November 26, 2014
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Alzheimer's disease

Of all your possessions, could there be any more precious than your memories? Unlike diseases that cause pain or loss of function, Alzheimer's disease (AD) is arguably worse, as it strips its victims of their past. Friends and family who helplessly watch the slow decline of the person they love seem to suffer almost as much. Disturbingly common, much about this disease remains a mystery.

The dementias are diseases of the brain causing memory loss, confusion, and loss of intellectual capacity. There is deterioration in emotional control, social behaviour, and motivation. By age 65, one in 11 of us will have dementia with the numbers relentlessly increasing by nearly 1% per year, so that by 85 the prevalence of dementia is over 30%. Over half of these are caused by AD.

Risk factors and prevention

If a close family member developed AD one's risk is increased threefold. For a minority of Alzheimer's victims, an identified gene that produces a detectable protein makes them vulnerable to develop this disorder. But in most other cases we don't know the cause. Suspected causes have included environmental toxins, such as metals (remember throwing out those aluminum pans?), infections, and autoimmune reactions in which the body's immune system attacks one of its tissues.

A research study recently described in the Journal of the American Medical Association reported that older people who eat foods rich in vitamin E receive some protection from acquiring the disease. For 5 years, investigators followed 800 men and women who, at the beginning of the study when they were 65, did not have AD. At the end of the study they compared the diets and medications of those who had acquired AD during that time with those who did not. Remarkably, people who ate foods rich in vitamin E received significant protection from the disease while those who took Vitamin E supplements, but did not eat the high Vitamin E diet, were not protected from developing AD.

Diagnosis and pathology

There is no single test diagnostic for AD. Other causes for intellectual and memory decline, confusion, or changed behaviours must first be ruled out. Dementia caused by alcohol, clogging of blood vessels to the brain, or normal pressure hydrocephalus (increased amounts of spinal fluid accompanied by loss of brain tissue) must be considered. Depression or adverse reactions to medications can mimic dementia. Infections, heart failure, or respiratory failure all may cause confusion and disorientation.

As AD progresses, CT Scans, PET Scans, and MRIs eventually show widespread loss of brain cells, especially cells rich in the neurotransmitter, acetylcholine. Brain areas where these cells are most concentrated include the hippocampus, locus ceruleus, frontal, temporal and parietal cortex, and substantia innominata. These areas control higher executive functions and emotional responses. Brain biopsy or autopsy demonstrates characteristic accumulation of protein plaques and neurofibrillary tangles in areas of lost neurons.

Course

Generally a disease of older people, Alzheimer's occasionally starts as early as the late 30s. First symptoms include memory lapses or momentary confusion followed by periods of apparently normal cognitive function. As the episodes become longer and more frequent, complex but routine behaviours, such as driving the car, become more difficult. The person will sometimes do bizarre things, like putting perishable food away in a cupboard or placing writing materials in the refrigerator. As cognitive decline continues, they become unable to care for themselves. They will often feel restlessness, confusion, and even paranoia. Not remembering that they moved an article, when they later are unable to find it, they become convinced intruders have come in and taken it.

Death occurs in 8 to 20 years, often due to pneumonia as the parts of the brain that control respiration and protective airway reflexes become impaired.

Early diagnosis is important in order to start treatment, ensure an environment in which the person is able to function safely, and to allow them to make their own plans for the future.

Treatment

There are several medications that work by increasing levels of acetylcholine in the brain, improving symptoms in mild to moderate AD. These medications delay the inevitable, improving brain function during earlier stages of disease. The substances used by the body to manufacture acetylcholine have been tried as supplements without success. Good clinical trials to evaluate Ginkgo biloba and other herbal remedies have failed to demonstrate effectiveness.

Treatment should be supportive. Create a simple, safe, and controlled environment. Ensure proper nutrition, exercise, and physical comfort. Avoid excess medications, although a low-dose sedating antidepressant is often helpful for mood and sleep.

Care for caregivers

Caring for a person with Alzheimer's requires extra patience and acceptance. Set realistic goals, both for the caregiver and the patient. Get community help, a homemaker, homecare nursing, and a visit from an occupational therapist to help with minor but important modifications in the home. When the time comes, be willing to turn to a residential extended care agency with skill in managing patients with AD. They know how to make your loved one most comfortable. You will be able to sleep better and refresh yourself so that when you do visit you are more positive. Most important to caregivers is to remember to look after yourself. It's easy to burn out.

10 warning signs of Alzheimer's disease

(from Alzheimer Society: www.alzheimer.ca/english/disease/warningsigns.htm)

  1. Worsening memory loss for day-to-day activities, such as names, phone numbers, and recent events.
  2. Loss of ability to perform certain familiar tasks.
  3. Forgetting simple words, sometimes replacing them with less appropriate words.
  4. Disorientation in time and place, becoming lost and not knowing how to get home.
  5. Worsening judgement, such as dressing inappropriately for the weather or not seeking help for a serious problem.
  6. Losing abstract reasoning, such as understanding the significance of events or the ability to understand a principle.
  7. Misplacing things, even placing things in strange places, sometimes becoming paranoid or suspicious because they have disappeared.
  8. Rapid mood swings for no apparent reason.
  9. Personality change, becoming apathetic, confused, suspicious, or fearful.
  10. Loss of initiative, to the point the person may not spontaneously engage in any activities.
  
Dr. Ray Baker, MD 
in association with the MediResource Clinical Team 

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