Alzheimer's disease (patient information)

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 * Assistant Editor-in-Chief: Meagan E. Doherty

Overview
Alzheimer's disease is a brain disease that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks. Memory problems are one of the first signs of Alzheimer's. People may have trouble remembering things that happened recently or names of people they know. Over time, symptoms will most often get worse, and problems can include getting lost, repeating questions, and taking longer than normal to finish daily tasks. As the disease progresses, people may have trouble learning new things, recognizing family and friends, and communicating. Eventually, they need total care.

Alzheimer's disease is the most common cause of dementia among older people. Dementia is a loss of thinking, remembering, and reasoning skills that interferes with a person's daily life and activities. Other causes of dementia include blood-vessel disease in the brain (called vascular dementia), Parkinson's disease, frontotemporal dementia, and Lewy body disease.

There are two types of AD -- early onset and late onset.
 * In early onset AD, symptoms first appear before age 60. Early onset AD is much less common than late onset. However, it tends to progress rapidly. Early onset disease can run in families. Several genes have been identified.
 * Late onset AD, the most common form of the disease, develops in people age 60 and older. Late onset AD may run in some families, but the role of genes is less clear.

What are the symptoms of Alzheimer's disease?
Dementia symptoms include difficulty with many areas of mental function, including:
 * Language
 * Memory
 * Perception
 * Emotional behavior or personality
 * Cognitive skills (such as calculation, abstract thinking, or judgment

Dementia usually first appears as forgetfulness.

Mild cognitive impairment is the stage between normal forgetfulness due to aging, and the development of AD. People with MCI have mild problems with thinking and memory that do not interfere with everyday activities. They are often aware of the forgetfulness. Not everyone with MCI develops AD.

Symptoms of Mild cognitive impairment include:
 * Forgetting recent events or conversations
 * Difficulty performing more than one task at a time
 * Difficulty solving problems
 * Taking longer to perform more difficult activities

The early symptoms of AD can include:
 * Language problems, such as trouble finding the name of familiar objects
 * Misplacing items
 * Getting lost on familiar routes
 * Personality changes and loss of social skills
 * Losing interest in things previously enjoyed, flat mood
 * Difficulty performing tasks that take some thought, but used to come easily, such as balancing a checkbook, playing complex games (such as bridge), and learning new information or routines

'''As the AD becomes worse, symptoms are more obvious and interfere with your ability to take care of yourself. Symptoms can include:'''
 * Forgetting details about current events
 * Forgetting events in your own life history, losing awareness of who you are
 * Change in sleep patterns, often waking up at night
 * Difficulty reading or writing
 * Poor judgment and loss of ability to recognize danger
 * Using the wrong word, mispronouncing words, speaking in confusing sentences
 * Withdrawing from social contact
 * Having hallucinations, arguments, striking out, and violent behavior
 * Having delusions, depression, agitation
 * Difficulty doing basic tasks, such as preparing meals, choosing proper clothing, and driving

People with severe AD can no longer:
 * Understand language
 * Recognize family members
 * Perform basic activities of daily living, such as eating, dressing, and bathing

Other symptoms that may occur with AD:
 * Incontinence
 * Swallowing problems

What causes Alzheimer's disease?
Scientists don’t yet fully understand what causes Alzheimer’s disease, but it is clear that it develops because of a complex series of events that take place in the brain over a long period of time. It is likely that the causes include genetic, environmental, and lifestyle factors. Because people differ in their genetic make-up and lifestyle, the importance of these factors for preventing or delaying Alzheimer’s differs from person to person.

In a very few families, people develop Alzheimer’s disease in their 30s, 40s, and 50s. Many of these people have a mutation, or permanent change, in one of three genes that they inherited from a parent. We know that these gene mutations cause Alzheimer’s in these “early-onset” familial cases. Not all early-onset cases are caused by such mutations.

Most people with Alzheimer’s disease have “late-onset” Alzheimer’s, which usually develops after age 60. Many studies have linked a gene called APOE to late-onset Alzheimer’s. This gene has several forms. One of them, APOE ε4, increases a person’s risk of getting the disease. About 40 percent of all people who develop late-onset Alzheimer’s carry this gene. However, carrying the APOE ε4 form of the gene does not necessarily mean that a person will develop Alzheimer’s disease, and people carrying no APOE ε4 forms can also develop the disease.

Most experts believe that additional genes may influence the development of late-onset Alzheimer’s in some way. Scientists around the world are searching for these genes. Researchers have identified variants of the SORL1, CLU, PICALM, and CR1 genes that may play a role in risk of late-onset Alzheimer’s.

Lifestyle Factors
A nutritious diet, physical activity, social engagement, and mentally stimulating pursuits can all help people stay healthy. New research suggests the possibility that these factors also might help to reduce the risk of cognitive decline and Alzheimer’s disease. Scientists are investigating associations between cognitive decline and vascular and metabolic conditions such as heart disease, stroke, high blood pressure, diabetes, and obesity. Understanding these relationships and testing them in clinical trials will help us understand whether reducing risk factors for these diseases may help with Alzheimer’s as well.

Who is at highest risk?

 * Age and family history are risk factors for AD.
 * As you get older, your risk of developing AD goes up. However, developing Alzheimer's disease is not a part of normal aging.
 * Having a close blood relative, such as a brother, sister, or parent who developed AD increases your risk.
 * Having certain combination of genes for proteins that appear to be abnormal in Alzheimer's disease also increases your risk.


 * Other risk factors that are not as well proven include:
 * Longstanding high blood pressure
 * History of head trauma
 * Female gender

Diagnosis

 * Alzheimer’s disease can be definitively diagnosed only after death by linking clinical course with an examination of brain tissue and pathology in an autopsy. But doctors now have several methods and tools to help them determine fairly accurately whether a person who is having memory problems has “possible Alzheimer’s disease” (dementia may be due to another cause) or “probable Alzheimer’s disease” (no other cause for dementia can be found). To diagnose Alzheimer’s, doctors:
 * ask questions about the person’s overall health, past medical problems, ability to carry out daily activities, and changes in behavior and personal
 * conduct diagnostic tests of memory, problem solving, attention, counting, and language
 * carry out medical tests, such as tests of blood, urine, or spinal fluid
 * perform brain scans, such as computerized tomography (CT) or magnetic resonance imaging (MRI)
 * In the early stages of dementia, brain image scans may be normal. In later stages, an MRI may show a decrease in the size of different areas of the brain.
 * While the scans do not confirm the diagnosis of AD, they do exclude other causes of dementia (such as stroke and tumor).


 * These tests may be repeated to give doctors information about how the person’s memory is changing over time.


 * Tests may be ordered to help determine whether other medical problems could be causing dementia or making it worse. These conditions include:
 * Thyroid disease
 * Vitamin deficiency
 * Brain tumor
 * Stroke
 * Intoxication from medication
 * Chronic infection
 * Anemia
 * Severe depression

When to seek urgent medical care?

 * Call your health care provider if someone close to you experiences symptoms of senile dementia/Alzheimer's type.


 * Call your health care provider if a person with this disorder experiences a sudden change in mental status. (A rapid change may indicate other illness.)


 * Discuss the situation with your health care provider if you are caring for a person with this disorder and the condition deteriorates to the point where you can no longer care for the person in your home.

Treatment options
Unfortunately, there is no cure for AD. The goals in treating AD are to:
 * Slow the progression of the disease (although this is difficult to do)
 * Manage behavior problems, confusion, sleep problems, and agitation
 * Modify the home environment
 * Support family members and other caregivers

Drug therapy
Most drugs used to treat Alzheimer's are aimed at slowing the rate at which symptoms become worse. The benefit from these drugs is often small, and patients and their families may not always notice much of a change.

Patients and caregivers should ask their doctors the following questions about whether and when to use these drugs:
 * What are the potential side effects of the medicine and are they worth the risk, given that there will likely be only a small change in behavior or function?
 * When is the best time, if any, to use these drugs in the course of Alzheimer's disease?

Two types of medicine are available:
 * Donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne, formerly called Reminyl) affect the level of a chemical in the brain called acetylcholine. Side effects include indigestion, diarrhea, loss of appetite, nausea, vomiting, muscle cramps, and fatigue.
 * Memantine (Namenda) is another type of drug approved for treating AD. Possible side effects include agitation or anxiety.

Other medicines may be needed to control aggressive, agitated, or dangerous behaviors. These are usually given in very low doses.

It may be necessary to stop any medications that make confusion worse. Such medicines may include painkillers, cimetidine, central nervous system depressants, antihistamines, sleeping pills, and others. Never change or stop taking any medicines without first talking to your doctor.

Supplement therapy
Many people take folate (vitamin B9), vitamin B12, and vitamin E. However, there is no strong evidence that taking these vitamins prevents AD or slows the disease once it occurs.

Some people believe that the herb ginkgo biloba prevents or slows the development of dementia. However, high-quality studies have failed to show that this herb lowers the chance of developing dementia. DO NOT use ginkgo if you take blood-thinning medications like warfarin (Coumadin) or a class of antidepressants called monoamine oxidase inhibitors (MAOIs).

If you are considering any drugs or supplements, you should talk to your doctor first. Remember that herbs and supplements available over the counter are NOT regulated by the FDA.

Diseases with similar symptoms

 * Multi-infarct dementia (MID)
 * Parkinson's disease (PD)
 * Huntington's disease (HD)
 * Creutzfeldt-Jakob disease (CJD)
 * Depression
 * Normal Pressure Hydrocephalus
 * Pick's disease
 * Lewy Body dementia
 * Binswanger's disease
 * Wernicke-Korsakoff
 * Brain Tumors
 * Infection
 * Tyroid Problems
 * Vitamin B12 deficiency

Where to find medical care for Alzheimer's disease?
Directions to Hospitals Treating Alzheimer's disease

Prevention
Although there is no proven way to prevent AD, there are some practices that may be worth incorporating into your daily routine, particularly if you have a family history of dementia. Talk to your doctor about any of these approaches, especially those that involve taking a medication or supplement.
 * Consume a low-fat diet.
 * Eat cold-water fish (like tuna, salmon, and mackerel) rich in omega-3 fatty acids, at least 2 to 3 times per week.
 * Reduce your intake of linoleic acid found in margarine, butter, and dairy products.
 * Increase antioxidants like carotenoids, vitamin E, and vitamin C by eating plenty of darkly colored fruits and vegetables.
 * Maintain a normal blood pressure.
 * Stay mentally and socially active throughout your life.
 * Consider taking nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil, Motrin), sulindac (Clinoril), or indomethacin (Indocin). Statin drugs, a class of medications normally used for high cholesterol, may help lower your risk of AD. Talk to your doctor about the pros and cons of using these medications for prevention.

In addition, early testing of a vaccine against AD is underway.

What to expect (Outlook/Prognosis)?
How quickly AD gets worse is different for each person. If AD develops quickly, it is more likely to worsen quickly.

Patients with AD often die earlier than normal, although a patient may live anywhere from 3 - 20 years after diagnosis.

The final phase of the disease may last from a few months to several years. During that time, the patient becomes immobile and totally disabled.

Death usually occurs from an infection or a failure of other body systems.

Possible complications

 * Loss of ability to function or care for self
 * Bedsores, muscle contractures (loss of ability to move joints because of loss of muscle function), infection (particularly urinary tract infections and pneumonia), and other complications related to immobility during end stages of AD
 * Falls and broken bones
 * Loss of ability to interact
 * Malnutrition and dehydration
 * Failure of body systems
 * Harmful or violent behavior toward self or others
 * Abuse by an over-stressed caregiver

Support groups

 * Alzheimer's Association
 * Alzheimer's Disease Education and Referral Center
 * Alzheimer's Disease Research