Thursday, July 2, 2020

Alzheimer’s Disease: Symptoms, Treatment & Prevention

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Private purgatory awaits people diagnosed with the chronic condition of Alzheimer’s disease (AD). Alzheimer’s disease destroys memory and personality and the disease always leads to death. Alzheimer’s disease can be considered unsuccessful cognitive aging, as the brain degenerates slowly but progressively. The onset of Alzheimer’s disease is sneaky and may not be noticed by the patient or others. Mild impairments in memory progresses to behavioral abnormalities and moves onto dysfunctions in daily living. The end of life is often spent in a catatonic state with no control over bodily functions.

Cognitively Unsuccessful Aging

No one is successful at aging, for aging always leads to death. However, many people successfully navigate their senior years with their memory and personality intact. Some people may become forgetful, but Alzheimer’s changes the brain fundamentally. Many processes in the body decline in advancing years including muscular tone, exercise tolerance, immune system, and metabolism. However, these changes are decreases or declines in functioning and not fundamental changes or illnesses. Alzheimer’s disease  is a non-reversible illness in the brain with a median life expectancy of 5 or 6 years after diagnosis. It is a chronic illness and not a normal part of aging.

Taking care of someone with Alzheimer’s is much different than taking care of a child or someone with physical disabilities. A child’s brain is open and growing at an exponential rate. Infants and children are also small people and easier to physically handle. An Alzheimer’s disease  patient’s mind is not growing but rather the opposite. Patients are physically large, full-grown adults who cannot really get your logic and are often defiant. Furthermore, as a large percentage of our society is overweight and obese, and Alzheimer’s disease is associated with obesity, handling the extra large patients will be challenging.

Fear of Dementia

Some studies have indicated that people fear dementia more than cancer, heart disease, stroke, gaining weight, crime, impotence, and car accidents, presumably because dementia is incurable or without remedy. Three out of five people are also concerned that they may be the caretaker for someone with Alzheimer’s disease. Many fears are really anxieties due to inadequate education and preparation. In addition, many people assume that Alzheimer’s is genetic, inevitable, and non-preventable. People fear Alzheimer’s disease  because there is no cure. One way to not fear it, while waiting for science to find the cure, is to take preventative measures to delay or prevent the disease.

Fortunately, science is working hard on this brain mystery. Many resources are being employed as further research is needed. Recent studies to unmask the mystery of Alzheimer’s disease show that it may not be inevitable and may indeed be preventable. Specific behaviors like exercising and cognitively rich experiences with other people are known to help memory. Sound dietary and sleeping strategies as well as avoidance of toxic behaviors can go a long way to setting up the brain for success in the long run.

A commitment to learning how the brain works in relation to the body as a whole, keeps you alert to the ways in which you shut down your brain unintentionally. It is possible to care for the brain, stimulate it and keep it healthy over the lifespan. Mostly, cultivating an attitude of openness to new experiences will help you to be sure that your body quits before your brain.

On the left is an image of a normal brain, and the right is and image or a brain with Alzheimer’s Disease (images from wikimedia.org):

Stages of Alzheimer’s disease

Alzheimer’s kills two birds with one stone. First it robs the victim and then it takes the life of the caretaker, the person or persons who must help the patient carry on. Sometimes full realization of the consequences is in the middle stage, when problems really start to develop.

The stages vary and symptoms overlap but most organizations world-wide agree on the following stages:

  • Mild Alzheimer’s/Early Stage – A long period of accumulating cerebral lesions precedes the appearance of symptoms, so that people may have biomarkers or brain imaging abnormalities but no signs of impairment. The person may act normally, have no memory problems and a physician cannot find symptoms. Later, the patient or people close to them may notice some problems with memory. They may lose items and/or have gaps in finding words or remembering names. Problems with balancing a checkbook or with organizing tasks may be evident to the patient, friends, co-workers, and physician.
  • Moderate Alzheimer’s/Middle Stage – The patient is clearly losing items, forgetting recent events, is mathematically challenged, forgets important dates or numbers in their personal history, may become angry or paranoid, often asks what day it is, and often needs assistance in daily living. However, patients can still usually make their own meals, dress and use the toilet by themselves. Wandering and getting lost is a concern at this stage and later.
  • Severe Alzheimer’s/Late Stage – Memory is very bad. Patients may remember their own names, may recognize faces but not the names of others. Memory of personal history is lost or returns intermittently. Recent memory is lost and patients often do not know where they are. Personality is often much different from normal. Individuals who were nice may change to angry and bitter and vice versa. Some people may become very paranoid or become obsessive-compulsive. Daily living is very difficult as sleep patterns may change, dressing is abnormal, and toilet functions often require assistance. Finally, the patient cannot respond, move, sit up, eat, or swallow.

The Caregiver

When a person becomes disabled, whether from AD or a physical ailment, one family member usually takes responsibility for caring for the patient. This unpaid army of caregivers is usually females who have full time jobs and families of their own. The patient does not choose them nor do they choose the role of caregiver. They default to the role or get the role because they are nearby, available and at least somewhat capable and motivated to carry out the duties. The caregiver can be a spouse, a sibling, an adult child, or be intimately related to the patient in some way.

The caretaker’s job is extremely difficult and rarely acknowledged by others who are not doing the caretaking. Siblings may live far from the aging parent and do not appreciate the demands of caretaking or they can be in denial that their parent has Alzheimer’s disease . Caregivers often shoulder the burden alone, without support. In so doing, giving the gift of caring can become life threatening for the caretaker. 40-70 percent of caretakers suffer clinical depression, develop their own illnesses, and often end up six feet under before their care recipient does.

Prominent People with Alzheimer’s disease  and Their Caregiver

  • Ronald Reagan (U.S. President), Nancy Reagan, wife.
  • Charles Bronson (tough guy Actor), Kim Weeks, wife, and Catherine Pidgeon, sister.
  • Sugar Ray Robinson (professional Boxer), Millie Wiggins Bruce, wife. His children attempted to be involved in his care.
  • Rita Hayworth (Actress), Princess Yasmin Khan, daughter.

Alzheimer’s disease  is the Most Common Type of Dementia

Dementia is a generic term used to indicate deficits in brain functioning including mental, emotional, memory, judgment, and concentration. Daily living becomes impaired and assistance is often required. Dementia can be caused by, but is not limited to, brain trauma, fever, drug and alcohol abuse, and brain tumors. Neuropsychiatric symptoms are common in all dementia types and lead to suffering for both patients and caregivers. Quality of life decreases and may lead to additional stress, institutionalization and financial hardship. The four most common dementia types and mixed types are listed below:

  • Alzheimer Disease (AD) – Alzheimer’s is the most common type of dementia, 60-80% of dementia cases. Alzheimer’s disease patients have moderate levels of mood, psychotic, and frontal (disinhibition, irritability, depression, apathy, and aggression) neuropsychiatric symptoms.
  • Vascular Dementia (VAD) – the second most common type of dementia. Small strokes block arteries and decrease blood flow and oxygen to the brain. Memory impairment is not as severe as Alzheimer’s disease . However, neuropsychiatric symptoms are the highest in this group.
  • Dementia with Lewy bodies (DLB) – Lewy bodies are deposits of the protein alpha-synuclein that impair memory, judgment, and behavior similar to Alzheimer’s disease, along with hallucinations and muscle impairment. Symptoms may vary day to day.
  • Parkinson Disease Dementia – an unknown cause destroys nerve cells in the brain and impairs muscular contractions and movement. Dementia often develops in Parkinson’s patients. This group has the lowest incidence of neuropsychiatric symptoms.
  • AD/VAD – combined symptoms and brain architecture of Alzheimer’s and Vascular Dementia.
  • AD/DLB – combined symptoms and brain architecture of Alzheimer’s and Dementia Lewy bodies.

Epidemiology

Rarely does Alzheimer’s disease develop before the age of 65. After the 65-year mark, the chance for Alzheimer’s disease is 6%. If it runs in the family, the risk becomes 65%. (A family history is having at least one biological parent with AD diagnosed before the age of 80 years. A negative family history is both biological parents living to age 70 or longer without AD). For people who live to be older than 80 years the prevalence increases to 30 percent. Currently 37 million people worldwide have Alzheimer’s disease . Global incidence of Alzheimer’s disease in the year 2050 is expected to be 115 million people. Alzheimer’s is the 6th leading cause of death in the United States.

Current incidence of Alzheimer’s disease:

  • 2.6% in Africa
  • 4.0% in China
  • 6.2% in Europe
  • 6.9% in North America
  • 6.4% in Australia
  • 6.1% Latin America

Causes of Alzheimer’sDisease

The cause of Alzheimer’s is not yet clear. Several theories are being investigated and new research changes those theories every day. Several associations are also in play. For example, diabetes and Alzheimer’s disease share a common metabolic pathway. For the purposes of this discussion, the evidence is presented first followed by a discussion of theories, with the favored theory at the top, and other theories in descending order. New research, however, could turn the situation upside down, as more is learned.

Evidence

  • Alzheimer’s disease brains have β-amyloid (βA) and hyper-phosphorylated tau peptides, aggregated into senile plaques and tangles. The brain loses neurons and atrophies or loses volume. Plaques and tangles are found in the hippocampus, amygdala, cortex, and nucleus basalis. Plaques occur between nerve cells. Tangles occur inside nerve cells.
  • Acetylcholine synthesis declines at the cellular level in the basal forebrain.
  • Brain weight is usually 100 to 200 g less than average brains of the same age. Brain atrophy is found in the temporal, frontal, and parietal areas but not in the thalamus, brainstem, cerebellar hemispheres, and basal ganglia. Sub regions undergo differing rates of atrophy.
  • The glutamate neurotransmitter system becomes overexcited and leads to neuronal injury.
  • The locus ceruleus and raphi nuclei induce deficiencies in serotonin, corticotrophin-releasing factor, glutamate, and noradrenaline.

Theories

Theory #1 – The Amyloid hypothesis

Inter-neuronal amyloid peptides are overproduced or not cleared from the neuron, which leads to deposits of dense amyloid oligomers or plaques. The plaque starts an inflammatory process leading to cell death or brain cells die due to calcium deposition, free radicals, and/or nitric oxide. However, some individuals have a high amyloid plaque load for decades without showing cognitive decline. These people may have a decreased tangle density and better vascular integrity.

Theory #2 – The Tau protein

The tau’s main function is to provide stability and flexibility in the axons. Too much tau protein forms masses of neurofibrillary tangles and dystrophic neurites.

Theory #3 – Genetics

Presenilin 1 and 2 genes and the Apolipoprotein E (ApoE)-4 genes are mutated and may be responsible for early and/or late onset of Alzheimer’s disease.

Theory #4 – Inflammation

Chronic inflammation is acknowledged as a common cause for many, if not all, chronic diseases. The mechanisms of the inflammatory process are similar in Alzheimer’s disease, heart disease, diabetes and cancer.

Theory #5 – Mitochondrial Failure

The frontal cortex in Alzheimer’s disease patients shows decreased mitochondrial biogenesis. Mitochondrial mass is reduced and shows deficits in mitochondrial respiratory capacity. Antioxidant proteins are also reduced.

Theory #6 – Childhood Stress Marks Genes

Adverse events in childhood may leave permanent marks on genes and the immune system. Early infections and maternal behaviors including neglect can trigger changes in gene expression affecting neuroendocrine systems. Gene mutations can induce higher circulatory levels of corticosterone, other stress hormones and immune reactions on a day to day basis and also in response to current stress.

Theory #7 – Cardiac Index

People with weakly pumping hearts show decreased brain volume. MRI studies have shown that patients with a low cardiac index (blood pumped relative to body size) had brains that appeared aged by two years. Even patients with small reductions in heart pumping showed cognitive decline. Researchers believe that cardiac specialists should review their recommendations for cardiac output. Guidelines that may be in normal range according to physical measures may not be good enough for cognitive health.

Theory #8 – Blood Vessel Growth

Scientists have discovered a link between macular degeneration and Alzheimer’s disease. In both conditions blood vessels grow too much, leak blood and fluid, leading to hemorrhaging, swelling, and formation of scar tissue. This deterioration might allow amyloid plaque development.

Theory #9 – Environmental

  • Head Injuries
  • Lifestyle factors including:
    • smoking
    • midlife obesity
    • diet high in saturated fats
    • Toxins – maternal, childhood and adult neurotoxins and genotoxins (toxic to the genes) may be culprits in Alzheimer’s disease. Cycasin, methylazoxymethanol, and nitrosamines from preserved meats, fertilizers, and the rubber and leather industries are notable toxins.

Complications

Pain – Without the capability to recognize or describe pain, many Alzheimer’s disease patients may suffer from the normal aches and pains of their age, or more serious pain due to developing but unrecognized illnesses.

Pneumonia – in the final stages of Alzheimer’s disease, pneumonia often recurs due to inability to swallow properly. Liquids and solids may be aspirated into the lungs.

Institutionalization – patients in the middle and late stages of Alzheimer’s disease may have to be cared for in an institution. Independence is lost and depression may develop.

Urinary tract infections (UTIs) – loss of toileting independence and incontinence may lead to a urinary catheter. UTI’s often develop and lead to infection and systemic failure.

Falls – a common risk for people as they age, but even more risky for those with reduced cognitive abilities. Alzheimer’s disease patients tend to wander to unfamiliar places and increase their risk of falls, head injury, broken bones, and complications including stroke and infection.

Elder abuse – the caregiver for an Alzheimer’s disease patient is often a default position, determined by who is available, not by who is best suited for the job. Caregivers may be limited in caring capacity, education, financial resources and often become very stressed which exacerbates the pre-existing problems. Abuse can be verbal, physical, emotional, and/or neglectful in nature.

Weight loss – Alzheimer’s disease patients often experience issues related to eating. They may have economic hardships, forget to eat or are unable to eat. Malnutrition can lead to much more serious problems like anemia, muscular atrophy, and immune system compromise.

Alzheimer’s Disease Diagnosis

Risk Factors

Many risk factors cannot be changed but some factors can be investigated, targeted, and modified with appropriate interventions.

  • Having a big belly – having abdominal fat in your 40’s increases the later incidence of Alzheimer’s disease by two times, even for those who are not overweight. Abdominal fat, visceral fat, secretes inflammatory hormones that cross the blood brain barrier and cause damage in the cells and brain functions.
  • Obesity – children, adolescents, and adults who are overweight and obese show reduced memory and IQ.
  • Being female – Alzheimer’s disease is more common in women than men, however women may be less prone to memory loss than men because of progesterone which protects neurotransmitters.
  • Lower education – higher education levels confer an advantage in that you may be older than others before you develop Alzheimer’s.
  • Advanced age – the longer you live, the more likely you are to get Alzheimer’s disease. After the age of 70, the risk doubles every five years.
  • Family history – early onset and late onset Alzheimer’s disease are inherited, and 25-50% of people who have first-degree relatives with Alzheimer’s disease, are likely to get it as well.
  • Down’s syndrome – people with mutations in chromosomes associated with Down’s syndrome may develop Alzheimer’s disease.
  • Being Black – people of African descent are at higher risk of developing dementia compared with white people.
  • Cerebrovascular disease – dementia often occurs with vascular problems in the cerebral regions and co-exists with Alzheimer’s disease.
  • Hyperlipidemia – often precedes vascular dementia, leading to Alzheimer’s disease.
  • Low IQ – an association exists between low childhood IQ and Alzheimer’s disease.
  • Traumatic brain injury (TBI) – brain injuries can cause seen and unseen problems including Alzheimer’s disease, memory and cognition, depression, suicidal behavior, poor impulse control, aggressiveness, and parkinsonism.
  • Depression – people with depression are more likely to get Alzheimer’s disease, but depression may be just a symptom of Alzheimer’s disease.
  • Diabetes mellitus – diabetes and Alzheimer’s disease share a common metabolic pathway and diabetes patients are twice as likely to get AD.
  • High cholesterol – high cholesterol contributes to plaques in the brain but cholesterol-lowering drugs failed in treating Alzheimer’s disease.
  • Atrial fibrillation – the risk of atrial fibrillation increases with age and increases the risk of stroke and consequent dementia. Atrial fibrillation also independently increases the risk of Alzheimer’s disease by two times.

Symptoms

  • Aggressiveness
  • Agitation
  • Anxiety
  • Apathy or passivity
  • Depression
  • Difficulties in using the toilet
  • Difficulties in word-finding
  • Difficulties naming objects/people
  • Disorientation to time and place
  • Failure to recognize oneself in the mirror
  • Forgetting how to do important, everyday things
  • Forgetting how to cook meals
  • Forgetting to get dressed or improperly dressing
  • Forgetting what they did yesterday
  • Getting lost
  • Getting confused easily
  • Having delusions or hallucinations
  • Insomnia
  • Loss of occupational functioning
  • Loss of social functioning
  • May not recognize even close family members
  • Memory loss
  • Mild forgetfulness
  • Moodiness
  • Motor deficits
  • Not wanting to perform usual activities
  • Pacing
  • Personality change
  • Poor organization and planning
  • Psychological disturbance
  • Sleeping more than usual
  • Speech deficits
  • Think that people are trying to hurt them or steal their things
  • Trouble talking to or understanding people
  • Wandering

Diagnostic Process

A general physician often makes the diagnosis using clinical findings based on the physical exam, cognitive testing, risk factors, and reports by the patient and family members. Neuropsychiatric testing, brain imaging, and biomarkers may be used to augment the clinical diagnosis. Medical causes or disorders such as HIV, Lyme disease, herpes infection, or prion disease are ruled out or treated first before a diagnosis is offered. While brain imaging techniques and biomarkers like cerebrospinal fluid are being aggressively sought in order to diagnose Alzheimer’s disease early, clinicians mainly rely on early signs of forgetfulness to diagnose the condition.

Early Detection is Critical

Clinicians and researchers urge that all older people be routinely screened for Alzheimer’s disease and mild cognitive impairment (MCI). Early detection is critical to proper management with pharmacological and behavioral strategies, as ten percent of people with mild cognitive issues will progress to Alzheimer’s disease. Interventions in the early stages improve outcomes, quality of life, independence and delay institutionalization. Knowing early helps the patient to make critical decisions while still cognitively capable. Early detection also helps the family and caregiver to prepare and cope for eventualities and the later more difficult days.

Patients initially present with forgetfulness, trouble finding words, having trouble driving, balancing the checkbook, trouble remembering what happened the day before, and/or remembering names. Some patients may not be able to organize their usual activities or their usual tasks. The Alzheimer’s Association lists 10 common symptoms that bring a patient into the clinician’s office and are indicative of early stage Alzheimer’s disease:

  1. Memory loss.
  2. Difficulty performing familiar tasks.
  3. Problems with language.
  4. Disorientation to time and place.
  5. Poor or decreased judgment.
  6. Problems with abstract thinking.
  7. Misplacing things.
  8. Changes in mood or behavior.
  9. Changes in personality.
  10. Loss of initiative.

Cognitive Testing

Commonly used tools include cognitive testing and co-morbid psychiatric disturbances screening instruments:

  • Folstein Mini-Mental State Examination (MMSE)
  • Mini-Mental State Examination (MMSE)
  • Blessed Dementia Scale
  • Saint Louis University Mental Status examination (SLUMS)
  • Geriatric Depression Scale
  • Confusion Assessment Method (CAM)
  • Wechsler’s tests  – intellectual functioning
  • Boston naming test – language processing
  • Rey-Ostrich Complex Figure test – visuo-spatial processing
  • Digit span and reverse/trail making – attention and memory
  • Wisconsin card sorting test – executive functioning
  • Minnesota Multiphase Personality Inventory – personality assessment

Physical examination

The exam is usually normal in the early stages. In the later stages, patients have a slow walk and stooped posture. The end stage is marked by rigid muscles, difficulty walking, speaking, and swallowing. Later stage physical exams focus on finding infections, pain and complicating illnesses. Patients always have other medical conditions or considerations at that stage in life. The patient should have a family physician or general practitioner over the course of the disease, to coordinate care with other physicians.

Laboratory Tests

  • FBC – full blood count, rules out anemia and other disorders.
  • Basic metabolic panel – for abnormal sodium, calcium, glucose levels.
  • Erythrocyte sedimentation rate (ESR) – for inflammatory conditions.
  • Thyroid-stimulating hormone (TSH) – may be low or high.
  • Vitamin B12 – for B12 deficiency-induced dementia.
  • Urine drug screen – for recreational drug use.
  • Syphilis (VDRL)
  • HIV testing
  • Head CT or MRI – to assess brain atrophy, tumors, and vascular disease.
  • Neuropsychiatric testing – for uncertain cases.
  • PET scan – identifies most affected brain regions.
  • Single-photon emission computed tomography (SPECT) – blood flow is reduced in the temporal lobes.
  • Genetic testing – for early onset dementia or for family history Alzheimer’s disease.
  • EEG – for temporal lobe or seizure phenomena.

Classification

Definite Alzheimer’s disease

  • meets the criteria for probable Alzheimer’s disease.
  • histopathological evidence of Alzheimer’s disease on autopsy or brain biopsy.

Probable Alzheimer’s disease

  • history of worsening of cognition with progressive deficits in 2 or more areas of cognition, including memory.
  • dementia established by clinical and neuropsychological examination.
  • Onset between the ages of 40 and 90 years.
  • Absence of systemic or other brain diseases capable of producing a dementia syndrome, including delirium.

Possible Alzheimer’s disease

  • dementia features with atypical presentation and progression.
  • without a known cause or comorbid disease capable of producing dementia.

Unlikely Alzheimer’s disease

  • dementia syndrome with sudden onset, focal neurological signs, seizures, or gait disturbance early in the course of the illness.

Alzheimer’s Disease Treatment

Treatment Overview

The goals of treatment for the individual with AD are to minimize further loss of memory, personality, and daily functioning and to maximize the retained functions. A multidisciplinary approach is needed with coordination between physicians, caregivers and patients. Much more communication between physicians may be needed than for someone with normal aging or someone with a physical illness. The behavioral and psychological symptoms of Alzheimer’s disease produce many issues and situations that need management on a case-by-case basis and with an individualized approach.

Theoretical Example – John is in middle staged Alzheimer’s disease. He finds a pill bottle and cannot understand the dosage. He has his doctor’s number and calls about the dosage. The doctor is unavailable but calls the caretaker later in the morning. The caretaker did not know the patient had called. The drug prescribed was not from the general physician but from the dermatologist. The GP calls the dermatologist and the rest of the day is spent on phone calls and unnecessary work. All John needed to know was that different drugs have different dosages, but since John may forget tomorrow, the same or different scene may play out again. As you can see, Alzheimer’s disease is exhausting for the physicians and caretaker.

Patients with mild cognitive impairment, mild dementia and early stage Alzheimer’s disease, as well as those with more advanced stages have preferences regarding their decision making rights. Caretakers and physicians then have an ethical and practical dilemma. A process must be implemented during the stages of the disease to determine the capacity of the patient to make decisions. This process should always be the first step in Alzheimer’s disease management and must be subsequently managed at regular intervals, especially in the early stages when patients demand that they be able to make decisions. A structured process of probing the patient’s decisional capabilities allows the physician and caretaker the ethical and practical freedom to carry on with the patient’s treatment.

In the above example of John, had the caregiver and general physician discussed John’s ability to understand and make decisions, the GP might not have spent his day on unnecessary phone calls. However, due to the need for communication between physicians, high level of caregiver stress and potential for neglect and abuse of the patient by the caregiver, the general physician’s management of the situation is almost always warranted. With Alzheimer’s disease incidence expected to triple in the coming years, physician and caregiver education and support is a top priority overall, and for the individual patient. Listed below are the main treatment goals for the triad of Alzheimer’s disease, the patient, caregiver, and multidisciplinary team of physicians:

  • Probe the patient’s decisional wishes and capabilities at every stage.
  • Maximize retained functions – organize routines with a well-structured, calm, daily routine.
  • Minimize disturbances – explain and re-explain all decisions, processes, and medications. Written explanations are particularly helpful for the patient to avoid symptoms such as suspiciousness and agitation.
  • Support to the family – education, support, and counseling for the local and distant caregivers are key to managing disease course. An Alzheimer’s disease diagnosis can be devastating for the family. The general physician, should if possible, verbally speak to every member of the immediate family to manage denial and expectations.
  • Support to the physicians – the general physician’s burden is high and care should be taken to not overwhelm him or her with extra or unneeded duties. Other physicians need to be informed of the Alzheimer’s disease diagnosis so they can coordinate care.
  • Medicines – medications can delay the Alzheimer’s disease course in some patients, but they do not work for everyone, and they cannot cure the disease.

Donepezil (Aricept) – mild to moderate Alzheimer’s disease.

Galantamine (Reminyl) – mild to moderate Alzheimer’s disease.

Rivastigmine (Exelon) – mild to moderate Alzheimer’s disease.

Memantine (Ebixa) – moderate to severe Alzheimer’s disease.

Pain management, medications for psychiatric symptoms, and medications for physical illnesses are often needed.

  • Non-drug treatments – a variety of activities, cognitive stimulation, herbal remedies and exercise often help.
  • Home safety evaluation – driving, cooking, using electrical appliances, and navigating the house needs evaluation at every stage.
  • Advance directive or power of attorney – early stage decision making for later needs in health care, respite care, property, wills and funeral arrangements should take place.

Treatment Details

Maximize Retained Functions

  • A well-structured, calm daily routine
  • Explain the caregiving actions in advance
  • Set clothes out the night before
  • Uses calendars, clocks, schedules and charts
  • Use positive techniques of affirmation and redirection

Minimize Symptoms

Written Instructions – make a notebook and continually update it. Include:

  1. contact numbers of family members, physicians, neighbors, service providers like the electric company, church and community members.
  2. medical diagnoses, medications and dosages. List foods and supplements to avoid which may interact with medications.
  3. schedule that patient prefers. Ex. Shower first, then breakfast, then watch the weather, then call sister, etc.
  4. include calendars, charts of their bank accounts, and anything the person normally likes to know or would wonder about.
  5. List what their keys are for, where their important documents are, who to answer the door for and what instances to call for assistance, for instance, letting workmen into the house.

Insomnia – keep the patient as active as possible during the day to minimize sleep disturbance. Sleep is an important process for everyone to secrete hormones, improve mood and appetite. Sleep deprivation in AD patients is common and can exacerbate psychiatric symptoms. Light therapy and other sleep culture techniques can be very helpful.

Social Gathering – another important aspect for everyone, but particularly helpful for AD patients in managing behavioral and psychological symptoms. Even routine activities such as vacuuming or setting the table with others can foster a sense of well-being, connectedness, and a feeling of being useful and not a burden.

Support to the Family

Every family member should have an opportunity to speak directly with the diagnosing physician. Education, support, and local resources should be provided to the patient and the family including a referral to a community service organization like an Alzheimer’s Association. A social worker or psychologist can be consulted for behavioral symptoms, for the likelihood of psychiatric symptoms include:

  • agitation in 50% to 70%
  • anxiety in 30% to 50%
  • delusions in 15% to 50%
  • depression in 25% to 50
  • hallucinations in 0% to 25%

Medicines

Benefits and risks accompany pharmacological medications. The patient and family need education, time and support in choosing medications. Drug choice and dosage may need to be adjusted, combined or discontinued. All drugs have side effects. Donepezil and Galantamine have fewer reports of side effects than Rivastigmine. The lowest possible dose is prescribed first and adjusted if necessary. Medications slow the rate of Alzheimer’s disease, not cure it. Care must be taken to avoid drugs, supplements or food that inhibit the chosen drug’s action or potential.

  • Cholinesterase inhibitors:

Galantamine: 4- 24 mg/day, once or twice daily

Donepezil: 5 -10 mg orally, once daily

Rivastigmine: 1.5- 12 mg orally twice daily or 4.6-9.5mg transdermal patch once daily

  • N-methyl D-aspartate (NMDA) receptor antagonists

Memantine

  • Antipsychotics
  • Mood stabilizers
  • Benzodiazepines
  • Pain Management
  • Sleep Medications

Non-drug Treatments

Herbal Products

Supplements are not tested like medications and vary in strength and purity. They can interfere with medications and oftentimes patients do not tell their doctors they are using them, which hampers treatment and may be dangerous.

  • Ginkgo Biloba – evidence is mixed. Some studies indicate improvements in thinking and socializing. Others find no benefits. Any improvement would be small at best. Talking with your doctor is the best course of action when considering any herbal remedy or supplement.

Cognitive Stimulation

  • Music therapy – listening to familiar tunes may be helpful in soothing anxieties, pulling up memories, feeling more positive and less agitated.
  • Validation or reminiscence therapy – seeks to reinforce current reality and affirm personal truths and memories.
  • Socializing – interacting with others demands brain power by interpreting facial expression, gestures, words and meaning. Interacting with pets can be helpful and soothing, too.
  • Mental exercise – puzzles, word games, practicing with money, aromatherapy, and looking at photographs stimulate brain processes. Art exercises, learning new languages, or reading or learning anything new is advised.
  • Physical exercise – increases blood flow to the brain, helps patients sleep better, improves appetite and self-esteem.

Home and Safety Procedures

  • Driving Status- evaluated and license revoked if necessary.
  • GPS (global positioning technology) shoes, bracelets, and services are available for patients with wandering tendencies.
  • Sound and motion detectors in the house can alert caregivers to movements.
  • Adequate lighting, especially at night.
  • Remove unnecessary furniture or tripping hazards.
  • Remove or disconnect stoves, appliances or other hazards as necessary.

Advanced Considerations

Advanced directives, respite care, power of attorney, wills, funeral arrangements, and financial instruments should be put in place while the patient is still in early stage Alzheimer’s disease and capable of decision making, or at least able to communicate their wishes.

Caregiver Tips

  • Take care of your own health and well-being first. Sleep and exercise are great ways to relieve tension.
  • Accept that your grief may come and go. You will have good days and bad days.
  • Never lose your temper. Seek ways to calm yourself on an everyday basis and be prepared for crisis situations.
  • Never use drugs or alcohol around the patient.
  • Seek support before you need it.
  • Find ways to work around problems. Arguing with the patient will not help. Put on music or go for a drive instead.

Prevention

Alzheimer’s disease is not inevitable. Certain strategies and lifestyle choices can go a long way to either preventing Alzheimer’s disease or delaying it. Treatment and prevention are mostly the same, except for the pharmacological medications. Prevention of Alzheimer’s disease is also the same for prevention of most physical diseases. Positive behaviors include adequate sleep, exercise, nutrition, social networks and avoidance of toxins like smoking. Specifically, prevention of Alzheimer’s disease consists of:

  • Lifelong Learning – cognitively active people who engage in classes, reading, and playing chess are 2.6 less likely to develop Alzheimer’s disease. Varying your habits and being creative is also learning – do tasks in a different way, talk more andsend fewer memos, and drive different routes to work.
  • Music – neural makeup is stimulated by music by helping access memories, process feelings, boosting immunity, increasing heart rate, and respiration rates. Listen to favorite tunes but also explore new ones, too.
  • Social Activities – conversations with others require more brain work that equal cognitive training like doing puzzles.Being with other people is a non-negotiable need for the human being. Lack of good relationships is bad for the brain because humans are social in nature. Studies have proven that isolation stress negatively impacts health, longevity and quality of life. Building social networks is important for all ages. Group activities like exercising, learning, and helping others are excellent stragies to both be with other people and learn new things at the same time. Cultivating relationships over the lifespan is highly favored for brain health.
  • Art – involves coordinating muscular movements and fine motor skills with cerebral processing.
  • Bilingualism – proven to delay Alzheimer’s disease by demanding more cerebral effort.
  • Physical Movement – may be the best prevention by increasing blood flow to the brain, Also helps by increasing hormone production, pleasure hormones like endorphins, flushing carcinogens, dampening pain, anger and depression. Best exercises are sprinting and balance movement like yoga. Any physical exercise is helpful, especially those using the large leg muscles which send more blood to the brain. Types of movement include balance, dancing, weight lifting, yoga, walking, running, sprinting, even sex.
  • Nutrition – people who ate at least 3 servings a week of fruits and vegetables had 76% lower incidence of Alzheimer’s disease. Anti-inflammatory foods like salmon, cruciferous vegetables and berries are the best choices. These foods in particular have been shown to be effective in helping Alzheimer’s disease.
    • Chocolate – increases blood flow to brain.
    • Curry – contains turmeric which is high in curcumin, which may explain the lesser incidence of Alzheimer’s disease in India.
    • Rosemary – carnosic acid signals brain to defend against free radicals.
    • Lentils – have folic acid and B vitamins which aid in thinking more quickly,having better recall, and a lesser decline in verbal skills.
    • Flaxseed – 2 mg of this phytoestrogen per days helped people retain more information, answer questions more quickly.
    • Coffee – better concentration, reaction time, word recall, and people’s names.
    • Omega-3 fatty acid – a critical anti-inflammatory aid.

 What’s Bad for Alzheimer’s Disease

  • Drugs
  • Toxic fumes
  • Night work
  • Head injuries
  • Alcohol
  • Smoking
  • Anemia
  • Carbohydrates not from fruits and vegetables.

Related Conditions

  • Frontotemporal dementia
  • Depression
  • Normal pressure hydrocephalus
  • Alcohol and Drug AbuseDelirium
  • Elder abuse

Videos on Alzeimer’s Disease

What is Alzheimer’s Disease?

Understanding Alzheimer’s Disease?

Stages of Alzheimer’s Disease

Treating Alzheimer’s Disease

References

  1. 2011 Alzheimer’s Disease Facts and Figures, Alzheimer’s Association (http://www.alz.org/downloads/Facts_Figures_2011.pdf)
  2. 2009 World Alzheimer Report, Alzheiemer’s Disease International (http://www.alz.co.uk/research/files/WorldAlzheimerReport-ExecutiveSummary.pdf)
  3. King’s College London (2011, September 13). Early diagnosis of Alzheimer’s disease has health, financial and social benefits (http://www.alz.co.uk/media/110913)
  4. Group Health Research Institute (2011, August 8). Common irregular heartbeat raises risk of dementia, study finds. (http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2011.03508.x/abstract)
  5. American Academy of Neurology (2011, September 12). Link between high cholesterol and Alzheimer’s disease revealed in new study. (http://www.neurology.org/content/77/11/1068)
  6. American Academy of Neurology (2011, September 19). Diabetes may significantly increase the risk of dementia (http://www.neurology.org/content/77/12/1126)
  7. Indiana University School of Medicine (2011, September 5). Even mild cognitive impairment appears to substantially increase risk for death (http://www.annals.org/content/155/5/300.abstract)
  8. University of British Columbia (2011, August 31). New culprit in Alzheimer’s disease: Too many blood vessels (http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0023789)
  9. JAMA and Archives Journals (2011, October 10). Family history may have more important role than previously thought in development of Alzheimer disease. (http://archneur.ama-assn.org/cgi/content/abstract/68/10/1313)
  10. Duke University (2011, October 26). Source found for immune system effects on learning, memory (http://www.jneurosci.org/content/31/43/15511)
  11. Lund University (2011, October 28). New findings contradict dominant theory in Alzheimer’s disease (http://www.jneurosci.org/content/31/43/15384)
  12. Mayo Clinic (2011, October 11). Identifying earliest stages of Alzheimer’s disease. (http://onlinelibrary.wiley.com/doi/10.1002/ana.22628/abstract)
  13. Wiley-Blackwell (2011, September 15). Some memory complaints in the elderly may be warning signs of cognitive problems (http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2011.03543.x/abstract)
  14. JAMA and Archives Journals (2011, September 6). Cognitive changes may predict Alzheimer’s disease development more accurately than biomarkers (http://archpsyc.ama-assn.org/cgi/content/abstract/68/9/961)
  15. University of California – San Diego (2011, October 20). Combination of available tests helps predict Alzheimer’s disease risk. (http://www.neurology.org/content/77/17/1619)

1 COMMENT

  1. Chi

    Hyperlipidemia, caused by the clogging of cholesterol and fat in the blood vessel, is not that lethal or threatening at ordinary times; however, it may eventually develop to arteriosclerosis, which is the prime cause of palsy or heart diseases. Regular aerobic exercise lowers the risk of arteriosclerosis by reducing fat, blood pressure, blood sugar. However, some anaerobic ones like dumbbell exercise are not greatly helpful; jogging, swimming, aerobic, riding on the bicycle are highly recommended. It’s good to do some physical exercises three time a week at first; then the number should increase bit by bit; the time of exercise should be more than 20 minutes, then it also should increase up to 40 minutes. Before starting the physical exercise, people should check the ‘yes’ or ‘no’ of the their heart condition. Besides, right before or right after the exercise, it is recommended to do some warming-ups. For this disease, the folk remedies like ‘san-jo-in'(wild jujube seed), jujube or cherry are very helpful. The healing term, viewed from oriental medicine, is about 9 to 12 months.

Jonathan
Medically trained in the UK. Writes on the subjects of injuries, healthcare and medicine. Contact me jonathan@cleanseplan.com

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