All About Alzheimer's & Dementia
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Gerontology
A Training Resource
By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T
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The Facts about Alzheimers’s Disease
(Alzheimer’s Association, 2019a)
Prevalence: 5.8 Million Americans are living with Alzheimer’s dementia. By 2050, this number is projected to rise to nearly 14 Million
Mortality and Morbidity: 145 percent is the increase in deaths from Alzheimer’s between 2000 and 2017. Alzheimer's Disease is the 6th leading cause of death in America
Caregiving: More than 18.5 Billion hurs of informal care were provided by Alzheimer’s and other dementia caregivers in 2018, a contribution to the nation valued at nearly $234 Billion.
Use and costs of health care, long-term care and hospice: $290 Billion is estimated amount of Alzheimer’s and other dementials will cost in health care, long-term care and hospice in 2019
Alzheimer’s detection in the primary care setting - Connecting patients with physicians: 16 Percent of seniors receive regular cognitive assessment during routine health check-ups
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How Alzheimer's Changes the Brain
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Types of Memory Loss
(2018, Alzheimer’s Association)
Memory loss has four different types:
1. Normal aging
Many things change as people age. In normal aging, people’s bodies and brains slow down, though intelligence remains stable. These people are less physically and mentally flexible and take more time to process information. Memory changes occur as well, and it’s common to have greater difficulty remembering names of people, places and other things.
2. Mild cognitive impairment (MCI)
In MCI, a person has problems with memory or another core brain function. These problems are severe enough to be noticeable to other people and show up on tests of mental function, but not serious enough to interfere significantly with daily life. People with MCI have an increased risk of developing Alzheimer’s disease in the near future, especially when their main symptom involves memory. However, not everyone diagnosed with MCI progresses to Alzheimer’s or another type of dementia.
3. Dementia
Dementia is not a specific disease. It is a general term that describes a set of symptoms that may be caused by a number of different brain disorders. These symptoms involve mental decline severe enough to disrupt daily life that affect more than one of the following core brain functions
• Recent memory — the ability to learn and recall recently learned information.
• Language — the ability to write, speak or understand written or spoken words.
• Visual spatial function — the ability to understand and use symbols, maps and the ability to correctly judge where objects are.
• Executive function — the ability to plan, reason, solve problems and focus on a task.
4. Alzheimer’s disease
Alzheimer’s disease is the most common cause of dementia. It is a slow, progressive illness that damages nerve cells in the brain. Symptoms gradually get worse over time as more brain cells are destroyed. Though people can have Alzheimer’s in their 40s, and 50s, the disease is most prevalent in people over age 65.
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Do Memory Problems Always Mean Alzheimer's Disease?
Many people worry about becoming forgetful. They think forgetfulness is the first sign of Alzheimer's disease. But not all people with memory problems have Alzheimer's. Other causes for memory problems can include aging, medical conditions, emotional problems, mild cognitive impairment, or another type of dementia
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10 Early Signs and Symptoms of Alzheimer's
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Early Signs & Symptoms of Alzheimer’s
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Typical Age-Related SIgns
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1. Memory loss that disrupts daily life: Forgetting recently learned information which is the most common sign. Other signs are: forgetting important dates or events, asking for the same information over and over, and increasingly needing to rely on memory aids (e.g., reminder notes or electronic devices) or family members for things they used to handle on their own.
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1. Sometimes forgetting names or appointments but remembering them later.
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2. Challenges in planning or solving problems: Some people may experience changes in their ability to develop and follow a plan or work with numbers. They may have trouble following a familiar recipe or keeping track of monthly bills. They may have difficulty concentrating and take much longer to do things than they did before.
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2. Making occasional errors when balancing a checkbook
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3. Difficulty completing familiar tasks at home, at work or at leisure: Find it hard to complete daily tasks. Sometimes, may have trouble driving to a familiar location, managing a budget at work or remembering the rules of a favorite game.
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3. Occasionally needing help to use the settings on a microwave or to record a television show
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4. Confusion with time or place: Can lose track of dates, seasons and passage of time. May have trouble understanding something if it is not happening immediately. May foret where they are or how they got there.
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4. Getting confused about the day of the week but figuring it out later
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5. Trouble understanding visual images and spatial relationships: Having vision problems resulting in having difficulty reading, judging distance and determining color or contrast which may cause problems with driving.
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5. Vision changes related to cataracts
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6. New problems with words in speaking or writing: May have trouble following or joining a conversation. May stop in the middle of a conversation and have no idea how to continue or may repeat themselves. They may struggle with vocabulary, have problems finding the right word or call things by the wrong name.
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6. Sometimes having trouble finding the right words
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7. Misplacing things and losing the ability to retrace steps: May put things in unusual places. May lose things and be unable to go back over their steps to find them again. May accuse others of stealing which may occur more frequently over time.
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7. Misplacing things from time to time and retracing steps to find them.
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8. Decreased or poor judgement: May experience changes in judgement or decision-making. May use poor judgment when dealing with money giving large amounts to telemarketers. May pay less attention to grooming or keeping themselves clean
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8. Making a bad decision once in a while.
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9. Withdrawal from work or social activities: May start to remove selves from hobbies, social activities, work projects or sports. May have trouble keeping up with a favorite sports team or remembering how to complete a favorite hobby. May avoid being social because of the changes they have experienced.
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9. Sometimes feeling weary of work, family and social obligations
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10. Changes in mood and personality: Mood and personalities may change, and they can become confused, suspicious, depressed, fearful or anxious. May be easily upset at home, at work, with friends or in places where they are out of their comfort zone.
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10. Developing very specific ways of doing things and becoming irritable when a routine is disrupted.
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(2019b, Alzheimer’s Association)
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Age-Related Changes in Memory
Forgetfulness can be a normal part of aging. As people get older, changes occur in all parts of the body, including the brain. As a result, some people may notice that it takes longer to learn new things, they don't remember information as well as they did, or they lose things like their glasses. These usually are signs of mild forgetfulness, not serious memory problems, like Alzheimer's disease (2018, NIH).
Some Memory Loss May be Related to Medical Conditions
Certain medical conditions can cause serious memory problems. These problems should go away once a person gets treatment. Medical conditions that may cause memory problems include:
- Tumors, blood clots, or infections in the brain
- Some thyroid, kidney, or liver disorders
- Drinking too much alcohol
- Head injury, such as a concussion from a fall or accident
- Medication side effects
- Not eating enough healthy foods, or too few vitamins and minerals in a person's body (like vitamin B12)
A doctor should treat serious medical conditions like these as soon as possible (2018, NIH).
Memory Loss Related to Emotional Problems
Emotional problems, such as stress, anxiety, or depression, can make a person more forgetful and can be mistaken for dementia. For instance, someone who has recently retired or who is coping with the death of a spouse, relative, or friend may feel sad, lonely, worried, or bored. Trying to deal with these life changes leaves some people feeling confused or forgetful.
The confusion and forgetfulness caused by emotions usually are temporary and go away when the feelings fade. Emotional problems can be eased by supportive friends and family, but if these feelings last for more than 2 weeks, it is important to get help from a doctor or counselor. Treatment may include counseling, medication, or both. Being active and learning new skills can also help a person feel better and improve his or her memory. (2018, NIH).
Diagnosis of Dementia Due to Alzheimer’s Disease
There is no single test for dementia due to Alzheimer’s disease. Instead, physicians (often with the help of specialists such as neurologists, neuropsychologists, geriatricians and geriatric psychiatrists) use a variety of approaches and tools to help make a diagnosis.
They include the following:
- Obtaining a medical and family history from the individual, including psychiatric history and history of cognitive and behavioral changes.- Asking a family member to provide input about changes in thinking skills and behavior.- Conducting cognitive tests and physical and neurologic examinations.- Having the individual undergo blood tests and brain imaging to rule out other potential causes of dementia symptoms, such as a tumor or certain vitamin deficiencies.- In some circumstances, using brain imaging tools to find out if the individual has high levels of beta-amyloid, a hallmark of Alzheimer’s; normal levels would suggest Alzheimer’s is not the cause of dementia (Alzheimer’s Association, 2019).
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Assessments for Mild Cognitive Impairment (MCI) Earliest Stage of Alzheimer's
ACE-R (Addenbrooke's Cognitive Examination-Revised)
AMTS (Abbreviaed Mental Test Score)
6-CIT (6-Item Cognitive Impairment Test)
CPCOC (General Practioner Assessment of Cognition)
MIS (Memory Impairment Screen)
MoCA (Montreal Cognitive Assessment)
SLUMS (Saint Louis University Mental Status Examination for Dementia)
TYM (Test Your Memory)
Background on Testing for MCI
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Alzheimer's stages: How the disease progresses
(adapted from Mayo Clinic, 2019)
Alzheimer's disease tends to develop slowly and gradually worsens up to ten years. Eventually, Alzheimer's disease affects most areas of a person’s brain. Memory, thinking, judgment, language, problem-solving, personality and movement can all be affected by the disease.
There are five stages associated with Alzheimer's disease: preclinical Alzheimer's disease, mild cognitive impairment due to Alzheimer's disease, mild dementia due to Alzheimer's disease, moderate dementia due to Alzheimer's disease and severe dementia due to Alzheimer's disease. Dementia is a term used to describe a group of symptoms that affect intellectual and social abilities severely enough to interfere with daily function. The five Alzheimer's stages can help explain what might happen, but it's important to know that these stages are only rough generalizations. The disease is a continuous process. Each person has a different experience with Alzheimer's and its symptoms.
Stage 1: Preclinical Alzheimer's disease
Alzheimer's disease begins long before any symptoms become apparent. This stage is called preclinical Alzheimer's disease, and it's usually identified only in research settings. People will not notice symptoms during this stage, nor will those around them.
This stage of Alzheimer's can last for years, possibly even decades. Although people won't notice any changes, new imaging technologies can now identify deposits of a protein called amyloid-beta that is a hallmark of Alzheimer's disease. The ability to identify these early deposits may be especially important for clinical trials and in the future as new treatments are developed for Alzheimer's disease.
Additional biomarkers, measures that can indicate an increased risk of disease, have been identified for Alzheimer's disease. These biomarkers can be used to support the diagnosis of Alzheimer's disease, typically after symptoms appear. Genetic tests also can tell if a person has a higher risk of Alzheimer's disease, particularly early-onset Alzheimer's disease. These tests aren't recommended for everyone, but the people and their personal doctors can discuss whether genetic testing might be beneficial for them. As with newer imaging techniques, biomarkers and genetic tests will become more important as new treatments for Alzheimer's disease are developed.
A recent study of people with rare genetic mutations that cause Alzheimer’s found that levels of beta-amyloid in the brain were significantly increased starting 22 years before symptoms were expected to develop (individuals with these genetic mutations usually develop symptoms at the same, or nearly the same, age as their parent with Alzheimer’s). Glucose metabolism began to decrease 18 years before expected symptom onset, and brain atrophy began 13 years before expected symptom onset (Gordon et al., 2018).
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Stage 2: Mild cognitive impairment (MCI) due to Alzheimer's disease
People with mild cognitive impairment have mild changes in their memory and thinking ability. These changes aren't significant enough to affect work or relationships yet. People with MCI may have memory lapses when it comes to information that is usually easily remembered, such as conversations, recent events or appointments.
People with MCI may also have trouble judging the amount of time needed for a task, or they may have difficulty correctly judging the number or sequence of steps needed to complete a task. The ability to make sound decisions can become harder for people with MCI.
Not everyone with mild cognitive impairment has Alzheimer's disease. MCI is often diagnosed based on the doctor's review of symptoms and professional judgment. But if necessary, the same procedures used to identify preclinical Alzheimer's disease can help determine whether MCI is due to Alzheimer's disease or something else.
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Stage 3: Mild dementia due to Alzheimer's disease
Alzheimer's disease is often diagnosed in the mild dementia stage, when it becomes clear to family and doctors that a person is having significant trouble with memory and thinking that impacts daily functioning.
In the mild dementia stage, people may experience:
Memory loss of recent events. Individuals may have an especially hard time remembering newly learned information and ask the same question over and over.
Difficulty with problem-solving, complex tasks and sound judgments. Planning a family event or balancing a checkbook may become overwhelming. Many people experience lapses in judgment, such as when making financial decisions.
Changes in personality. People may become subdued or withdrawn, especially in socially challenging situations or show uncharacteristic irritability or anger. Reduced motivation to complete tasks also is common.
Difficulty organizing and expressing thoughts. Finding the right words to describe objects or clearly express ideas becomes increasingly challenging.
Getting lost or misplacing belongings. Individuals have increasing trouble finding their way around, even in familiar places. It's also common to lose or misplace things, including valuable items.
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Stage 4: Moderate dementia due to Alzheimer's disease
During the moderate dementia stage of Alzheimer's disease, people grow more confused and forgetful and begin to need more help with daily activities and self-care.
People with the moderate dementia stage of Alzheimer's disease may:
Show increasingly poor judgment and deepening confusion. Individuals lose track of where they are, the day of the week or the season. They may confuse family members or close friends with one another or mistake strangers for family. They may wander, possibly in search of surroundings that feel more familiar. These difficulties make it unsafe to leave those in the moderate dementia stage on their own.
Experience even greater memory loss. People may forget details of their personal history, such as their address or phone number, or where they attended school. They repeat favorite stories or make up stories to fill gaps in memory.
Need help with some daily activities. Assistance may be required with choosing proper clothing for the occasion or the weather and with bathing, grooming, using the bathroom and other self-care. Some individuals occasionally lose control of their bladder or bowel movements.
Undergo significant changes in personality and behavior. It's not unusual for people with the moderate dementia stage to develop unfounded suspicions — for example, to become convinced that friends, family or professional caregivers are stealing from them or that a spouse is having an affair. Others may see or hear things that aren't really there. Individuals often grow restless or agitated, especially late in the day. Some people may have outbursts of aggressive physical behavior.
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Stage 5: Severe dementia due to Alzheimer's disease
In the late stage of the disease, called severe dementia due to Alzheimer's disease, mental function continues to decline, and the disease has a growing impact on movement and physical capabilities.
In late stage severe dementia due to Alzheimer's disease, people generally:
Lose the ability to communicate coherently. The people can no longer converse or speak in ways that make sense, although they may occasionally say words or phrases.
Require daily assistance with personal care. This includes total assistance with eating, dressing, using the bathroom and all other daily self-care tasks.
Experience a decline in physical abilities. The people may become unable to walk without assistance, then unable to sit or hold up their head without support. Muscles may become rigid and reflexes abnormal. Eventually, they lose the ability to swallow and to control bladder and bowel functions.
Rate of progression through Alzheimer's disease stages
The rate of progression for Alzheimer's disease varies widely. On average, people with Alzheimer's disease live between three and 11 years after diagnosis, but some survive 20 years or more. The degree of impairment at diagnosis can affect life expectancy. Pneumonia is a common cause of death because impaired swallowing allows food or beverages to enter the lungs, where an infection can begin. Other common causes of death include dehydration, malnutrition, falls and other infections.
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Medications for Treating Alzheimer's Disease
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Generic
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Commercial
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Approved for Stage of Alzheimer’s
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Side Affects
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Donepezil
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Aricept
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All Stages
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Nausea, vomiting, loss of appetite and increase frequency of bowel movement
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Galantamine
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Razadyne
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Mild to Moderate
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Nausea, vomiting, loss of appetite and increase frequency of bowel movement
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Memantine
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Namenda
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Moderate to Severe
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Headaches, constipation, confusion & dizziness
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Rivasatigmine
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Exelon
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Mild to Moderate
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Nausea, vomiting, loss of appetite and increase frequency of bowel movement
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Memantine & Donepezil
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Namzric
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Moderate to Severe
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Nausea, vomiting, loss of appetite and increase frequency of bowel movement, headaches, constipation, confusion & dizziness
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More Information from the Alzheimer's Association's on the
Treatment of Alzheimer's Disease
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Tips for Dealing with Forgetfulness
People with some forgetfulness can use a variety of techniques that may help them stay healthy and deal with changes in their memory and mental skills. Here are some tips:
- Learn a new skill.- Stay involved in activities that can help both the mind and body.- Volunteer in your community, at a school, or at your place of worship.- Spend time with friends and family.- Use memory tools such as big calendars, to-do lists, and notes to yourself.- Put your wallet or purse, keys, and glasses in the same place each day.- Get lots of rest.- Exercise and eat well.- Don’t drink a lot of alcohol.- Get help if you feel depressed for weeks at a time. (NIH, 2017)
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References
Alzheimer’s Association (2019a). 2019 Alzheimer’s disease facts and figures. Retrieved
at: https://www.alz.org/media/Documents/alzheimers-facts-and-figures-2019-r.pdf
Alzheimer’s Association (2019b). 10 early signs and symptoms of Alzheimer's
Retrieved at: https://alz.org/alzheimers-dementia/10_signs
Alzheimer’s Association (2017). Taking action workbook. Retrieved at:
https://www.alz.org/getmedia/da9e2ce1-d73c-437a-be7c-d5761afd06e9/taking-action-workbook
Gordon, B.A., Blazey, T.M., Su, Y., Han-Rahm A,, Dincer, A. , Flores, S., Christensen,
J., McDade, E., Wang, G., Xion, C., Nigel, C., Hassenstab, J., Marcus, D.S., Fagan, A.M. Jack, C.R., Hornbeck, R.C., Paumier, K.I, Ances, B.M., Berman, S.B., Brickman, A.M. (2018). Spatial patterns of neuroimaging biomarker change in individuals from families with autosomal dominant Alzheimer's disease: A longitudinal study. Lancet Neurology. 17(3), 241-250. DOI: 10.1016/S1474-4422(18)30028-0.
Mayo Clinic (2019). Alzheimer's stages: How the disease progresses. Retrieved at:
https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/in-depth/alzheimers-stages/art-20048448?utm_source=newsletter&utm_medium=email&utm_campaign=alzheimers-caregiving
National Institute of Health -National Institute of Aging. (2017). Noticing memory problems? What to do next. Retrieved at: https://www.nia.nih.gov/health/noticing-memory-problems-what-do-next
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