Alzheimer's disease facts*

*Alzheimer's disease facts author: William C. Shiel Jr., MD, FACP, FACR
Alzheimer's disease (AD) is a slowly progressive disease of the brain
that is characterized by impairment of memory and eventually by
disturbances in reasoning, planning, language, and perception.
The likelihood of having Alzheimer's disease increases substantially
after the age of 70 and may affect around 50% of persons over the age
of 85.
The main risk factor for Alzheimer's disease is increased age. There are
also genetic risk factors and others.
There are 10 classic warning signs of Alzheimer's disease: memory
loss, difficulty performing familiar tasks, problems with language,
disorientation to time and place, poor or decreased judgment, problems
with abstract thinking, misplacing things, changes in mood or behavior,
changes in personality, and loss of initiative.
The cause(s) of Alzheimer's disease is (are) not known. Although,
accumulation of the protein amyloid in the brain is suspected to play a
role.
Alzheimer's disease is diagnosed when: 1) a person has sufficient
cognitive decline to meet criteria fordementia; 2) the clinical course is
consistent with that of Alzheimer's disease; 3) no other brain diseases or
other processes are better explanations for the dementia. Many other
causes of dementia are screened for prior to diagnosing Alzheimer's
disease.
The management of Alzheimer's disease consists of medication based
and non-medication based treatments.
What is dementia?
Dementia is a syndrome characterized by:
1. impairment in memory,
2. impairment in another area of thinking such as the ability to organize
thoughts and reason, the ability to use language, or the ability to see
accurately the visual world (not because of eye disease), and
3. these impairments are severe enough to cause a decline in the patient's
usual level of functioning.
Although some kinds of memory loss are normal parts of aging, the changes
due to aging are not severe enough to interfere with the level of function.
Many different diseases can cause dementia, but Alzheimer's disease is by
far the most common cause for dementia in the United States and in most
countries in the world.
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What is Alzheimer's disease?
Alzheimer's disease (AD) is a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in
reasoning, planning, language, and perception. Many scientists believe that Alzheimer's disease results from an increase in the production or
accumulation of a specific protein (beta-amyloid protein) in the brain that leads to nerve cell death.
The likelihood of having Alzheimer's disease increases substantially after the age of 70 and may affect around 50% of persons over the age of 85.
Nonetheless, Alzheimer's disease is not a normal part of aging and is not something that inevitably happens in later life. For example, many people live
to over 100 years of age and never develop Alzheimer's disease.
Who develops Alzheimer's disease?
The main risk factor for Alzheimer's disease is increased age. As a population ages, the frequency of Alzheimer's disease continues to increase. Ten
percent of people over 65 years of age and 50% of those over 85 years of age have Alzheimer's disease. Unless new treatments are developed to
decrease the likelihood of developing Alzheimer's disease, the number of individuals with Alzheimer's disease in the United States is expected to be
13.8 million by the year 2050.
There are also genetic risk factors for Alzheimer's disease. Most patients develop Alzheimer's disease after age 70. However, less than 5% of patients
develop the disease in the fourth or fifth decade of life (40s or 50s). At least half of these early onset patients have inherited gene mutations associated
with their Alzheimer's disease. Moreover, the children of a patient with early onset Alzheimer's disease who has one of these gene mutations has a
50% risk of developing Alzheimer's disease.
There is also a genetic risk for late onset cases. A relatively common form of a gene located on chromosome 19 is associated with late onset
Alzheimer's disease. In the majority of Alzheimer's disease cases, however, no specific genetic risks have yet been identified.
Other risk factors for Alzheimer's disease include high blood pressure (hypertension), coronary artery disease, diabetes, and possibly elevated
blood cholesterol. Individuals who have completed less than eight years of education also have an increased risk for Alzheimer's disease. These
factors increase the risk of Alzheimer's disease, but by no means do they mean that Alzheimer's disease is inevitable in persons with these factors.
A majority of patients with Down syndrome will develop the brain changes of Alzheimer's disease by 40 years of age. This fact was also a clue to the
"amyloid hypothesis of Alzheimer's disease.
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What are the symptoms of Alzheimer's disease?
The onset of Alzheimer's disease is usually gradual, and it is slowly
progressive. Memory problemsthat family members initially dismiss as "a
normal part of aging" are in retrospect noted by the family to be the first
stages of Alzheimer's disease. When memory and other problems with
thinking start to consistently affect the usual level of functioning; families
begin to suspect that something more than "normal aging" is going on.
Problems of memory, particularly for recent events (short-term memory)
are common early in the course of Alzheimer's disease. For example, the
individual may, on repeated occasions, forget to turn off an iron or fail to
recall which of the morning'smedicines were taken. Mild personality
changes, such as less spontaneity, apathy, and a tendency to withdraw from
social interactions, may occur early in the illness.
As the disease progresses, problems in abstract thinking and in other
intellectual functions develop. The person may begin to have trouble with
figures when working on bills, with understanding what is being read, or
with organizing the day's work. Further disturbances in behavior and
appearance may also be seen at this point, such as agitation, irritability,
quarrelsomeness, and a diminishing ability to dress appropriately.
Later in the course of thedisorder, affected individuals may
become confused or disoriented about what month or year it is, be unable to
describe accurately where they live, or be unable to name a place being
visited. Eventually, patients may wander, be unable to engage in
conversation, erratic in mood, uncooperative, and lose bladder and bowel
control. In late stages of the disease, persons may become totally incapable
of caring for themselves. Death can then follow, perhaps from pneumonia
or some other problem that occurs in severely deteriorated states of health.
Those who develop the disorder later in life more often die from other
illnesses (such as heart disease) rather than as a consequence of Alzheimer's
disease.

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Ten warning signs of Alzheimer's disease
The Alzheimer's Association has developed the following list ofwarning signs that include common symptoms of
Alzheimer's disease. Individuals who exhibit several of these symptoms should see a physician for a complete
evaluation.
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
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IN THIS ARTICLE
What are causes of Alzheimer's disease?
The cause(s) of Alzheimer's disease is (are) not known. The "amyloid cascade hypothesis" is the most widely
discussed and researched hypothesis about the cause of Alzheimer's disease. The strongest data supporting the
amyloid cascade hypothesis comes from the study of early-onset inherited (genetic) Alzheimer's disease. Mutations
associated with Alzheimer's disease have been found in about half of the patients with early-onset disease. In all of
these patients, the mutation leads to excess production in the brain of a specific form of a small protein fragment
called ABeta (A). Many scientists believe that in the majority of sporadic (for example, non-inherited) cases of
Alzheimer's disease (these make up the vast majority of all cases of Alzheimer's disease) there is too little removal of
this A protein rather than too much production. In any case, much of the research in finding ways to prevent or slow
down Alzheimer's disease has focused on ways to decrease the amount of A in the brain.
What are risk factors for Alzheimer's disease?
The biggest risk factor for Alzheimer's disease is increased age. The likelihood of developing Alzheimer's disease
doubles every 5.5 years from 65 to 85 years of age. Whereas only 1% to 2% of individuals 70 years of age have
Alzheimer's disease, in some studies around 40% of individuals 85 years of age have Alzheimer's disease.
Nonetheless, at least half of people who live past 95 years of age do not have Alzheimer's disease.
Common forms of certain genes increase the risk of developing Alzheimer's disease, but do not invariably cause
Alzheimer's disease. The best-studied"risk" gene is the one that encodes apolipoprotein E (apoE). The apoE gene
has three different forms (alleles) -- apoE2, apoE3, and apoE4. The apoE4 form of the gene has been associated
with increased risk of Alzheimer's disease in most (but not all) populations studied. The frequency of the apoE4
version of the gene in the generalpopulation varies, but is always less than 30% and frequently 8% to 15%. People
with one copy of the E4 gene usually have about a two- to three-fold increased risk of developing Alzheimer's
disease. Persons with two copies of the E4 gene (usually around 1% of the population) have about a nine-fold
increase in risk. Nonetheless, even persons with two copies of the E4 gene don't always get Alzheimer's disease. At
least one copy of the E4 gene is found in 40% of patients with sporadic or late-onset Alzheimer's disease.
This means that in majority of patients with Alzheimer's disease, no genetic risk factor has yet been found. Most
experts do not recommend that adult children of patients with Alzheimer's disease should have genetic testing for the
apoE4 gene since there is no treatment for Alzheimer's disease. When medical treatments that prevent or decrease
the risk of developing Alzheimer's disease become available, genetic testing may be recommended for adult children
of patients with Alzheimer's disease so that they may be treated.
Many, but not all, studies have found that women have a higher risk for Alzheimer's disease than men. It is certainly
true that women live longer than men, but age alone does not seem to explain the increased frequency in women.
The apparent increased frequency of Alzheimer's disease in women has led to considerable research about the role
of estrogen in Alzheimer's disease. Recent studies suggest that estrogen should not be prescribed to post-
menopausal women for the purpose of decreasing the risk of Alzheimer's disease. Nonetheless, the role of estrogen
in Alzheimer's disease remains an area of research focus.
Some studies have found that Alzheimer's disease occurs more often among people who suffered significant
traumatic head injuries earlier in life, particularly among those with the apoE 4 gene.
In addition, many, but not all studies, have demonstrated that persons with limited formal education - usually less
than eight years - are at increased risk for Alzheimer's disease. It is not known whether this reflects a decreased
"cognitive reserve" or other factors associated with a lower educational level.
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How is the diagnosis of Alzheimer's disease made?
No specific blood test or imaging test exists for the diagnosis of
Alzheimer's disease. Alzheimer's disease is diagnosed when: 1) a
person has sufficient cognitive decline to meet criteria for
dementia; 2) the clinical course is consistent with that of
Alzheimer's disease; 3) no other brain diseases or other processes
are better explanations for the dementia.
What other conditions should be screened for?
There are many conditions that can cause dementia, to include the
following:
Neurological disorders:Parkinson's disease, cerebrovascular
disease and strokes, brain tumors, blood clots, and multiple
sclerosis can sometimes be associated withdementia although
many patients with these conditions are cognitively normal.
Infectious diseases: Some brain infections such as chronic
syphilis, chronic HIV, or chronicfungal meningitis can cause
dementia.
Side effects of medications:Many medicines can causecognitive
impairment, especially in elderly patients. Perhaps the most
frequent offenders are drugs used to control bladder urgency and
incontinence. "Psychiatric medications" such as anti-depressants
and anti-anxiety medications and "neurological medications" such
as anti-seizure medications can also be associated with cognitive
impairment.
If a physician evaluates a person with cognitive impairment who is
on one of these medications, the medication is often gently tapered
and/or discontinued to determine whether it might be the cause of
the cognitive impairment. If it is clear that the cognitive
impairment preceded the use of these medications, such tapering
may not be necessary. On the other hand, "psychiatric,"
"neurological," and "incontinence" medications are often
appropriately prescribed to patients with Alzheimer's disease. Such
patients need to be followed carefully to determine whether these
medications cause any worsening of cognition.
Psychiatric disorders: In older persons, some forms
ofdepression can cause problems with memory and concentration
that initially may be indistinguishable from the early symptoms of
Alzheimer's disease. Sometimes, these conditions, referred to as
pseudodementia, can be reversed. Studies have shown that persons
with depression and coexistent cognitive (thinking, memory)
impairment are highly likely to have an underlying dementia when
followed for several years.
Substance Abuse: Abuse of legal and/or illegal drugs and
alcohol abuse is often associated with cognitive impairment.
Metabolic Disorders: Thyroid dysfunction, some steroiddisorders,
and nutritional deficiencies such as vitamin B12 deficiency or
thiamine deficiency are sometimes associated with cognitive
impairment.
Trauma: Significant head injuries with brain contusions may
cause dementia. Blood clots around the outside of the brain
(subdural hematomas) may also be associated with dementia.
Toxic Factors: Long term consequences of acute carbon monoxide
poisoning can lead to an encephalopathy with dementia. In some
rare cases, heavy metal poisoning can be associated with dementia.
Tumors: Many primary and metastatic brain tumors can cause
dementia. However, many patients with brain tumors have no or
little cognitive impairment associated with the tumor.
The Importance of Comprehensive Clinical Evaluation
Because many other disorders can be confused with Alzheimer's
disease, a comprehensive clinical evaluation is essential in arriving
at a correct diagnosis. Such an assessment should include at least
three major components; 1) a thorough general medical workup, 2)
a neurological examination including testing of memory and other
functions of thinking , and 3) a psychiatric evaluation to assess
mood, anxiety, and clarity of thought.
Such an evaluation takes time - usually at least an hour. In the
United States healthcare system, neurologists, psychiatrists, or
geriatricians frequently become involved. Nonetheless, any
physician may be able to perform a thorough evaluation.
The American Academy of Neurology has published guidelines
that include imaging of the brain in the initial evaluation of patients
with dementia. These studies are either a noncontrast CT scan or
an MRI scan. Other imaging procedures that look at the function of
the brain (functional neuroimaging), such as SPECT, PET, and
fMRI, may be helpful in specific cases, but generally are not
needed. However, in many healthcare systems outside of the
United States, brain imaging as not a standard part of the
assessment for possible Alzheimer's disease.
Despite many attempts, identification of a blood test to diagnose
Alzheimer's disease has remained elusive. Such testing is neither
widely available nor recommended.




What is the prognosis for a person with Alzheimer's disease?
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Alzheimer's disease is invariably progressive. Different studies have stated that Alzheimer's disease progresses over
two to 25 years with most patients in the eight to 15 year range. Nonetheless, defining when Alzheimer's disease
starts, particularly in retrospect, can be very difficult. Patients usually don't die directly from Alzheimer's disease. They
die because they have difficulty swallowing orwalking and these changes make overwhelming infections, such as
pneumonia, much more likely.
Most persons with Alzheimer's disease can remain at home as long as some assistance is provided by others as the
disease progresses. Moreover, throughout much of the course of the illness, individuals maintain the capacity for
giving and receiving love, sharing warm interpersonal relationships, and participating in a variety of meaningful
activities with family and friends.
A person with Alzheimer's disease may no longer be able to do math but still may be able to read a magazine with
pleasure.Playing the piano might become too stressful in the face of increasing mistakes, but singing along with
others may still be satisfying. The chessboard may have to be put away, but playing tennis may still be enjoyable.
Thus, despite the many exasperating moments in the lives of patients with Alzheimer's disease and their families,
many opportunities remain for positive interactions. Challenge, frustration, closeness, anger, warmth, sadness, and
satisfaction may all be experienced by those who work to help the person with Alzheimer's disease. For more, please
read the Caregiving and Alzheimer's Disease: Caregiving Challenges articles.
The reaction of a patient with Alzheimer's disease to the illness and his or her capacity to cope with it also vary, and
may depend on such factors as lifelong personality patterns and the nature and severity of stress in the
immediate environment. Depression, severe uneasiness,paranoia, or delusions may accompany or result from the
disease, but these conditions can often be improved by appropriate treatments. Although there is no cure for
Alzheimer's disease, treatments are available to alleviate many of the symptoms that cause suffering.
Medically Reviewed by a Doctor on 12/5/2013
What treatment and management options are available for Alzheimer's disease?
Comment on thisRead 1 CommentShare Your Story
The management of Alzheimer's disease consists of medication based and non-medication based treatments. Two
different classesof pharmaceuticals are approved by the FDA for treating Alzheimer's disease:
cholinesteraseinhibitors and partial glutamate antagonists. Neither class of drugs has been proven to slow the rate of
progression of Alzheimer's disease. Nonetheless, many clinical trialssuggest that these medicationsare superior to
placebos (sugar pills) in relieving somesymptoms.
Cholinesterase inhibitors
In patients with Alzheimer's disease there is a relative lack of a brain chemical neurotransmitter called acetylcholine.
(Neurotransmitters are chemical messengers produced by nerves that the nerves use to communicate with each
other in order to carry out their functions.) Substantial research has demonstrated that acetylcholine is important in
the ability to form new memories. The cholinesterase inhibitors (ChEIs) block the breakdown of acetylcholine. As a
result, more acetylcholine is available in the brain, and it may become easier to form new memories.
Four ChEIs have been approved by the FDA, but only donepezilhydrochloride (Aricept),rivastigmine (Exelon),
andgalantamine (Razadyne - previously called Reminyl) are used by most physicians because the fourth
drug, tacrine(Cognex) has more undesirableside effects than the other three. Most experts in Alzheimer's disease do
not believe there is an important difference in the effectiveness of these three drugs. Several studies suggest that the
progression of symptoms of patients on these drugs seems to plateau for six to 12 months, but inevitably progression
then begins again.
Of the three widely used AchEs, rivastigmine and galantamine are only approved by the FDA for mild to moderate
Alzheimer's disease, whereas donepezil is approved for mild, moderate, and severe Alzheimer's disease. It is not
known whether rivastigmine and galantamine are also effective in severe Alzheimer's disease, although there does
not appear to be any good reason why they shouldn't.
The principal side effects of ChEIs involve the gastrointestinal system and include nausea, vomiting, cramping,
and diarrhea. Usually these side effects can be controlled with change in size or timing of the dose or administering
the medications with a small amount of food. A majority of patients will tolerate therapeutic doses of ChEIs.