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Forget-Me-Nots?

May 1, 2008 By:
Todd H. Goldberg, M.D.
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Alzheimer's disease -- a well-known cause of memory impairment in aging -- is surely the most common and feared problem consulted about in geriatric medicine today.

Although it was only recognized as a specific illness in the last 100 years, Alzheimer's obviously is not really new, since throughout history people have become old, feeble and confused; however, they were just called "senile." And most people didn't live to be very old, so the problems of senility were uncommon and not all that important.

Only in the 1960s did the medical community begin to realize that most "senile" old people really had a similar or identical condition to the brain disease reported on in 1907 by German pathologist Dr. Alois Alzheimer.

About two-thirds of elderly patients with what is now called "senile dementia" have Alzheimer's; one-third have had strokes or other miscellaneous brain diseases; and some have more than one condition at the same time.

It is very important to realize that some patients who appear to have dementia actually suffer from depression, infections, nutritional problems, drug toxicity, poor hearing or vision, or other potentially avoidable or treatable conditions.

Thus, when evaluating a patient with dementia or suspected Alzheimer's, doctors perform a complete general medical exam to rule out other conditions.

In addition, a neurological and psychiatric exam, social/ functional evaluation and brain scans, such as CT or MRI, help to clarify the diagnosis. However, there is still no definitive test for Alzheimer's except for a brain biopsy or autopsy.

How common is Alzheimer's? During my training in geriatrics in the 1970s and '80s, it was always said that only about 5 percent to 10 percent of seniors (usually defined as individuals over the age of 65) qualified for a diagnosis of dementia, although certainly it must be acknowledged that even with "normal" aging, the memory may not be quite as sharp as it used to be.

However, this is misleading because most 65-year-olds are more like middle-aged people than geriatric, and the prevalence of dementia skyrockets with advancing age as people go from their 60s to their 90s.

Surveys in Boston, Canada and Sweden found that a staggering 25 percent to 50 percent of individuals over age 85 -- when appropriately tested -- show enough memory impairment to qualify for a diagnosis of dementia or Alzheimer's.

Middle-aged people with only slight memory impairment may not need to worry, but older individuals whose ability to function is impaired need to be evaluated by their family physician or a specialist in geriatrics, psychiatry or neurology.

Unfortunately, though individuals vary, most patients with Alzheimer's become progressively confused and dysfunctional, over a period of about five to 10 years, to the point where they are bedridden, stop walking, talking and eating, and eventually, die.

Most families cannot cope with the difficulties involved in caring for such patients and for keeping them safe; nursing-home placement is often necessary.

Recently, a possible genetic link to Alzheimer's disease has been highly publicized. Certain familial cases seem to be linked to genetic defects, and a cholesterol-related protein called Apo E also appears to be correlated to Alzheimer's.

These factors are still rare and controversial, and are not presently considered to be clinically useful or relevant in most cases. So it is useless to worry simply because a relative suffers from this common condition.

But intensive research on Alzheimer's is improving understanding of the disease and beginning to yield potentially useful treatments.

In the past, little treatment was available for Alzheimer's other than tranquilizers for the patient, and sympathy and support for the family. But several new developments have made the field much less discouraging and much more promising.

After years of intensive research, four new drugs have been approved in the last decade by the U.S. Food and Drug Administration for treatment of the disease: Aricept, Exelon, Razadyne and Namenda. These drugs stimulate memory by increasing levels in the brain of certain neurotransmitter chemicals.

Several studies have shown these drugs to be modestly but statistically significant in their effect in improving memory and behavior in Alzheimer's patients. The combination of Aricept and Namenda is felt to be more effective than either drug alone.

Since these drugs are safe and relatively free of serious side effects, they are worth trying in most patients. Other new drugs attacking amyloid plaques and neurofibrillary tangles -- the pathological hallmarks of the disease -- are still being tested, but should be available in the coming years.

Several other nonprescription drugs and supplements have been suggested to possibly --possibly! -- be of benefit to dementia, but the research is too inconclusive to firmly recommend any of these, including estrogens, nonsteroidal anti-inflammatory (arthritis) medicines, statins (anti-cholesterol medicines), gingko biloba and red wine.

Exercising regularly and following a Mediterranean-type diet rich in olive oil, fruits, vegetables and fish have been found to reduce the incidence of dementia, as well as heart disease. A healthy lifestyle can always be supported as doing wonders for a patient.

Nothing so far can completely prevent or cure Alzheimer's, but these new discoveries add some hope to a previously discouraging condition, and even a mild improvement in memory and behavior may improve quality of life and delay the need for nursing-home placement.

Finally, since Alzheimer's is such a stress on the family, it is important to be aware of available sources of support and assistance.

Where to Find Help

Sources of information and assistance include:

· The Alzheimer's Association (www.alz.org);

· Books such as The 36-Hour Day;

· Geriatrics and Alzheimer's programs at most hospitals and universities;

· Social and nursing agencies, such as Jewish Family and Children's Service of Greater Philadelphia, and the Visiting Nurse Association; and

· Hospice care, to be considered to help the family and patient in cases of advanced dementia, which is, unfortunately, a fatal condition.

Todd H. Goldberg M.D, CMD, FACP, is associate professor/director of geriatrics in the department of internal medicine at West Virginia University Health Sciences Center, Charleston Division.

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