CASE STUDY: ALZHEIMERS

Celica Livingstone, 74 years old brought to her daughter's family doctor for evaluation.
Mrs. Livingstone has lived alone for the past several years, doing her own cooking and caring for
herself. Her daughter, Judy, who lives in another city, calls Mrs. Livingstone each week although she
has not seen her mother for about 6 months.
During the last phone call, Judy became concerned. Her mother seemed distracted, frequently
interrupted the conversation and repeatedly said that she was "so worried." When asked what
worried her, Mrs. Livingstone said, "I just don't know." She repeatedly asked the same question.
Alarmed, Judy drove to her mother's home six hours away. When she arrived, Judy was shocked to
see how thin her mother had become. There was little in the house to eat except tapioca pudding,
gelatin and applesauce. Judy was able to figure out that Mrs. Livingstone had broken her dentures
and was having difficulty chewing. Her skin turgor is sluggish.
Mrs. Livingstone said the coffeemaker and the TV did not work. The daughter used both and found
them to be working. Mrs. Livingstone often started tasks but did not finish them, she seemingly forgot
what she was doing. Often could not think of words, such as the name of the dresser in her bedroom
As evening approached Mrs. Livingstone became more agitated and was unable to sleep. She said she
had to "see about the children."
Judy brought her mother home with her the following day and made an urgent appointment with her
family doctor to evaluate Mrs. Livingstone's condition.
During the examination, Mrs. Livingstone was unable to focus on the nurse's questions and
instructions. She knew her own identity, was unsure of her exact location and did not know the
current date. She became visibly agitated with the questions and said she didn't want to answer or
says 'I don't know, well I do know but I am not going to answer." (probably because she was unable to
answer).
Mrs. Livingstone thought the physician was the son of one of her friends from home and asked him
several times about his mother. She complained of fatigue and epigastric tenderness. She was 20
pounds under her ideal body weight and she was pale. Lab tests revealed iron deficiency anemia, low
albumin, and dehydration.
BACKGROUND:

Alzheimer disease (AD) is an acquired disorder of cognitive and behavioral impairment that markedly interferes
with social and occupational functioning. It is an incurable disease with a long and progressive course. In AD,
plaques develop in the hippocampus, a structure deep in the brain that helps to encode memories, and in other
areas of the cerebral cortex that are used in thinking and making decisions. Whether plaques themselves
cause AD or whether they are a by-product of the AD process is still unknown. The most common form of
dementia, Alzheimer disease (AD) affects approximately 5.3 million people in the United States alone, and that
number is projected to reach 13.8 million by the year 2050 (see Epidemiology). Economically, AD is a major
public health problem. In the United States in 2015, the cost of health care, long-term care, and hospice
services for people aged 65 years and older with AD and other dementias was expected to be $226 billion, and

this figure does not include the contributions of unpaid caregivers. By 2015, these costs could rise as high as
$1.1 trillion.
Currently, an autopsy or brain biopsy is the only way to make a definitive diagnosis of AD. In clinical practice,
the diagnosis is usually made on the basis of the history and findings on Mental Status Examination
Symptomatic therapies are the only treatments available for AD. The standard medical treatments include
cholinesterase inhibitors and a partial N -methyl-D-aspartate (NMDA) antagonist. Psychotropic medications are
often used to treat secondary symptoms of AD, such as depression, agitation, and sleep disorders.
PATHOPYSIOLOGY:
A continuum exists between the pathophysiology of normal aging and that of AD. Pathologic hallmarks of AD
have been identified; however, these features also occur in the brains of cognitively intact persons. For
example, in a study in which neuropathologists were blinded to clinical data, they identified 76% of brains of
cognitively intact elderly patients as demonstrating AD.
AD affects the 3 processes that keep neurons healthy: communication, metabolism, and repair. Certain nerve
cells in the brain stop working, lose connections with other nerve cells, and finally die. The destruction and
death of these nerve cells causes the memory failure, personality changes, problems in carrying out daily
activities, and other features of the disease.
The accumulation of SPs primarily precedes the clinical onset of AD. NFTs, loss of neurons, and loss of
synapses accompany the progression of cognitive decline.
Considerable attention has been devoted to elucidating the composition of SPs and NFTs to find clues about
the molecular pathogenesis and biochemistry of AD. The main constituent of NFTs is the microtubuleassociated protein tau (see Anatomy). In AD, hyperphosphorylated tau accumulates in the perikarya of large
and medium pyramidal neurons. Somewhat surprisingly, mutations of the tau gene result not in AD but in some
familial cases of frontotemporal dementia.
Since the time of Alois Alzheimer, SPs have been known to include a starchlike (or amyloid) substance, usually
in the center of these lesions. The amyloid substance is surrounded by a halo or layer of degenerating
(dystrophic) neurites and reactive glia (both astrocytes and microglia).
One of the most important advances in recent decades has been the chemical characterization of this amyloid
protein, the sequencing of its amino acid chain, and the cloning of the gene encoding its precursor protein (on
chromosome 21). These advances have provided a wealth of information about the mechanisms underlying
amyloid deposition in the brain, including information about the familial forms of AD.

SIGNS AND SYMPTOMS:

At first, increasing forgetfulness or mild confusion may be the only symptoms of Alzheimer's disease that you notice.
But over time, the disease robs you of more of your memory, especially recent memories. The rate at which
symptoms worsen varies from person to person.If you have Alzheimer's, you may be the first to notice that you're
having unusual difficulty remembering things and organizing your thoughts. Or you may not recognize that anything is
wrong, even when changes are noticeable to your family members, close friends or co-workers.

Brain changes associated with Alzheimer's disease lead to growing trouble with:
Memory
Everyone has occasional memory lapses. It's normal to lose track of where you put your keys or forget the name of
an acquaintance. But the memory loss associated with Alzheimer's disease persists and worsens, affecting your
ability to function at work and at home.People with Alzheimer's may:

Repeat statements and questions over and over, not realizing that they've asked the question before.

Forget conversations, appointments or events, and not remember them later

Routinely misplace possessions, often putting them in illogical locations

Get lost in familiar places

Eventually forget the names of family members and everyday objects

Have trouble finding the right words to identify objects, express thoughts or take part in conversations

Thinking and reasoning

Alzheimer's disease causes difficulty concentrating and thinking, especially about abstract concepts like numbers.
Multitasking is especially difficult, and it may be challenging to manage finances, balance checkbooks and pay bills
on time. These difficulties may progress to inability to recognize and deal with numbers.
Making judgments and decisions

Responding effectively to everyday problems, such as food burning on the stove or unexpected driving situations,
becomes increasingly challenging.
Planning and performing familiar tasks

Once-routine activities that require sequential steps, such as planning and cooking a meal or playing a favorite game,
become a struggle as the disease progresses. Eventually, people with advanced Alzheimer's may forget how to
perform basic tasks such as dressing and bathing.
Changes in personality and behavior

Brain changes that occur in Alzheimer's disease can affect the way you act and how you feel. People with Alzheimer's
may experience:

Depression

Apathy

Social withdrawal

Mood swings

Distrust in others

Irritability and aggressiveness

Changes in sleeping habits

Wandering

Loss of inhibitions

Delusions, such as believing something has been stolen

Many important skills are not lost until very late in the disease. These include the ability to read, dance and sing,
enjoy old music, engage in crafts and hobbies, tell stories, and reminisce.This is because information, skills and
habits learned early in life are among the last abilities to be lost as the disease progresses; the part of the brain that
stores this information tends to be affected later in the course of the disease. Capitalizing on these abilities can foster
successes and maintain quality of life even into the moderate phase of the disease.

CAUSES:

Scientists believe that for most people, Alzheimer's disease is caused by a combination of genetic, lifestyle and
environmental factors that affect the brain over time.Less than 5 percent of the time, Alzheimer's is caused by specific
genetic changes that virtually guarantee a person will develop the disease.

Although the causes of Alzheimer's aren't yet fully understood, its effect on the brain is clear. Alzheimer's disease
damages and kills brain cells. A brain affected by Alzheimer's disease has many fewer cells and many fewer
connections among surviving cells than does a healthy brain.

As more and more brain cells die, Alzheimer's leads to significant brain shrinkage. When doctors examine
Alzheimer's brain tissue under the microscope, they see two types of abnormalities that are considered hallmarks of
the disease:

Plaques. These clumps of a protein called beta-amyloid may damage and destroy brain cells in several
ways, including interfering with cell-to-cell communication. Although the ultimate cause of brain-cell death in
Alzheimer's isn't known, the collection of beta-amyloid on the outside of brain cells is a prime suspect.

Tangles. Brain cells depend on an internal support and transport system to carry nutrients and other
essential materials throughout their long extensions. This system requires the normal structure and functioning
of a protein called tau.

In Alzheimer's, threads of tau protein twist into abnormal tangles inside brain cells, leading to failure of the
transport system. This failure is also strongly implicated in the decline and death of brain cells.

RISK FACTORS:
Age
Increasing
age is the greatest known risk factor for Alzheimer's. Alzheimer's is not a part of normal aging, but your risk increases
greatly after you reach age 65. The rate of dementia doubles every decade after age 60.People with rare genetic
changes linked to early-onset Alzheimer's begin experiencing symptoms as early as their 30s.
Family history and genetics

Your risk of
developing Alzheimer's appears to be somewhat higher if a first-degree relative your parent or sibling has the
disease. Scientists have identified rare changes (mutations) in three genes that virtually guarantee a person who
inherits them will develop Alzheimer's. But these mutations account for less than 5 percent of Alzheimer's
disease.Most genetic mechanisms of Alzheimer's among families remain largely unexplained. The strongest risk
gene researchers have found so far is apolipoprotein e4 (APoE4), though not everyone with this gene goes on to
develop Alzheimer's disease. Other risk genes have been identified but not conclusively confirmed.
Down syndrome
Many people with Down syndrome develop Alzheimer's disease. Signs and symptoms of Alzheimer's tend to appear
10 to 20 years earlier in people with Down syndrome than they do for the general population. A gene contained in the
extra chromosome that causes Down syndrome significantly increases the risk of Alzheimer's disease.
Sex

Women seem to be more likely than are men to develop Alzheimer's disease, in part because they live longer.

Mild cognitive impairment

People with mild cognitive impairment (MCI) have memory problems or other symptoms of cognitive decline that are
worse than might be expected for their age, but not severe enough to be diagnosed as dementia.Those with MCI
have an increased risk but not a certainty of later developing dementia. Taking action to develop a healthy
lifestyle and strategies to compensate for memory loss at this stage may help delay or prevent the progression to
dementia.
Past head traumaPeople who've had a severe head trauma seem to have a greater risk of Alzheimer's disease.
Lifestyle and heart health

There's no lifestyle factor that's been definitively shown to reduce your risk of Alzheimer's disease.

However, some evidence suggests that the same factors that put you at risk of heart disease also may increase the
chance that you'll develop Alzheimer's. Examples include:

Lack of exercise

Obesity

Smoking or exposure to secondhand smoke

High blood pressure

High blood cholesterol

Poorly controlled type 2 diabetes

A diet lacking in fruits and vegetables

These risk factors are also linked to vascular dementia, a type of dementia caused by damaged blood vessels in the
brain. Working with your health care team on a plan to control these factors will help protect your heart and may
also help reduce your risk of Alzheimer's disease and vascular dementia.

COMPLICATION:

Memory and language loss, impaired judgment, and other cognitive changes caused by Alzheimer's can complicate
treatment for other health conditions. A person with Alzheimer's disease may not be able to:

Communicate that he or she is experiencing pain for example, from a dental problem

Report symptoms of another illness

Follow a prescribed treatment plan

Notice or describe medication side effects

As Alzheimer's disease progresses to its last stages, brain changes begin to affect physical functions, such as
swallowing, balance, and bowel and bladder control. These effects can increase vulnerability to additional health
problems such as:

Inhaling food or liquid into the lungs (aspiration)

Pneumonia and other infections

Falls

Fractures

Bedsores

Malnutrition or dehydration

PREVENTION:
Right now, there's no proven way to prevent Alzheimer's disease. Research into prevention strategies is ongoing. The
strongest evidence so far suggests that you may be able to lower your risk of Alzheimer's disease by reducing your
risk of heart disease. Many of the same factors that increase your risk of heart disease can also increase your risk of
Alzheimer's disease and vascular dementia. Important factors that may be involved include high blood pressure, high
blood cholesterol, excess weight and diabetes.

The Mediterranean diet a way of eating that emphasizes fresh produce, healthy oils and foods low in saturated fat
can lower the risk of death from cardiovascular disease and stroke. This diet has also been associated with a
reduced risk of Alzheimer's disease. Keeping active physically, mentally and socially may make your life more
enjoyable and may also help reduce the risk of Alzheimer's.

TREATMENT:

There is currently no cure for Alzheimer's disease, although medication is available that can temporarily
reduce some symptoms or slow down the progression of the condition in some people.
Support is also available to help someone with the condition cope with everyday life.
CARE PLAN
Once you've been diagnosed with Alzheimer's disease, your future health and social care needs will need to be
assessed and a care plan drawn up.
A care plan is a way of ensuring you receive the right treatment for your needs. It involves identifying areas where
you may need some assistance, such as:

what support you or your carer need for you to remain as independent as possible

whether there are any changes that need to be made to your home to make it easier to live in

whether you need any financial assistance

Healthcare professionals (such as your GP or psychiatrist) and social care services, which is normally your local
council working in conjunction with the NHS, will usually both be involved in helping draw up and implement care
plans.
Read more about care plans for long-term conditions.
Medication
A number of medications may be prescribed for Alzheimer's disease to help temporarily improve some symptoms and
slow down the progression of the condition.
These include donepezil, galantamine, rivastigmine and memantine. Whether these medications are used will
depend on the severity of the condition.
Donepezil, galantamine and rivastigmine (known as AChE inhibitors) can be prescribed for people with early to midstage Alzheimer's disease. Memantine may be prescribed for people with mid-stage disease who cannot take AChE
inhibitors, or for those with late-stage disease.