UNDERSTANDING ALZHEIMER’S DISEASE & OTHER DEMENTIAS

Appreciating the specialized care delivered by Hope Assisted Living & Memory Care Center begins with an understanding of Alzheimer’s disease and other dementias. Dementia is a general term for loss of memory and other mental abilities severe enough to interfere with daily life. It is caused by physical changes in the brain. Alzheimer’s disease is the most common type of dementia, accounting for approximately 70 percent of cases.

The following briefly describes various forms of dementia, as well as the symptoms of and treatment for each type of dementia.

MILD COGNITIVE IMPAIRMENT
Mild Cognitive Impairment (MCI) a condition in which a person has problems with memory, language, or another mental function severe enough to be noticeable to other people and to show up on tests, but not serious enough to interfere with daily life.

Because the problems do not interfere with daily activities, the person does not meet criteria for being diagnosed with dementia. The best-studied type of MCI involves a memory problem and is called Amnestic MCI.

Research has shown that individuals with MCI have an increased risk of developing Alzheimer’s disease over the next few years, especially when their main problem is memory.

Not everyone diagnosed with MCI goes on to develop Alzheimer’s.

There is currently no treatment for MCI approved by the FDA.

Results of a large, federally funded trial showed that 10 milligrams of donepezil (Aricept) daily can reduce the risk of progressing from amnestic MCI to Alzheimer’s disease for about a year, but the benefit disappears within three years. The trial also showed that 2,000 international units of vitamin E daily do not reduce the risk of progressing.

The study authors say the results were not strong enough to support a clear recommendation to treat amnestic MCI with donepezil, but it might be reasonable for patients and their physicians to talk about the possible benefits and risks of treatment on an individual basis. Two other studies have tested galantamine (Razadyne) as a treatment for MCI. These studies found no benefit, but the data showed an increased number of deaths in participants taking galantamine compared with those receiving the placebo.

Alzheimers’ Disease (AD)
Alzheimer’s disease is a degenerative and terminal disease, which affects almost 30 million sufferers worldwide.  Its earliest signs can be mistaken for age-related concerns or manifestations of stress. One of the earliest stages involves the inability to acquire new memories. As the disease progresses, the symptoms can include confusion, irritability and aggression, mood swings, language breakdown, long-term memory loss and withdrawal from life in general as senses decline. Eventually bodily functions are lost, ultimately leading to death.

Diagnosing Alzheimer’s disease involves behavioral assessments, cognitive tests and sometimes a brain scan. Because decline in the earliest stages can be so mild, it can take years for a diagnosis. Individual prognosis is hard to assess, as the duration of the disease as well as the duration of each stage can vary greatly. The mean life expectancy following diagnosis is approximately seven years. Fewer than three percent of individuals live more than fourteen years after diagnosis.

One of the most important things to realize is that there are different stages associated with the patterns of decline in Alzheimers patients. These stages, defined by experts, are a general characterization of the progression a patient experiences when moving from normal behavior towards the advanced stages of the disease. Although the progression of Alzheimer’s disease is a unique course for every individual, many common symptoms appear in each stage. This makes each stage unique in its specific care requirements.

This seven-stage framework is based on a system developed by Barry Reisberg, M.D., clinical director of the New York University School of Medicine’s Silberstein Aging and Dementia Research Center.

Stage 1:
No impairment (normal function)
The person does not experience any memory problems. An interview with a medical professional does not show any evidence of symptoms.

Stage 2:
Very mild cognitive decline (may be normal age-related changes or earliest signs of Alzheimer’s disease)

The person may feel as if he or she is having memory lapses‚ forgetting familiar words or the location of everyday objects. But no symptoms can be detected during a medical examination or by friends, family or co-workers.

Stage 3:
Mild cognitive decline‚ Early-stage Alzheimer’s can be diagnosed in some, but not all, individuals with these symptoms

Friends, family or co-workers begin to notice difficulties. During a detailed medical interview, doctors may be able to detect problems in memory or concentration.

Common stage 3 difficulties include:

• Noticeable problems coming up with the right word or name
  
• Trouble remembering names when introduced to new people
  
• Having noticeably greater difficulty performing tasks in social or work settings
  
• Forgetting material that one has just read
  
• Losing or misplacing a valuable object
  
• Increasing trouble with planning or organizing

Stage 4:
Moderate cognitive decline (Mild or early-stage Alzheimer’s disease)

At this point, a careful medical interview should be able to detect clear-cut problems in several areas:

• Forgetfulness of recent events
  
• Impaired ability to perform challenging mental arithmetic for example, counting backward from 100 by 7s
  
• Greater difficulty performing complex tasks, such as planning dinner for guests, paying bills or managing finances
  
• Forgetfulness about one’s own personal history
  
• Becoming moody or withdrawn, especially in socially or mentally challenging situations

Stage 5:
Moderately severe cognitive decline (Moderate or mid-stage Alzheimer’s disease)

Gaps in memory and thinking are noticeable, and individuals begin to need help with day-to-day activities. At this stage, those with Alzheimer’s may:

• Be unable to recall their own address or telephone number or the high school or college from which they graduated
  
• Become confused about where they are or what day it is
  
• Have trouble with less challenging mental arithmetic, such as counting backward from 40 by subtracting 4s or from 20 by 2s
  
• Need help choosing proper clothing for the season or the occasion
  
• Still remember significant details about themselves and their family
  
• Still require no assistance with eating or using the toilet

Stage 6:
Severe cognitive decline (Moderately severe or mid-stage Alzheimer’s disease)

Memory continues to worsen, personality changes may take place and individuals need extensive help with daily activities. At this stage, individuals may:

• Lose awareness of recent experiences as well as of their surroundings
  
• Remember their own name but have difficulty with their personal history
  
• Distinguish familiar and unfamiliar faces but have trouble remembering the name of a spouse or caregiver
  
• Need help dressing properly and may, without supervision, make mistakes such as putting pajamas over daytime clothes or shoes on the wrong feet
  
• Experience major changes in sleep patterns sleeping during the day and becoming restless at night
  
• Need help handling details of toileting (for example, flushing the toilet, wiping or disposing of tissue properly)
  
• Have increasingly frequent trouble controlling their bladder or bowels
  
• Experience major personality and behavioral changes, including suspiciousness and delusions (such as believing their caregiver is an impostor), or compulsive, repetitive behavior like hand-wringing or tissue shredding
  
• Tend to wander or become lost

Stage 7:
Very severe cognitive decline (Severe or late-stage Alzheimer’s disease)

In the final stage of this disease, individuals will lose:

• the ability to respond to their environment
  
• the ability to carry on a conversation and, eventually, to control movement
  
• Individuals at this stage may still say words or phrases
  
• At this stage, individuals need help with much of their daily personal care, including eating or using the toilet.
• They may also lose the ability to smile, to sit without support and to hold their heads up.
• Reflexes become abnormal. Muscles grow rigid. Swallowing impaired.

Vascular Dementia (VD)
Vascular dementia is widely considered the second most common type of dementia. It develops when impaired blood flow to parts of the brain deprives cells of food and oxygen.

The diagnosis may be clearest when symptoms appear soon after a single major stroke blocks a large blood vessel and disrupts the blood supply to a significant portion of the brain. This situation is sometimes called “post-stroke dementia.”

There is also a form in which a series of very small strokes, or infarcts, block small blood vessels. Individually, these strokes do not cause major symptoms, but over time their combined effect becomes noticeable. This type is referred to as Vascular Cognitive Impairment (VCI) or multi-infarct dementia.

Symptoms of vascular dementia can vary, depending on the specific brain areas deprived of blood. Impairment may occur in “steps,” where there is a fairly sudden, noticeable change in function, rather than the slow, steady decline usually seen in Alzheimer’s disease.

The person may have a past history of heart attacks. High blood pressure, high cholesterol, hardening of the arteries, diabetes, or other risk factors for heart disease are often present.

Symptoms of Vascular Dementia

• Memory problems may or may not be a prominent symptom, depending on whether brain regions important in memory are affected.
  
• Confusion, which may get worse at night.
  
• Difficulty concentrating, planning, communicating and following instructions.
  
• Reduced ability to carry out daily activities.
  
• Physical symptoms associated with strokes, such as sudden weakness, difficulty speaking or confusion.
  
• Magnetic resonance imaging (MRI) of the brain may show characteristic abnormalities associated with vascular damage.

Treatment of Vascular Dementia
Because vascular dementia is closely tied to diseases of the heart and blood vessels, many experts consider it the most potentially treatable form.
 

• Monitoring of blood pressure, weight, blood sugar and cholesterol should begin early in life.
• Managing these risk factors, avoiding smoking and excess alcohol, and treating underlying diseases of the heart and blood vessels could play a major role in preventing later cognitive decline for many individuals. In some cases, active management of these factors in older adults who develop vascular dementia may help symptoms from getting worse.
  
• Once vascular dementia develops, there are no drugs currently approved by the U.S. Food and Drug Administration (FDA) to treat it.
  
• Most of the drugs used to treat cognitive symptoms of Alzheimer’s disease have also been shown to help individuals with vascular dementia to about the same extent they help those with Alzheimer’s. However, in March 2006, Eisai Co. Ltd., manufacturer of donepezil (Aricept), reported that in a clinical trial of donepezil for vascular dementia, a significantly greater number of deaths occurred in study participants receiving donepezil than in those taking the placebo.

Mixed Dementia
Mixed dementia is a condition in which Alzheimer’s disease and vascular dementia occur at the same time. Many experts believe mixed dementia occurs more often than was previously realized and that it becomes increasingly common in advanced age. This belief is based on brain autopsies showing up to 45 percent of people with dementia have signs of both Alzheimer’s and vascular disease.

The concept of mixed dementia is clinically important because the combination of the two diseases may have a greater impact on the brain than either by itself.

Symptoms
May follow a pattern similar to either Alzheimer’s or vascular dementia or a combination of the two.
Some experts recommend suspecting mixed dementia whenever a person has both, evidence of cardiovascular disease and dementia symptoms that get worse slowly.

Treatment
As with vascular dementia, lifelong attention to risk factors and overall health of the heart and blood vessels could play a key role in preventing mixed dementia. These measures might also help delay or prevent progression of symptoms in older adults.

Since most of the drugs approved to treat Alzheimer’s disease have also shown a similar benefit in treating vascular dementia, there is reason to believe they may also be of some help in mixed dementia. Two of the drugs galantamine (Razadyne) and rivastigmine (Exelon) have been tested and shown to offer modest benefit specifically in mixed dementia.

No drugs are currently approved by the FDA to treat mixed dementia.

Dementia with Lewy Bodies
Dementia with Lewy bodies is characterized by abnormal deposits of a protein called alpha-synuclein that form inside the brain’s nerve cells.

These deposits are called Lewy bodies after the scientist who first described them. Lewy bodies have been found in several brain disorders, including dementia with Lewy bodies, Parkinson’s disease and some cases of Alzheimer’s.

Symptoms of Dementia with Lewy bodies

• Memory problems, poor judgment, confusion and other cognitive symptoms that overlap with Alzheimer’s disease
  
• Excessive daytime drowsiness
  
• Visual hallucinations
  
• Cognitive symptoms and level of alertness may get better or worse (fluctuate) during the day or from one day to another
  
• Movement symptoms, including stiffness, shuffling walk, shakiness, lack of facial expression, and problems with balance and falls

In about 50 percent of cases, dementia with Lewy bodies is associated with a condition called rapid eye movement (REM) sleep disorder. REM sleep is the stage where people usually dream. During normal REM sleep, body movement is suppressed and people do not act out their experiences while dreaming. In REM sleep disorder, movement is not blocked and people act out their dreams, sometimes vividly and violently

Treatment of Dementia with Lewy bodies
There are no drugs currently approved by the U.S. Food and Drug Administration (FDA) specifically to treat dementia with Lewy bodies.

Some experts believe this condition may have the best response of any dementia to Alzheimer drugs called cholinesterase inhibitors.

If the movement symptoms are severe, medications used in Parkinson’s disease may be considered.

Antipsychotic drugs should not be used in Lewy body dementia. Individuals with Lewy body dementia are extremely sensitive to these drugs, which are sometimes used to treat hallucinations or behavioral symptoms of dementia.

Parkinson’s Disease
Parkinson’s disease begins by affecting movement, resulting in tremors and shakiness, stiffness, difficulty with walking and muscle control, lack of facial expression and impaired speech.

Parkinson’s is another disease in which Lewy bodies are found in the brain. Many individuals with Parkinson’s develop dementia in later stages of the disease.

Treatment of Parkinson’s disease
There are currently no drugs approved by the FDA specifically to treat the dementia associated with Parkinson’s disease.

There is some evidence that cholinesterase inhibitors may help some individuals.

Frontotemporal Dementia
Frontotemporal dementia is a rare disorder that affects the front (frontal lobes) and the sides (temporal lobes) of the brain. Because these regions often, but not always, shrink, brain imaging can be useful in diagnosis.

There is no specific abnormality associated with all cases of Frontotemporal Dementia. In one type called Pick’s disease, there are abnormal microscopic deposits called Pick bodies, but these are not always present.

Symptoms of Frontotemporal Dementia
A more rapid onset than in Alzheimer’s disease

First symptoms often involve changes in personality, judgment, planning and social functioning. Individuals may make rude or off-color remarks to family or strangers. They may make unwise decisions about finances or personal matters.

Individuals’ feelings may seem disconnected from the situation. They may show apathy and loss of interest or excessive happiness and excitement.

Individuals may have a strong desire to eat and gain weight as a result.

Treatment of Frontotemporal Dementia
There are no treatments approved by the FDA for Frontotemporal Dementia, and none that have been shown to be effective.

Creutzfeldt-Jakob Disease
Creutzfeldt-Jakob disease (CJD) (pronounced CROYZ-felt YAH-cob) is a rare, rapidly fatal disorder affecting about 1 out of 1 million people per year worldwide. It usually affects individuals older than 60.

CJD is one of the prion (PREE-awn) diseases. These diseases occur when prion protein, which is present throughout the brain, begins to assume an abnormal three-dimensional shape. This shape gradually triggers the protein throughout the brain to fold into the same abnormal shape, leading to increasing damage and destruction of brain cells.

Recently, variant Creutzfeldt-Jakob disease (vCJD) was identified as the human disorder believed to be caused by eating meat from cattle affected by mad cow disease. It tends to occur in much younger individuals, in some cases as early as their teens.

Symptoms of Creutzfeldt-Jakob disease

• The first symptoms may involve impairment in memory, thinking and reasoning or changes in personality and behavior
  
• Depression or agitation also tend to be early symptoms
  
• Problems with movement may be present from the beginning or appear shortly after the other symptoms
  
• Symptoms progress rapidly and death typically occurs within a year.
  
• There may be characteristic changes on an electroencephalogram (EEG, or brain wave test)
  
• There may also be a characteristic substance called 14-3-3 protein in the spinal fluid.

Treatment of Creutzfeldt-Jakob disease (CJD)
There is currently no treatment for CJD or vCJD.

Normal Pressure Hydrocephalus
Normal pressure hydrocephalus (NPH) is another rare disorder in which fluid surrounding the brain and spinal cord is unable to drain normally.

The fluid builds up, enlarging the ventricles (fluid-filled chambers) inside the brain. As the chambers expand, they can compress and damage nearby tissue.

The normal pressure refers to the fact that the spinal fluid pressure often, although not always, falls within the normal range on a spinal tap.

Symptoms of NPH

• Difficulty walking
  
• Loss of bladder control.
  
• Mental decline, usually involving an overall slowing in processing and reacting to information.
• A person’s responses are delayed, but they tend to be accurate and appropriate to the situation when they finally come.
  

Treatment of NPH
NPH can occasionally be treated by surgically inserting a long thin tube called a shunt to drain fluid from the brain to the abdomen.

Certain television broadcasts and commercials have portrayed NPH as a highly treatable condition that is often misdiagnosed as Alzheimer’s, another dementia or Parkinson’s disease. However, most experts believe it is unlikely that significant numbers of people diagnosed with Alzheimer’s or Parkinson’s actually have NPH that could be treated with surgery.

NPH is rare, and it looks different from Alzheimer’s, another dementia or Parkinson’s to a physician with experience in assessing brain disorders.
When shunting surgery is successful, it tends to help more with walking and bladder control than with mental decline.

Brain imaging by itself cannot diagnose normal pressure hydrocephalus. Many disorders that cause dementia, including Alzheimer’s disease, cause the brain to shrink, making the fluid-filled chambers appear larger.

Huntington’s Disease
Huntington’s disease is a rare fatal brain disorder caused by inherited changes in a single gene. These changes lead to destruction of nerve cells in certain brain regions.

Scientists identified the gene in 1993. Anyone with a parent with Huntington’s has a 50 percent chance of inheriting the gene, and everyone who inherits it will eventually develop the disorder. In about 1 to 3 percent of cases, no history of the disease can be found in other family members.

Symptoms of Huntington’s

• Involuntary movements such as twitches and muscle spasms
  
• Problems with balance and coordination
  
• Personality changes such as irritability, depression and mood swings
  
• Trouble with memory, concentration or making decisions
  
• Age of symptom onset and rate of disease progression varies
  

Treatment of Huntington’s
There is currently no cure for Huntington’s, but research on potential treatments is accelerating since scientists identified the gene involved. In 2008, the U.S. Food and Drug Administration (FDA) approved tetrabenazine (Xenazine‚Ñ¢) as the first drug specifically approved in the United States to treat the involuntary movements (chorea) associated with Huntington’s. Doctors also sometimes prescribe other drugs to manage symptoms.