Alzheimer's Disease

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What is Alzheimer's Disease?

Alzheimer’s Disease is a slow onset, a progressive disorder affecting the brain causing brain cell degeneration and death, resulting in a decline of intellectual abilities and behavioral changes. It is one of the most common forms of dementia.

Is Alzheimer's Disease a Medical emergency?

Alzheimer’s Disease is not a medical emergency.

Causes

The exact cause of Alzheimer's disease is not yet fully known, but genetic, environmental, and lifestyle factors may play a role in its development. In this, the communication, metabolism, and the repair of nerve cells are affected, which results in the death of these neurons, and a gradual shrinkage of the brain.

The main changes that are seen in this disease include:

  • Senile plaques: These are accumulated deposits of beta-amyloid protein in the microtubules of the neurons in the regions of the temporal, parietal, and the frontal lobes; the presence of these amyloid plaques results in the disruption of communication between the neurons.
  • Neurofibrillary tangles: This occurs when the protein called tau which strengthens the microtubules by binding to them starts to bind with adjacent tau proteins resulting in a bundled or tangled bunch of tau proteins. This results in both the disruption of both the communication between the neurons, as well as metabolism and the repair of the neurons.

Risk factors

The risk of Alzheimer's disease may increase with the following:

  • Aging
  • Family history
  • Mutation of certain genes on chromosome 21, 14, or 1
  • Smoking
  • A sedentary lifestyle and lack of exercise
  • Obesity
  • Poorly controlled type 2 diabetes
  • Insulin resistance
  • Hypertension
  • High cholesterol and other lipids
  • Down syndrome
  • Trauma to the head and brain
  • Long term infections with some organisms such as spirochetes
  • Depression
  • Some disorders affecting the blood vessels and blood circulation

Signs & symptoms

Alzheimer’s Disease is slow-progressing, and the symptoms and signs develop over the four stages as follows:

  • Pre-clinical also is known as mild cognitive impairment (MCI) - The symptoms are non-specific and mostly related to memory and may include:
    • Short term memory loss
    • Apathy
    • Irritability
    • Mild inattention
    • Mild depression
    • General lack of awareness of memory lapses
    • Misplacing items sometimes
  • Mild or Early Alzheimer's disease - At this stage, the following may be noticed.
    • Memory loss - Such as forgetting names of friends and family members
    • Confusion in situations that are not familiar
    • Getting lost and confused with known and familiar places
    • The trouble with normal daily tasks, handling money and paying bills
    • Compromised decision-making abilities
    • Apathy, loss of spontaneity
    • Anxiety, and other mood and personality changes
  • Moderate or Middle-stage Alzheimer's disease of symptoms and signs at this stage may include:
    • Increasing memory loss and confusion
    • Sleep problems
    • Shortened attention span
    • Problems recognizing friends and family members
    • Difficulty with language; problems with reading, writing, working with numbers
    • Difficulty in thinking logically
    • Inability to learn new things or to cope with new or unexpected situations
    • Restlessness, agitation, anxiety, crying, wandering off and not knowing locations
    • Repetitive statements or movements
    • occasional muscle twitches
    • Hallucinations, delusions, suspicion or paranoia, irritability
    • Loss of impulse control (shown through behavior such as undressing at inappropriate times or places or vulgar language)
    • Perceptual-motor problems (such as trouble getting out of a chair or setting the table)
  • Advanced or severe Alzheimer’s Disease - The severity of the symptoms is much more and also, the following may be seen:
    • Need round-the-clock assistance with daily activities and personal care
    • Weight loss
    • Loss of bowel and bladder control
    • Increased sleeping
    • Lose awareness of recent experiences as well as of their surroundings
    • Experience changes in physical abilities, including the ability to walk, sit and, eventually, swallow
    • Have increasing difficulty communicating
    • Vulnerable to infections, especially pneumonia and skin infections

Investigations

The following investigations may be done to establish a diagnosis as well as to rule out other conditions:

  • Laboratory tests:
    • CBP, ESR
    • Serum B12
    • Liver function tests
    • Thyroid profile
    • Rapid plasma reagent (RPR) to rule out syphilis
    • Hiv serology to rule out HIV/aids
    • Paraneoplastic antibodies to rule out autoimmune encephalitis
  • Imaging tests:
    • MRI and/or CT brain
    • PET scan
      • Fluorodeoxyglucose (FDG) pet to identify areas of poor metabolism in the brain.
      • An amyloid pet is useful in very early onset dementia and helps to visualize amyloid deposits in the brain.
    • Electroencephalography (EEG) - To rule Creutzfeldt-Jacob disease, and when seizures are present.
    • Lumbar puncture - CSF analysis can help to measure tau and amyloid levels and to rule Creutzfeldt-Jacob disease.
    • Genetic testing - Genotyping of the apolipoprotein E (APOE), in symptomatic individuals with early-onset dementia, who have a family history.
    • Mental state and neurophysiological testing.

Diagnosis

The diagnosis of Alzheimer's disease is established based on medical history and history from family and friends, clinical evaluation, and results of the investigations done. The following eight parameters of cognitive or intellectual abilities need to be affected namely:

  • Memory
  • Language
  • Perception
  • Attention
  • Motor skills
  • Orientation
  • Problem-solving
  • Executive functional abilities

Further, the Mini-mental state examination (MMSE) score may also be used to assess cognitive impairment.

  • Severe impairment - Score of less than 9 on MMSE
  • Moderate impairment - Score of 10 - 18 on MMSE
  • Mild impairment - Score between 11-23 on MMSE
  • Normal cognition - Score above 24

A confirmed diagnosis of Alzheimer's disease can only be established by microscopic examination of brain tissue, usually after death.

Course & Stages

Alzheimer’s Disease stages based on symptoms are as follows:

  • Pre-clinical
  • Mild Alzheimer's disease
  • Moderate Alzheimer's disease
  • Severe Alzheimer's disease

Treatment options

There is no cure for Alzheimer's disease and the treatment is aimed at improving the cognitive abilities at least for some time, and improving the symptoms.

Medical management

Medical management of Alzheimer’s Disease may include the use of the following:

  • Cholinesterase inhibitors: Such as donepezil, rivastigmine to prevent the breakdown of acetylcholine which may have a role in the early symptoms of Alzheimer's disease. It is used in the management of mild to moderate Alzheimer's disease.
  • Nmda antagonists: Such as memantine are used to prevent further nerve damage, used in the management of moderate to severe Alzheimer's disease.
  • Caprylidine: To supplement the energy requirements of the brain. Used in mild to moderate Alzheimer's disease.

Other medications to treat secondary symptoms such as depression, anxiety, or other behavioral changes may include:

  • Antidepressants
  • Anxiolytics
  • Antiparkinsonian drugs
  • Beta-blockers
  • Anti-epileptic drugs

Role of diet/ Exercise/ Lifestyle changes/ Preventive measures

Supportive care is essential in the management of Alzheimer's disease progress, and the affected individuals are slowly unable to take care of themselves and day to day tasks.

Some of the supportive measures can include:

  • Keeping essential items and valuables at the same place
  • Keeping medications in a secure place, and monitoring the intake
  • Location tracking of the affected through smartphone and GPS
  • Removing clutter and excess furniture to avoid falls
  • Wearable identification and medical alert bracelets
  • The comforting and calm atmosphere

A few lifestyle changes may help to lower the risks of developing Alzheimer's disease, but they cannot help to prevent it. Some of these measures include:

  • Cessation of smoking
  • Exercising and maintaining an active and disciplined lifestyle
  • Eating healthy food rich in fruits and vegetables
  • Managing and controlling preexisting conditions such as hypertension, diabetes, and high cholesterol levels.

Complications

The complications of Alzheimer’s Disease can stem from the affected individual's inability to communicate his or her problems, as well as from intellectual decline.

The following may be a consequence of that and may include:

  • Unable to express pain or symptoms from another medical ailment.
  • Unable to take medication or follow medical advice.
  • Unable to describe the side effects of medication.

Also, as the disease progresses, the following may be seen:

  • Inability to feed or drink
  • Falls and fractures
  • Malnutrition and dehydration
  • Bedsores
  • Skin infections and lung infections

Prognosis

Alzheimer’s Disease is usually difficult to diagnose in the early stages, and the prognosis for the condition is poor as the disease advances. The prognosis of Alzheimer's disease depends on the severity of the cognitive impairment and the presence of other conditions such as heart disease, or diabetes, as well as on complications such as falls and fractures, or serious infections or severe dehydration that may occur. Life expectancy is reduced in this disease and men have a poorer prognosis when compared to women.

When to contact the doctor or hospital? / How to identify the emergency or complications?

It is advisable to seek medical attention if incidents of memory lapses are noticed or observed, so that early diagnosis and management can be planned.

Indications for hospitalization if required

Hospitalization is not required for Alzheimer's disease unless warranted by certain complications.

Suggested clinical specialist/ Departments to consult for this condition

Alzheimer’s Disease will be attended by specialists from the Departments of Neurology and Psychiatry.

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