You are 48 years old. You are driving down the road to visit a good friend, a friend whose home you have been to many times in the past. You are listening to the radio, singing along with some tunes from the 70’s (…Stayin Alive, Stayin Alive…).
The light up ahead turns red and you come to a stop. You wait. The light turns green, and suddenly you don’t know where you are. For a brief second you are lost. You hesitate, the car behind you blows his horn, and you are confused for a moment. Was I supposed to go straight or turn right at this intersection?
After a second or two it all comes back to you and you breath a sigh of relief as you drive on. And then suddenly you become anxious as the thought hits you: Was that a sign of Alzheimer’s disease? Could I be manifesting the early symptoms of dementia?
Well, the 48 year old mentioned above is me, and I am pretty sure I don’t have Alzheimer’s disease. And I am sure that many of you who have experienced the same thing, that brief lapse in orientation, do not have Alzheimer’s disease either.
But how can we really be sure?
Alzheimer’s Disease-Growing in Number
There are about 4 million Americans who currently have Alzheimer’s disease, or approximately 1 1/2 % of the population. That number is expected to grow to over 20 million in the next 50 years.
Alzheimer’s disease is the most common cause of dementia, a scary word physicians use to describe a significant decline in our cognitive (thinking) abilities, usually brought on by brain degeneration or dysfunction. The classic diagnostic features of dementia are memory impairment, disturbances in executive (or higher order) thinking, language disturbance (just can’t think of the correct word), impaired ability to recognize familiar objects, and difficulty performing common motor activities such as dressing, brushing the teeth, etc.
Dementia may be caused by diseases other than Alzheimer’s Disease, and many of these may even be correctable or treatable. Examples include cerebrovascular disease (e.g. stroke and multi-infarct dementia); medication side effects; psychiatric illness; and some chronic illnesses such as hypertension, diabetes, and low thyroid. But by far, Alzheimer’s Disease is the most common cause of dementia (accounting for about 50-75% of cases).
Early Clinical Course:
The clinical progression of Alzheimer’s Disease usually occurs over many years (approximately a decade from onset of symptoms to death). The earliest symptoms of the disease are lumped together into a term we call mild cognitive impairment (e.g. being lost at the stoplight, as in our example above). But everyone over 40 seems to have had an episode of that, haven’t they? The key is when these episodes keep recurring.
Other significant early symptoms are forgetfulness, repetitive questioning (Honey, where did you say you put my reading glasses?), and getting lost in otherwise familiar surroundings.
As the disease progresses, the performance of common daily activities begins to decline. We see that preparing a meal becomes frustrating and confusing, or mowing the lawn is difficult because you can’t remember exactly how to start the lawnmower. Managing money becomes confusing and more and more impossible.
We begin to see that even routine activities such as shopping for groceries or performing house work begin to suffer. At work, job performance declines.
In addition to these cognitive deficiencies, many patients begin to manifest behavioral and personality changes. Some begin to socially withdraw because of their embarrass-ment over their cognitive disabilities. Many begin to show mood changes such as depression, anger, irritability and aggressiveness.
This is the point at which most patients present to their physicians for evaluation-the memory loss, the cognitive decline, the personality changes, are beginning to affect the patient’s lives (and the lives of their loved ones).
Not a pretty picture is it? My heart goes out to anyone experiencing this affliction. There’s no sugar-coating it: Alzheimer’s disease is a horrific, unrelenting assault on the brain.
But what exactly is happening on a microscopic level?
The Pathology behind Alzheimer’s Disease:
For some as yet unknown reason, an abnormal protein called amyloid forms in the brain, deep among the brain cells (the neurons), creating multiple hard, insoluble plaques that injure and ultimately destroy these neurons. At the same time, something is happening within the neurons themselves: tangles are being formed in the microtubules that normally criss-cross the cell. These neurofibrillary tangles also cause neuron death.
So Alzheimer’s disease is a process of abnormal protein plaques (amyloid) and intra-cellular tangles-all leading to neuron cell death.
What causes all this to happen?
Unfortunately, at the present time, we just don’t know for sure. We do know that there are some risk factors, which tend to increase our chances of getting Alzheimer’s disease, such as advancing age and genetics (but good luck trying to change those!). Genetics particularly plays a role in early onset Alzheimer’s Disease, the dementia syndrome which occurs in younger patients, as early as age 40.
But are there risk factors that we can do something about?
Yes, there are some risk factors which we know increase our chance of getting Alzheimer’s dementia, and which we know we can modify or improve upon. For example, cerebrovascular disease (i.e. hardening of the arteries in the brain), which is caused by cholesterol build up, high blood pressure, diabetes, and cigarette smoking, is a significant risk factor for Alzheimer’s. So when we attack our cholesterol, exercise, eat right, lower our blood pressure, and quit smoking, we are reducing our risks for Alzheimer’s Disease as well as cardiovascular disease.
We also know that brain injury, whether it be from external sources such as repeated head trauma (boxing, football, hockey, etc), or from internal sources such as hemorrhagic stroke, brain infection (encephalitis or meningitis), or exposure to toxic chemicals, can lead to Alzheimer’s disease.
We have also found that in some patients clinical depression can increase the risk for Alzheimer’s. But we don’t know if treating the depression actually forestalls the disease.
And we know for sure that less educated and less intellectually stimulated patients are more at risk for Alzheimer’s (the old saying “use it or lose it” seems to apply here).
Diagnosis:
Actually, clinicians are quite good at diagnosing Alzheimer’s disease in all but the very earliest stages. Unfortunately, there are no clinical markers for the disease, so we can’t just draw a blood sample or do a brain scan to detect it. Therefore, we must rely heavily on the patient’s history and symptoms, which we discussed above.
Medical specialists have developed very specific questioneers, which aid in the diagnosis. However, having said that, the physician will still do a thorough medical exam, basic lab tests, and brain imaging to rule out other disorders which can cause dementia, some of which might even be treatable.
Regarding genetic testing, this is expensive and only indicated where there seems to be a strong family history for the disease, such as that seen in the early-onset type of Alzheimer’s.
We are diagnosing Alzheimer’s disease at a much earlier stage these days, which is helpful not only for the patient and family’s own understanding and well-being, but also because newer drugs are available which slow (but not halt) the progression of the disease.
After the Diagnosis:
There are several aspects to the total care of the Alzheimer patient. First, we want to slow the progression of the dementia as much as possible by using prescription medications as well as several natural compounds, both of which seem to work (at least for a while). And second, we want to offer common sense support and advice for the patient (and his family) as his intellectual function further declines. For example, how long can an Alzheimer’s patient continue to safely drive? What about money management and financial matters? And even more urgent, what safeguards do we have in place to prevent the patient from wandering off and getting lost or hurt?
Drug Therapy:
First, let us discuss the many new drugs which assist us in our goal of slowing the intellectual decline. But be forewarned: not every patient responds to them, the results can be quite variable, and the effectiveness seems to wane over time (we are talking months, not years).
Until last year we only had one class of drugs for the treatment of mild to moderate Alzheimer’s disease. This class, the so called “cholinesterase inhibitors,” includes several medications which you might have heard of on the TV or radio: Aricept, Cognex, Exelon, and Reminyl.
Studies that I reviewed for this article seem to show the following about these medications: while all of these drugs seem to have some benefit, Aricept seemed to have fewer side effects than the others (less nausea, vomiting). One study I read indicated that Cognex might be a little less effective than the other drugs in this class. But all seemed to slow the progression in the dementia for several months.
Now, for some good news:
A new drug, just released this year, is called Namenda (memantine). It is a new class of Alzheimer’s drug (an NMDA antagonist), not related to the cholinesterase inhibitors (no nausea or vomiting, but it can cause some lightheadedness, dizziness and minor headache). It has shown to be moderately effective, just like the others, but with less side effects. That in and of itself is good news.
But what is really exciting is that recent studies seem to indicate that when Namenda is used in combination with donepezil (Aricept), it is even better. Studies are still ongoing to see how long this effectiveness might last, and to also discover if the combination of Namenda with the other cholinesterase inhibitors works equally well. But for the patients and their families fighting this terrible nightmare, this is terrific news.
Non-Prescription Medication Options:
I also want to tell you about other options, i.e. non-prescription, naturally occurring compounds that seem to help some patients. The herb gingko biloba is somewhat effective in slowing Alzheimer’s progression (but not preventing it). It is a natural compound with very few side effects. It is not dramatic, but studies seem to indicate it can help. I would advise talking to your doctor first, because it is not clear how gingko might react with the other prescription Alzheimer’s medications.
Many naturalists have touted Vitamin E as being helpful in Alzheimer’s prevention and treatment. Studies are conflicting. One study showed that 1000 units of Vitamin E twice a day did seem to slow down the progression of moderate stage Alzheimer’s to the severe stage. But vitamin E in high doses can be problematic, so talk to your doctor first before ever trying this high a dose. On the other hand, moderate doses (400-800 units) shouldn’t really harm anyone, so I am not against trying it as a preventative measure, or in the adjunct treatment of early Alzheimer’s.
Some naturopaths suggest adding Vitamin C to the E, but again, studies have not confirmed effectiveness.
Anti-inflammatories such as aspirin, ibuprophen, and naprosyn may seem to have minor protective effects in preventing dementia (apparently by reducing central nervous system inflammation), but they also carry significant side effects and risks, especially in our older patients. The use of these types of medications after the dementia has begun has not been shown to be effective, but studies are ongoing in this area.
The Non Medical Treatments:
Other treatment options, besides medications, are the therapies designed for the physical and emotional support of the patient, as well as his family and caregivers. The Alzheimer’s Association (AA) has wonderful and practical advice in the general care of and support for the patient and his family. Another great source is Alzheimer’s Disease Education and Referral Center (www.alzheimers.org).
In Conclusion:
Knowing what I know about Alzheimer’s Disease as of September 2004, I would recommend the following to reduce one’s risks for getting Alzheimer’s dementia:
1) Do not smoke;
2) Exercise daily– by walking briskly, or by lifting light weights, or by doing any activity which increases your heart rate by 60% for a sustained period of time, (usually 30 minutes). The average adult’s heart rate is around 75, so exercise it up to 120 beats per minute;
3) Get your cholesterol checked and treat it if it is high (and do not fear the statin drugs-they are lifesavers!);
4) check your blood pressure and keep it at or below 120/70!
5) check your fasting blood sugar, looking for diabetes, and get immediate treatment if elevated; and if overweight, please try and shed just ten pounds;
6) Exercise your brain! Read, study, debate, discuss, do crossword puzzles; anything but sit and look at the TV!
7) Eat more cold water fish (halibut, sea bass, snapper and the like, or, if you do not like fish that much, try taking a fish oil supplement rich in omega-3 fatty acids;
8) take a multi-vitamin with at least 400 mg of folic acid; there are no studies which say it helps, but it doesn’t hurt.
9) take 400-800 units of Vitamin E (still don’t know if it prevents, but it shouldn’t do any harm); and consider taking ginko biloba as well;
10) Be very cautious about engaging in activities which can injure your brain, especially if you ever receive a concussion more than once; at that point your free-wheeling days of head-butting are over!
11) Address any mental or psychological symptoms you may have-depression, for some unknown reason, increases your risk.
12) Say your prayers every day!
