacological Practices to Address Behavioral and Psychological Symptoms of Dementia. The Gerontologist, 58(suppl_1), S88-S102.