Alzheimer’s Disease

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Alzheimer’s disease is the most common form of dementia.  Older adults often live in fear of the diagnosis.  One of  the most difficult duties of a psychologist is to inform family members a loved one has Alzheimer’s disease.  It is a death sentence without any firm termination.  The condemned is blithely unaware, while the caretakers assume a huge burden.

There are many facets of this disease, and likely even more misconceptions.  In my opinion, to call Alzheimer’s a “disease” is a misnomer.  Normal aging includes erosion of the neocortex and hippocampal areas of the brain.  Once the degree of cortical damage reaches roughly thirty percent, then the unlucky person exhibits symptoms of a senile dementia of the Alzheimer’s type.  The professional literature abbreviates this as SDAT.  The neurodegenerative changes are not unusual or pathological.  If one lives to 80 years of age, without any cognitive impairment, they will still possess neuritic plaques and neurofibrillary tangles.  This is an aspect of normal age-related cognitive decline.  The presence of a pathological memory impairment is associated with the degree of cortical atrophy, not with some exogenous disease process.

By the age of 50, we all begin to have a reduced ability to find names for things, and difficulty recalling verbal information without some prompt or context.  Many people call this the CRS Syndrome; alternately entitled “can’t remember sh–.”  The differential diagnosis is the recognition memory of the person.  Utilizing memory tests with a recognition component reduces the gulf between a 20 and a 90 year old.  Another difference is called “source amnesia.”  Your 85 year old father may forget to do a task, or forget that they had learned something, but will recall when prompted.  In the early stages of a SDAT, the patient will sometimes remember verbal or visual information with a cue, yet be completely baffled as to where they acquired the information.  In more advanced stages of a SDAT, one can teach these patients procedure rules.  They can be taught a card game, for example, yet be totally amnestic as to who taught them the game, and will even deny they know anything about how to play the game.

Two early symptoms of SDAT that goes unnoticed is decreased social interest and poor planning ability.  As the disease begins to take hold, the spouse of a dementia victim will almost always notice a decrease in their willingness to visit with friends and family.  It is often misdiagnosed as a clinical depression or chronic fatigue.  Even more subtle are deficits of planning.  The sequencing of new behaviors to accomplish a goal is impaired even in the early stages.  Many people confuse this with old routines acquired over a lifetime, which are extremely resistant to the disease.  It is very apparent when on tries to have them plan something new, something they have not done before.  While in training, a patient of mine was due to go home to live independently by themselves.  I noticed his helplessness when trying to take apart and put together a broken electric shaver.  He ignored all discharge planning to the exclusion of the shaver, which he could not put together after disassembling.  This patient would have returned to the hospital within a month or two, dehydrated and malnourished.  He did well at an ALF for many years.

The last subtle symptom of early SDAT is a lack of self-awareness.  People who suffer with SDAT are not aware of their memory impairment, diminished social interest and poor planning.  They always answer “fine” when questioned regarding their memory.  Nearly all normal aging persons remark that their memory is terrible!  I consider this to be an extremely important diagnostic indicator of a SDAT.  If your 80 year old husband or wife maintains their memory is normal, and you notice some of the symptoms I’ve mentioned, then I would consider a consult with a neuropsychologist.  Please leave your comments in the space provided below.

  • By Confused, March 31, 2010 @ 7:45 am

    My mother seems to be getting more forgetful. How do I find out if she has Alzheimer’s disease or dementia?

  • By orlandopsychcom, April 5, 2010 @ 8:53 am

    A reply to “Confused,”

    This is a very important question, which I would rephrase as how do I tell normal aging from a dementia. It is helpful to know that “dementia” is a general term for a progressive loss of memory, and Alzheimer’s Disease is a specific type of dementia.

    The initial starting point should be a consultation with your family physician, in order to rule out common medical causes of forgetfulness. The general practitioner tries to rule out urinary tract infections, vitamin deficiencies, metabolic imbalance, etc. I advise keeping copies of any lab tests so they can be provided to other clinicians.

    From the family physician I suggest visiting the neuropsychologist next. The NIMH’s guidelines recommend this order of consultation as well. The neuropsychologist can give your mother select tests that can differentiate one kind of dementia from another. Even more importantly, the neuropsychological report gives a “snapshot” of your mother’s cognitive skills, which can serve as a benchmark of her cognition at a given moment in time.

    Most of my comments regarding medication are towards decreasing or discontinuing medications that may impair cognitive functioning. There are various memory enhancing drugs on the market, but none are able to slow the progression of Alzheimer’s Disease. Nor should you expect a robust response from the drugs, such as the ability to move from a nursing home back to independent living. The goal of behavioral intervention and medications is helping the person stay as independent as possible. Thank you for your important comment.

  • By Confused, April 28, 2010 @ 7:44 am

    Our family doctor ddin’t give us very much information on Alzheimer’s disease or what we should do. Is there a specialist doctor we should bring our mother to?

  • By orlandopsychcom, April 29, 2010 @ 11:10 am

    You obviously have checked with your family physician regarding possible medical causes of dementia, which is an excellent start. If you want a complete picture of your mother’s current cognitive abilities, and some idea of what to expect in the future, I recommend having a neuropsychologist evaluate your mother. Thanks for the comment.

  • By Newby, June 2, 2010 @ 7:37 am

    My father has Alzheimer’s disease. He is waking up at night and saying he has to go to work. But he hasn’t worked for 30 years!!! He threatened to hit my mom last week. What should we do?

  • By orlandopsychcom, June 3, 2010 @ 3:10 pm

    A reply to Newby,

    If the diagnosis of Alzheimer’s Disease is correct, your father may be entering the final two stages of the disease. Disorientation to time and impulsive acting out are increasingly prevalent, though not all Alzheimer’s sufferers become aggressive. Consider a consult with your family doctor to rule out an infection, dehydration or malnutrition that could worsen the dementia on a temporary basis. Next, consider a follow-up with the neuropsychologist who diagnosed the condition. The neuropsychologist would be in the best position to determine steps that could keep your father in the home for as long as possible. Unfortunately, at this stage of the disease, it often helps to develop a relationship with an institution that manages dementia victims. You do not want to find a facility in an emergency, and that is often the case when someone reaches your father’s level of dementia. I hope this is helpful. Thank you for the comment.

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