Alzheimer’s Disease

• Unimpaired individuals experience no memory problems and none are evident to a health care professional during a medical interview.

• Individuals at this stage feel as if they have memory lapses, especially in forgetting familiar words or names or the location of keys, eyeglasses, or other everyday objects. But these problems are not evident during a medical examination or apparent to friends, family, or co-workers.

Early-stage Alzheimer’s can be diagnosed in some, but not all, individuals with these symptoms. Friends, family, or co-workers begin to notice deficiencies. Problems with memory or concentration may be measurable in clinical testing or discernible during a detailed medical interview. Common difficulties include:

• Word- or name-finding problems noticeable to family or close associates
• Decreased ability to remember names when introduced to new people
• Performance issues in social or work settings noticeable to family, friends, or co-workers
• Reading a passage and retaining little material
• Losing or misplacing a valuable object
• Decline in ability to plan or organize

At this stage, a careful medical interview detects clear-cut deficiencies in the following areas:

• Decreased knowledge of recent occasions or current events
• Impaired ability to perform challenging mental arithmetic-for example, to count backward from 100 by 7s
• Decreased capacity to perform complex tasks, such as marketing, planning dinner for guests, or paying bills and managing finances
• Reduced memory of personal history
• The affected individual may seem subdued and withdrawn, especially in socially or mentally challenging situations

Major gaps in memory and deficits in cognitive function emerge. Some assistance with day-to-day activities becomes essential. At this stage, individuals may:

• Be unable during a medical interview to recall such important details as their current address, their telephone number, or the name of the college or high school from which they graduated
• Become confused about where they are or about the date, day of the week, or season
• Have trouble with less challenging mental arithmetic; for example, counting backward from 40 by 4s or from 20 by 2s
• Need help choosing proper clothing for the season or the occasion
• Usually retain substantial knowledge about themselves and know their own name and the names of their spouse or children
• Usually require no assistance with eating or using the toilet

Memory difficulties continue to worsen, significant personality changes may emerge, and affected individuals need extensive help with customary daily activities. At this stage, individuals may:

• Lose most awareness of recent experiences and events as well as of their surroundings
• Recollect their personal history imperfectly, although they generally recall their own name
• Occasionally forget the name of their spouse or primary caregiver but generally can distinguish familiar from unfamiliar faces
• Need help getting dressed properly; without supervision, may make such errors as putting pajamas over daytime clothes or shoes on wrong feet
• Experience disruption of their normal sleep/waking cycle
• Need help with handling details of toileting (flushing toilet, wiping, and disposing of tissue properly)
• Have increasing episodes of urinary or fecal incontinence
• Experience significant personality changes and behavioral symptoms, including suspiciousness and delusions (for example, believing that their caregiver is an impostor); hallucinations (seeing or hearing things that are not really there); or compulsive, repetitive behaviors such as hand-wringing or tissue shredding
• Tend to wander and become lost

This is the final stage of the disease when individuals lose the ability to respond to their environment, the ability to speak, and, ultimately, the ability to control movement.

• Frequently individuals lose their capacity for recognizable speech, although words or phrases may occasionally be uttered
• Individuals need help with eating and toileting and there is general incontinence of urine
• Individuals lose the ability to walk without assistance, then the ability to sit without support, the ability to smile, and the ability to hold their head up. Reflexes become abnormal and muscles grow rigid. Swallowing is impaired.

The U.S. Food and Drug Administration (FDA) has approved two classes of drugs to treat cognitive symptoms of Alzheimer’s disease. The first Alzheimer medications to be approved were cholinesterase (KOH luh NES ter ays) inhibitors. Three of these drugs are commonly prescribed donepezil (Aricept), approved in 1996; rivastigmine (Exelon), approved in 2000; and galantamine (Reminyl), approved in 2001. Tacrine (Cognex), the first cholinesterase inhibitor, was approved in 1993 but is rarely prescribed today because of associated side effects, including possible liver damage.

All of these drugs are designed to prevent the breakdown of acetylcholine (pronounced a SEA til KOH lean), a chemical messenger in the brain that is important for memory and other thinking skills. The drugs work to keep levels of the chemical messenger high, even while the cells that produce the messenger continue to become damaged or die. About half of the people who take cholinesterase inhibitors experience a modest improvement in cognitive symptoms.

Memantine (Namenda) is a drug approved in October 2003 by the FDA for treatment of moderate to severe Alzheimer’s disease. Memantine is classified as an uncompetitive low-to-moderate affinity N-methyl-D-aspartate (NMDA) receptor antagonist, the first Alzheimer drug of this type approved in the United States. It appears to work by regulating the activity of glutamate, one of the brains specialized messenger chemicals involved in information processing, storage and retrieval.

Glutamate plays an essential role in learning and memory by triggering NMDA receptors to allow a controlled amount of calcium to flow into a nerve cell, creating the chemical environment required for information storage.

Excess glutamate, on the other hand, overstimulates NMDA receptors to allow too much calcium into nerve cells, leading to disruption and death of cells. Memantine may protect cells against excess glutamate by partially blocking NMDA receptors.

Vitamin E supplements are often prescribed as a treatment for Alzheimer’s disease, because they may help brain cells defend themselves from attacks Normal cell functions create a byproduct a called free radical, a kind of oxygen molecule that can damage cell structures and genetic material. This damage, called oxidative stress, may play a role in Alzheimer’s disease.

Cells have natural defenses against this damage, including the antioxidants vitamins C and E, but with age some of these natural defenses decline.

Research has shown that taking vitamin E supplements may offer some benefit to people with Alzheimer’s.

Most people can take vitamin E without side effects. However, any change in medications should first be discussed with a primary care physician because all medication can cause side effects or interactions with other medications. A person taking blood-thinners, for example, may not be able to take Vitamin E or will need to be monitored closely by a physician.