Alzheimers Disease guidelines

What Is Alzheimer's?

"Alzheimer's disease" is the term used to describe a dementing disorder marked by certain brain changes, regardless of the age of onset. Alzheimer's disease is not a normal part of aging--it is not something that inevitably happens in later life. Rather, it is one of the dementing disorders, a group of brain diseases that lead to the loss of mental and physical functions. The disorder, whose cause is unknown, affects a small but significant percentage of older Americans. A very small minority of Alzheimer's patients are under 50 years of age. Most are over 65.

Alzheimer's disease is the exception, rather than the rule, in old age. Only 5 to 6 percent of older people are afflicted by Alzheimer's disease or a related dementia--but this means approximately 3 to 4 million Americans have one of these debilitating disorders. Research indicates that 1 percent of the population aged 65-74 has severe dementia, increasing to 7 percent of those aged 75-84 and to 25 percent of those 85 or older. At least half the people in U.S. nursing homes have Alzheimer's disease or a related disorder; in 1985, the annual cost of caring for individuals with Alzheimer's disease and related dementias in institutional and community settings was estimated between $24 billion and $48 billion for direct costs alone and is probably higher today. As our population ages and the number of Alzheimer's patients increases, costs of care will rise as well.

Although Alzheimer's disease is reversible, there are ways to alleviate symptoms and suffering and to assist families. Not every person with this illness must necessarily move to a nursing home. Many thousands of patients--especially those in the early stages of the disease--are cared for by their families in the community. Indeed, one of the most important aspects of medical management is family education and family support services. When, or whether, to transfer a patient to a nursing home is a decision to be carefully considered by the family.

Who Gets Alzheimer's Disease?

The main risk factor for Alzheimer's disease is increased age. The rates of the disease increase markedly with advancing age, with 25 percent of people over 85 suffering from Alzheimer's or other severe dementia.

At the same time, data indicate that the likelihood that a close relative (sibling, child, or parent) of an afflicted individual will develop Alzheimer's disease is low. In most cases, such an individual's risk is only slightly higher than that of someone in the general population, where the lifetime risk is below 1 percent. And, of course, many disorders have a genetic potential that is never expressed--that is, despite being at risk for a certain illness, one might go through life without ever developing any symptom of the disease.

What To Expect When Someone Has Alzheimer's Disease

-- The person will lose memory, forget to do what they are supposed to do. Such as buying grocery, paying bills and doing the day to day things.
Some people get agitated, delirious, develop paranoid symptoms and are restless. There is a personality change!

They need help with eating, going to the bathroom and dressing.

The onset of Alzheimer's disease is usually very slow and gradual, seldom occurring before age 65. Over time, however, it follows a progressively more serious course. Among the symptoms that typically develop, none is unique to Alzheimer's disease at its various stages. It is therefore essential for suspicious changes to be thoroughly evaluated before they become inappropriately or negligently labeled Alzheimer's disease.

Problems of memory, particularly recent or short-term memory, are common early in the course of the disease. For example, the individual may, on repeated occasions, forget to turn off the iron or may not recall which of the morning's medicines were taken. Mild personality changes, such as less spontaneity or a sense of apathy and a tendency to withdraw from social interactions, may occur early in the illness. As the disease progresses, problems in abstract thinking or in intellectual functioning develop. The individual may begin to have trouble with figures when working on bills, with understanding what is being read, or with organizing the day's work. Further disturbances in behavior and appearance may also be seen at this point, such as agitation, irritability, quarrelsomeness, and diminishing ability to dress appropriately.

Later in the course of the disorder, the affected individuals may become confused or disoriented about what month or year it is and be unable to describe accurately where they live or to name correctly a place being visited. Eventually they may wander, be unable to engage in conversation, seem inattentive and erratic in mood, appear uncooperative, lose bladder and bowel control, and, in extreme cases, become totally incapable of caring for themselves if the final stage is reached. Death then follows, perhaps from pneumonia or some other problem that occurs in severely deteriorated states of health. The average course of the disease from the time it is recognized to death is about 6 to 8 years, but it may range from under 2 to over 20 years. Those who develop the disorder later in life may die from other illnesses (such as heart disease) before Alzheimer's disease reaches its final and most serious stage.

Though the changes just described represent the general range of symptoms for Alzheimer's disease, the specific problems, along with the rate and severity of decline, can vary considerably with different individuals. Indeed, most persons with Alzheimer's disease can function at a reasonable level and remain at home far into the course of the disorder. Moreover, throughout much of the course of the illness individuals maintain the capacity for giving and receiving love, for sharing warm interpersonal relationships, and for participating in a variety of meaningful activities with family and friends.

A person with Alzheimer's disease may no longer be able to do math, but still be able to read a magazine with pleasure for months or years to come. Playing the piano might become too stressful in the face of increasing mistakes, but singing along with others may still be satisfying. The chess board may have to be put away, but one may still be able to play tennis. Thus, despite the many exasperating moments in the lives of Alzheimer patients and their families, many opportunities remain for positive interactions. Challenge, frustration, closeness, anger, warmth, sadness, and satisfaction may all be experienced by those who work to help the person with Alzheimer's disease cope as well as possible with the disease.

The reaction of an individual to the illness--his or her capacity to cope with it--also varies and may depend on such factors as lifelong personality patterns and the nature and severity of stress in the immediate environment. Depression, severe uneasiness, and paranoia or delusions may accompany or result from the disease, but they can often be alleviated by appropriate treatments. Although there is no cure for Alzheimer's disease, treatments are available to alleviate many of the symptoms that cause suffering.

The Diagnosis Of Alzheimer's Disease

Abnormal Brain Tissue Findings

1. Plaques and Tangles

Microscopic brain tissue changes have been described in Alzheimer's disease since Alois Alzheimer first reported them in 1906. The two principal changes are senile or neuritic plaques (chemical deposits consisting of degenerating nerve cells combined with a form of protein called beta amyloid) and neurofibrillary tangles (malformations within nerve cells). The brains of Alzheimer's disease patients of all ages reveal these findings on autopsy examination.

The plaques found in the brains of people with Alzheimer's disease appear to be made, in part, from protein molecules--amyloid precursor protein (APP)--that normally are essential components of the brain. Plaques are made when an enzyme snips APP apart at a specific place and then leaves the fragments--beta amyloid--in brain tissue where they come together in abnormal deposits. It has not as yet been definitely determined how neurofibrillary tangles are formed.

As research on Alzheimer's disease progresses, scientists are describing other abnormal anatomical and chemical changes associated with the disease. These include nerve cell degeneration in the brain's nucleus basalis of Meynert and reduced levels of the neurotransmitter acetylcholine in the brains of Alzheimer's disease victims. But from a practical standpoint, the "classical" plaque and tangle changes seen in the brain at autopsy typically suffice for a diagnosis of Alzheimer's disease. In fact, it is still only through the study of brain tissue from a person who was thought to have Alzheimer's disease that a definitive diagnosis of the disorder can be made.

2. Brain Scans

Computer-Assisted Tomography (CAT scan) changes become more evident as the disease progresses--not necessarily early on. Thus a CAT scan performed in the first stages of the disease cannot in itself be used to make a definitive diagnosis of Alzheimer's disease; its value is in helping to establish whether certain disorders (some reversible) that mimic Alzheimer's disease are present. Later on, CAT scans often reveal changes characteristic of Alzheimer's disease, namely an atrophied (shrunken) brain with widened sulci (tissue indentations) and enlarged cerebral ventricles (fluid-filled chambers).

Several new types of instrumentation are enabling researchers to learn even more about the brain. Both positron emission tomography (PET scan) and SPECT (single photon emission computerized tomography) can map regional cerebral blood flow, metabolic activity, and distribution of specific receptors, as well as integrity of the blood-brain barrier. These procedures may reveal abnormalities characteristic of Alzheimer's disease. Another method, magnetic-resonance imaging (MRI), probes the brain by examining the interaction of the magnetic properties of atoms with an external magnetic field. MRI provides both structural and chemical information and distinguishes moving blood from static brain tissue (Taylor, 1990).

Clinical Features of Alzheimer's Disease

The "clinical" features of Alzheimer's disease, as opposed to the "tissue" changes, are threefold:

1. Dementia--significant loss of intellectual abilities such as memory capacity, severe enough to interfere with social or occupational functioning;

2. Insidious onset of symptoms--subtly progressive and irreversible course with documented deterioration over time;

3. Exclusion of all other specific causes of dementia by history, physical examination, laboratory tests, psychometric, and other studies.

Diagnosis by Exclusion

Based on these criteria, the clinical diagnosis of Alzheimer's disease has been referred to as "a diagnosis by exclusion," and one that can only be made in the face of clinical deterioration over time. There is no specific clinical test or finding that is unique to Alzheimer's disease. Hence, all disorders that can bring on similar symptoms must be systematically excluded or "ruled out." This explains why diagnostic workups of individuals where the question of Alzheimer's disease has been raised can be so frustrating to patient and family alike; they are not told that Alzheimer's disease has been specifically diagnosed, but that other possible diagnoses have been dismissed, leaving Alzheimer's disease as the likely diagnosis by the process of elimination.

Some scientists think that the results from biochemical research may lead to a diagnostic "marker" for certain persons evaluated for Alzheimer's disease. For example, research has discovered a protein, called Alzheimer's Disease Associated Protein (ADAP), in the autopsied brains of Alzheimer's patients. The protein, which seems to appear only in people with Alzheimer's, is mainly concentrated in the cortex covering the front and side sections of the brain, regions involved in memory function. Researchers have found ADAP not only in brain tissue but also in spinal fluid. If they can perfect a test to detect the protein in the cerebrospinal fluid, or potentially even circulating in the blood, it may be possible to use this method of diagnosis on living patients.

Many scientists are working at developing other tests or procedures that may someday identify living persons with the disorder, perhaps even early in its course before behavioral changes become evident. Still, a reliable, specific diagnostic marker for Alzheimer's disease is not yet available.

Meanwhile, Alzheimer's disease is the most overdiagnosed and misdiagnosed disorder of mental functioning in older adults. Part of the problem, already alluded to, is that many other disorders show symptoms that resemble those of Alzheimer's disease. The crucial difference, though, is that many of these disorders--unlike Alzheimer's disease--may be stopped, reversed, or cured with appropriate treatment. But first they must be identified and not dismissed as Alzheimer's disease or senility.

Conditions that affect the brain and result in intellectual, behavioral, and psychological dysfunction are referred to as "organic mental disorders." These disorders represent a broad grouping of diseases and include Alzheimer's disease. Organic mental disorders that can cause clinical problems like those of Alzheimer's disease, but which might be reversible or controlled with proper diagnosis and treatment, include the following:

Side Effects of Medications: Unusual reactions to medications, too much or too little of prescribed medications, combinations of medications which, when taken together, cause adverse side effects.
Substance Abuse: Abuse of legal and/or illegal drugs, alcohol abuse.
Metabolic Disorders: Thyroid problems, nutritional deficiencies, anemias, etc.
Circulatory Disorders: Heart problems, strokes, etc.
Neurological Disorders: Normal-pressure hydrocephalus, multiple sclerosis, etc.
Infections: Especially viral or fungal infections of the brain.
Trauma: Injuries to the head.
Toxic Factors: Carbon monoxide, methyl alcohol, etc.
Tumors: Any type within the skull--whether originating or metastasizing there.

In addition to organic mental disorders resulting from these diverse causes, other forms of mental dysfunction or mental health problems can also be confused with Alzheimer's disease. For example, severe forms of depression can cause problems with memory and concentration that initially may be indistinguishable from early symptoms of Alzheimer's disease. Sometimes these conditions, referred to as "pseudodementia," can be reversed. Other psychiatric problems can similarly masquerade as Alzheimer's disease, and, like depression, respond to treatment.

Of course, not all memory changes or complaints in later life signal Alzheimer's disease or mental disorder. Many memory changes are only temporary, such as those that occur with bereavement or any stressful situation that makes it difficult to concentrate. In fact, older people are often accused or accuse themselves of memory changes which are not really taking place. If a person in his thirties misplaces keys or a wallet, forgets the name of a neighbor, or calls one sibling by another's name, nobody gives it a second thought. But the same normal forgetfulness for people in their seventies may raise unjustifiable concern. On the other hand, serious memory difficulties should not be dismissed as an unavoidable part of normal aging. Since rigorous studies on intelligence in later life show that healthy people who stay intellectually active maintain a sharp mind throughout the life cycle, noticeable decline in older adults that interferes with functioning should be clinically explored for an underlying problem.

The Importance of a Comprehensive Clinical Evaluation

Because of the many other disorders that can be confused with Alzheimer's disease, a comprehensive clinical evaluation is essential to arrive at a correct diagnosis of symptoms that look like those of Alzheimer's disease. Such an assessment should include at least three major components--(1) a thorough general medical workup, (2) a neurological examination, and (3) a psychiatric evaluation that may include psychological or psychometric testing. The family physician can be consulted about the best way to get the necessary examinations.

Is there any treatment?
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www.cidpusa.org www.cidpusa.org/P/ivig.htm http://www.cidpusa.org/disease.html http://www.cidpusa.org/Lahore.html

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