Alzheimer's disease

Definition
Alzheimer's disease is the most common cause of dementia, which is the loss of i
ntellectual and social abilities severe enough to interfere with daily functioni
ng. Dementia occurs in people with Alzheimer's disease because healthy brain tis
sue degenerates, causing a steady decline in memory and mental abilities. About
4 million older Americans have Alzheimer's, a disease that usually develops in p
eople age 65 or older. This number is expected to triple by the year 2050 as the
population ages. Although there's no cure for Alzheimer's disease, researchers
have made progress. Treatments are available that improve the quality of life fo
r some people with Alzheimer's. Also, more drugs are being studied, and scientis
ts have discovered several genes associated with Alzheimer's, which may lead to
new treatments to block progression of this complex disease. In the meantime, ca
ring for someone with Alzheimer's takes patience and a focus on the things a per
son can still do and enjoy. Those with Alzheimer's — as well as those who care for
them — need support and affection from friends and family to cope.
Symptoms
Everyone has occasional lapses in memory. It's normal to forget the names of peo
ple whom you rarely see. But it's not a normal part of aging to forget the names
of familiar people and objects. Alzheimer's disease — a progressive, degenerative
brain disease — causes more than simple forgetfulness. It may start with slight m
emory loss and confusion, but it eventually leads to irreversible mental impairm
ent that destroys a person's ability to remember, reason, learn and imagine. Mos
t people with Alzheimer's share certain signs and symptoms of the disease. These
may include:

Increasing and persistent forgetfulness. At its onset, Alzheimer's disease is ma

rked by periods of forgetfulness, especially of recent events or simple directio
ns. But what begins as mild forgetfulness persists and worsens. People with Alzh
eimer's may repeat things and forget conversations or appointments. They routine
ly misplace things, often putting them in illogical locations. They frequently f
orget names, and eventually, they may forget the names of family members and eve
ryday objects. Difficulties with abstract thinking. People with Alzheimer's may
initially have trouble balancing their checkbook, a problem that progresses to t
rouble recognizing and dealing with numbers.
Difficulty finding the right word. It may be a challenge for those with Alzheime
r's to find the right words to express thoughts or even follow conversations. Ev
entually, reading and writing also are affected. Disorientation. People with Alz
heimer's often lose their sense of time and dates, and may find themselves lost
in familiar surroundings. Loss of judgment. Solving everyday problems, such as k
nowing what to do if food on the stove is burning, becomes increasingly difficul
t, eventually impossible. Alzheimer's is characterized by greater difficulty in
doing things that require planning, decision making and judgment. Difficulty per
forming familiar tasks. Once-routine tasks that require sequential steps, such a
s cooking, become a struggle as the disease progresses. Eventually, people with
advanced Alzheimer's may forget how to do even the most basic things. Personalit
y changes. People with Alzheimer's may exhibit mood swings. They may express dis
trust in others, show increased stubbornness and withdraw socially. Early on, th
is may be a response to the frustration they feel as they notice uncontrollable
changes in their memory. Depression often coexists with Alzheimer's disease. Res
tlessness also is a common sign. As the disease progresses, people with Alzheime
r's may become anxious or aggressive and behave inappropriately.
Because early Alzheimer's symptoms progress slowly, diagnosis is often delayed.
People developing the condition may be frighteningly aware of their problems — but
careful to keep them hidden, refusing to see a doctor. As a result, even their
families may fail to see what's going on. When the signs and symptoms are too ob
vious to miss, those closest to the person often realize that similar — but less s
evere — difficulties have been present for years. The disease's course varies from
person to person. Eight years is the average length of time from diagnosis of A
lzheimer's to death. Survival begins to decline three years after diagnosis, but
some people live more than a decade with the disease.
Causes
The causes of Alzheimer's are poorly understood, but its effect on brain tissue
has been demonstrated clearly. Alzheimer's damages and kills brain cells. A heal
thy brain has billions of nerve cells called neurons. Neurons generate electrica
l and chemical signals that are relayed from neuron to neuron to help you think,
remember and feel. Chemicals called neurotransmitters help these signals flow s
eamlessly between neurons. Initially in people with Alzheimer's, neurons in cert
ain locations of the brain begin to die. When they die, lower levels of neurotra
nsmitters are produced, creating signaling problems in the brain. Plaques and ta
ngles Alzheimer's disease is named after Dr. Alois Alzheimer, a German neurologi
st. In 1906, he examined the brain of a woman who had died after years of progre
ssive
dementia. Her brain tissue showed abnormal clumps and irregular knots of brain c
ells. Today, these clumps (now called plaques) and knots (now called tangles) ar
e considered hallmarks of Alzheimer's disease. Studies of plaques and tangles fr
om the brains of people who have died of Alzheimer's suggest several possible ro
les these structures might play in the disease. Some of the theories:

Possible role of plaques. Plaques are made up of a normally harmless protein cal
led beta-amyloid. Although the ultimate cause of neuron death in Alzheimer's isn
't known, mounting evidence suggests that a form of betaamyloid protein may be t
he culprit. Three genetic mutations — in amyloid precursor protein and presenilin
1 (PS1) and presenilin 2 (PS2) proteins — are known to cause a small number of ear
ly-onset forms of Alzheimer's disease. These mutations result in the production
of amyloid plaques. Together, these three genetic mutations account for less tha
n 10 percent of all Alzheimer's cases. Possible role of tangles. The internal su
pport structure for brain neurons depends on the normal functioning of a protein
called tau. In people with Alzheimer's, threads of tau protein undergo alterati
ons that cause them to become twisted. Many researchers believe this may serious
ly damage neurons, causing them to die.
Inflammatory response as the common path. Researchers have observed inflammation
in the brains of some people with Alzheimer's disease. Inflammation is your bod
y's response to injury or infection and a natural part of the healing process. E
ven as beta-amyloid plaques develop in the spaces between neurons, immune cells
are at work getting rid of dead cells and other waste products in the brain. Alt
hough researchers believe the inflammation occurs before plaques have fully form
ed, they aren't sure how this development relates to the disease process. There'
s also debate about whether inflammation has a damaging effect on neurons or whe
ther it is beneficial in clearing away plaques.
Risk factors
Alzheimer's is a complex disease likely caused by a combination of factors — such
as infection or reduced circulation — and genetic susceptibility. Although all the
contributing factors may never be known, scientists have identified several com
mon threads. They include:

Age. Alzheimer's usually affects people older than 65, but can, rarely, affect t
hose younger than 40. Less than 5 percent of people between 65 and 74 have Alzhe
imer's. For people 85 and older, that number jumps to nearly 50 percent. Heredit
y. Your risk of developing Alzheimer's appears to be slightly higher if a first-
degree relative — parent, sister or brother — has the disease. Although the genetic
mechanisms of Alzheimer's among families remain largely unexplained, researchers
have identified a few genetic mutations that greatly increase risk in some fami
lies. Three genetic mutations are known to cause
early-onset Alzheimer's. In addition, one form of the apolipoprotein E (APOE) ge
ne increases your chance of developing late-onset Alzheimer's. Sex. Women are mo
re likely than men are to develop the disease, in part because they live longer.
Lifestyle. The same factors that put you at risk of heart disease, such as high
blood pressure and high cholesterol, may also increase the likelihood that you'
ll develop Alzheimer's disease. Poorly controlled diabetes is another risk facto
r. And keeping your body fit isn't your only concern — you've got to exercise your
mind as well. Some studies have suggested that remaining mentally active throug
hout your life, especially in your later years, reduces the risk of Alzheimer's
disease. Education levels. Studies have found an association between less educat
ion and the risk of Alzheimer's. Some researchers theorize that the more you use
your brain, the more synapses you create, which provides a greater reserve as y
ou age. It remains unclear, however, whether less education and less mental acti
vity create a risk of Alzheimer's or if it's simply harder to detect Alzheimer's
in people who exercise their minds frequently or who have more education. Toxic
ity. One long-standing theory is that overexposure to certain trace metals or ch
emicals may cause Alzheimer's. For a time, aluminum seemed a likely candidate, b
ecause some people with Alzheimer's have deposits of aluminum in their brains. A
fter many years of studies, however, no one has been able to link aluminum expos
ure directly to Alzheimer's. At this point, there's no evidence that any particu
lar substance increases a person's risk of Alzheimer's. Head injury. The observa
tion that some ex-boxers eventually develop dementia suggests that serious traum
atic injury to the head (for example, a concussion with a prolonged loss of cons
ciousness) may be a risk factor for Alzheimer's. Several studies indicate a defi
nite link between the two, but others show no link. Hormone replacement therapy.
The exact role hormone replacement therapy may play in the development of demen
tia isn't yet clear. Throughout the 1980s and '90s, evidence seemed to show that
estrogen supplements given after menopause could reduce the risk of dementia. B
ut results from the large-scale Women's Health Initiative Memory Study indicated
an increased risk of dementia for women taking estrogen after age 65. The verdi
ct is not yet in on whether estrogen affects the risk of dementia if given at an
earlier age.
Tests and diagnosis
There's no one test to diagnose Alzheimer's disease. Typically, doctors start th
e diagnostic process by ruling out other diseases and conditions that also can c
ause memory loss. Small, undetected strokes, for example, can cause dementia by
temporarily interrupting blood flow to the brain. People with Parkinson's diseas
e, a degenerative nerve disorder, also can develop dementia. Depression, too, ca
n cause lapses in memory. In addition, many older adults are on multiple medicat
ions that may impair their ability to think clearly.
To help distinguish Alzheimer's disease from other causes of memory loss, doctor
s typically rely on the following:
Medical history. Doctors may ask about a person's general health and past medica
l problems. They'll want to know about any problems a person may have in carryin
g out daily activities. If possible, doctors will also want to speak with a pers
on's family or friends to get more information. Basic medical tests. Blood tests
may be done to help doctors rule out other potential causes of the dementia, su
ch as thyroid disorders or vitamin deficiencies. Mental status evaluation. These
tests screen memory, problem-solving abilities, attention spans, counting skill
s and language. They help doctors pinpoint specific problems a person may have w
ith cognition. For instance, doctors might test recent and long-term memory by a
sking: What day is it today? Or: When was World War II? Recall tests are another
example. Doctors may list familiar objects, and then ask a person to repeat the
m immediately, and again five minutes later. Neuropsychological testing. Sometim
es doctors undertake a more extensive assessment of memory, problem-solving abil
ities, attention spans, counting skills and language. This is especially helpful
in trying to detect Alzheimer's and other dementias at an early stage. Doctors
use formal psychological tests to determine if a person's mental abilities are a
s expected for his or her age and education. The patterns of any mental deficits
observed during neuropsychological testing can help doctors sort out possible c
auses of dementia. Brain scans. Doctors may want to take a picture of the brain
using a brain scan. Several types of brain scans are available — including a compu
terized tomography (CT) scan, a magnetic resonance imaging (MRI) scan and a posi
tron emission tomography (PET) scan. By looking at images of the brain, doctors
may be able to pinpoint any visible abnormalities. Researchers are studying whet
her brain scans can eventually be used to detect an increased risk of Alzheimer'
s in healthy people before symptoms begin.

Using the methods above, doctors can accurately diagnose 90 percent of Alzheimer
's cases. Alzheimer's can be diagnosed with complete accuracy only after death,
using a microscopic examination of brain tissue, which checks for plaques and ta
ngles. Genetic testing for Alzheimer's is in its beginning stages. Blood tests a
re available that can tell whether a person carries the genetic mutations believ
ed to be associated with Alzheimer's, but the tests can't tell who will or will
not get the disease.
Complications
In advanced Alzheimer's disease, people may lose all ability to care for themsel
ves. This can make them more prone to additional health problems such as:

Pneumonia. Difficulty swallowing food and liquids may cause people with Alzheime
r's to inhale (aspirate) some of what they eat and drink into their airways and
lungs, which can lead to pneumonia. Infections. Urinary incontinence may require
the placement of a urinary catheter, which increases the risk of urinary tract
infections. Untreated urinary tract infections can lead to more serious, life-th
reatening infections. Falls and their complications. People with Alzheimer's may
become disoriented, increasing their risk of falls. Falls can lead to fractures
. In addition, falls are a common cause of serious head injuries, such as bleedi
ng in the brain. Surgery to repair injury from a fall carries risks as well. For
instance, prolonged immobilization — which may be necessary to recover from injur
ies related to a fall — increases the risk of a blood clot in the lungs (pulmonary
embolism), which can be life-threatening.
Treatments and drugs
Currently, there's no cure for Alzheimer's disease. Doctors sometimes prescribe
drugs to improve symptoms that often accompany Alzheimer's, including sleeplessn
ess,
wandering, anxiety, agitation and depression. But only two varieties of medicati
ons have been proved to slow the cognitive decline associated with Alzheimer's.
Cholinesterase inhibitors This group of medications — which includes donepezil (Ar
icept), rivastigmine (Exelon) and galantamine (Reminyl) — works by improving the l
evels of neurotransmitters in the brain. Donepezil has been approved by the Food
and Drug Administration for the treatment of mild, moderate and severe Alzheime
r's disease. Donepezil also appears to delay the onset of Alzheimer's for about
a year in people who have mild cognitive impairment (MCI). People who have MCI h
ave more memory problems than other people their age, but they are not demented.
Cholinesterase inhibitors don't work for everyone. As many as half the people w
ho take these drugs show no improvement. Other people may choose to stop taking
the drugs because of the side effects, which include diarrhea, nausea and vomiti
ng. Memantine (Namenda) The first drug approved to treat moderate to severe stag
es of Alzheimer's, memantine (Namenda), protects brain cells from damage caused
by the chemical messenger glutamate. It sometimes is used in combination with a
cholinesterase inhibitor. Memantine's most common side effect is dizziness, alth
ough it also appears to increase agitation and delusional behavior in some peopl
e.
Prevention
Right now, there's no proven way to prevent the onset of Alzheimer's disease. Re
searchers had developed what looked to be a promising vaccine against Alzheimer'
s that worked by stopping deposits of beta-amyloid in the brain. Animal studies
were so encouraging that human trials began in 2001. Unfortunately, they soon ha
d to be stopped because some people experienced serious inflammation of the brai
n. While these results were disappointing, scientists learned from these experim
ents and many researchers continue to look for ways to reduce the risk of this d
isease. Several leads are hopeful, but still preliminary. They include:

Healthy aging. Some of the most recent research indicates that taking steps to i
mprove your cardiovascular health, such as losing weight, exercising and control
ling high blood pressure and cholesterol, may also help prevent Alzheimer's dise
ase. Nonsteroidal anti-inflammatory drugs (NSAIDs). Several studies have shown t
hat the NSAIDs ibuprofen (Advil, Motrin, others), naproxen sodium (Aleve) and in
domethacin (Indocin) may reduce the risk of developing Alzheimer's. This may be
because inflammation appears to play a role in Alzheimer's. What isn't known, ho
wever, is whether inflammation is a cause of Alzheimer's or simply an effect of
the disease. Because NSAIDs can cause serious gastrointestinal bleeding, clinica
l trials need to be completed before it's clear whether people should take NSAID
s solely to prevent Alzheimer's. Statins. These drugs — a class that includes ator
vastatin (Lipitor), rosuvastatin (Crestor) and simvastatin (Zocor) — are normally
used to lower
cholesterol levels, but recent studies have shown that they may also reduce the
risk of Alzheimer's disease. More studies are being done to determine exactly wh
at role, if any, statins may have in Alzheimer's prevention. Selective estrogen
receptor molecules (SERMs). A SERM called raloxifene (Evista) is used to protect
against the bone loss associated with osteoporosis. It also appears to lower th
e risk of developing mild cognitive impairment, a memory disorder that often pre
cedes Alzheimer's. Vitamin E and ginkgo. Both these substances have been linked
to improvements in cognitive abilities, and their potential effects on Alzheimer
's are being studied. One large study, however, showed that vitamin E has no eff
ect on the development of Alzheimer's in people who have mild cognitive impairme
nt. Mental fitness. Maintaining mental fitness may delay onset of dementia. Some
researchers believe that lifelong mental exercise and learning may promote the
growth of additional synapses, the connections between neurons, and delay the on
set of dementia. Other researchers argue that advanced education gives a person
more experience with the types of memory and thinking tests used to measure deme
ntia. This advanced level of education simply may help some people "cover up" th
eir condition until later.
Delaying the onset of Alzheimer's is an important step in fighting the disease.
If the onset of Alzheimer's could be postponed by just five years, it would dram
atically reduce the number of people who have the disease.
Coping and support
People with Alzheimer's disease often experience a mixture of emotions — confusion
, frustration, anger, fear, uncertainty, grief and depression. You can help a pe
rson cope with the disease by being there to listen, reassuring the person that
life can still be enjoyed, providing unconditional love, and doing your best to
help the person retain dignity and self-respect. A calm and stable home environm
ent reduces behavior problems. New situations, noise, large groups of people, be
ing rushed or pressed to remember, or being asked to do complicated tasks can ca
use anxiety. As a person with Alzheimer's becomes upset, the ability to think cl
early declines even more. Providing care for a person with Alzheimer's disease i
s physically and emotionally demanding. Feelings of anger and guilt, frustration
and discouragement, worry and grief, and social isolation are common. If you're
a caregiver for someone with Alzheimer's disease, you can help yourself by:

Asking friends or other family members for help when you need it Taking care of
your health Learning as much about the disease as you can Asking questions of do
ctors, social workers and others involved in the care of your loved one Joining
a support group
Many people with Alzheimer's and their families benefit from counseling or local
support groups. Contact your local Alzheimer's Association affiliate to get con
nected with support groups, doctors, resources and referrals, home care agencies
, supervised living facilities, a telephone help line, and educational seminars.