Guide to Understanding

Alzheimers Disease
by the Editors of Johns Hopkins Health Alerts

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Special Report

Understanding Alzheimers Disease

Table of Contents

Alzheimers Disease: An Introduction .............................................................1 Progression of Alzheimers Disease ...........................................................2 Causes of Alzheimers Disease .................................................................2 Is It Normal Aging or Something More Serious: Diagnosing Alzheimers Disease ......................................................................3 The Mini-Mental State Exam and Other Tests for Alzheimers Disease ....................................................................................3 Why Pursue Diagnosis? ................................................................................3 Further Resources .............................................................................................4 Disclaimer ..........................................................................................................5

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Alzheimers Disease: An Introduction

lzheimers disease (AD) is the leading cause of dementia in the United States, affecting nearly 4 million older adults. Alzheimers disease is named after Dr. Alois Alzheimer, a German doctor who, while performing an autopsy in 1906, first noticed changes in the brain tissue of a woman who had died of an unusual mental illness. The plaques and tangles that he discovered in the brain are now considered hallmarks of Alzheimers disease. A progressive disorder of the brain, Alzheim-

ers disease is characterized by the deterioration of mental faculties due to the loss of nerve cells and the connections between them. Alzheimers disease is often accompanied by changes in behavior and personality. The course of the disease is relentless, although the rates of its progress and mental decline vary from person to person. Recent research suggests that, on average, a patient with Alzheimers disease survives 3 to 5 years after the initial diagnosisa survival time much shorter than was previously reported.

amyloid plaques microtubules

neurofibrillary tangles

Normal neuron

Alzheimers Disease

Amyloid plaques and neurofibrillary tangles (which arise from collapsed microtubules, the brains internal transport system) are found at autopsy in virtually every patient with Alzheimers disease.

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Progression of Alzheimers Disease Alzheimers disease advances slowly in three general symptomatic stages, ranging from mild forgetfulness to severe dementia. Symptoms of the first stagewhich include impaired memory of recent events, faulty judgment, and poor insightappear most commonly after age 70. (However, in a small group of patients, symptoms may emerge as early as age 30 or 40.) In the first stage of the disease, people with AD may forget important appointments, recent family events, and highly publicized news items. Other symptoms include frequently losing or misplacing possessions, repetition of questions or statements, and minor or occasional disorientation. As the disease progresses into the second stage, memory problems grow worse and basic self-care skills begin to decline. Alzheimers disease patients may have trouble expressing themselves verbally or in writing, and be unable to perform everyday activities such as dressing, bathing, using a knife or fork, or brushing their teeth. They may also suffer from delusions or hallucinations. In the third stage, people with Alzheimers disease lose almost all capacity for reasoning. They may end up completely dependent on

others for their care. The disorder eventually becomes so debilitating that patients cannot walk or feed themselves and become susceptible to other diseases. Lung and urinary tract infections are common. Pneumonia is the most frequent cause of death. Causes of Alzheimers Disease Despite tremendous advances in the understanding of Alzheimers disease, scientists have yet to pinpoint a true cause for the disorder. Some patients may have a single underlying cause, but in others, a whole host of factors appear to interact in some way to bring on the disease. Old age is the strongest risk factor for AD; others are Down syndrome, a family history of dementia, and the presence of a specific form (e4) of the gene that makes a certain protein, called apolipoprotein E, or APOE. Women may also be at higher risk for Alzheimers disease than men; and cardiovascular disorders such as high blood pressure and heart attack are also possible risk factors. Another possible risk factor is head injury. Other conditions that have been considered potential triggers of Alzheimers disease include immune system malfunctions, endocrine (hormonal) disorders, slow-acting viruses, and toxins.

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Is It Normal Aging or Something More Serious: Diagnosing Alzheimers Disease

f youre worried about Alzheimers disease, the first step is to talk to your primary care physician about any symptoms youve been experiencing. Because diagnosing Alzheimers disease is primarily a process of elimination, your medical history and any recent health changes youve noticed might point to an explanation other than dementia. Your physician should screen you for depression, which can impair memory and cause anxiety, irritability, and poor concentration. Your physician should also inquire about any medications and dietary supplements you are taking: Are you taking the proper dosage? Are you on the right schedule? Has another physician recently prescribed a new drug or changed your dosage? Again, medications can have effects that mimic those of Alzheimers disease, and this possibility must be ruled out. The Mini-Mental State Exam and Other Tests for Alzheimers Disease If your physician suspects Alzheimers disease, he or she may perform a test called the MiniMental State Exam (MMSE), a 17-item screening test that assesses general cognitive function and provides a single numerical score. A score of 24 or higher is considered normal. The MMSE is not a particularly sensitive test for Alzheimers disease. Scores can drift up or down according

to educational level, cultural background, reading level, and language skills. Further testing may be needed at a separate office visit with a dementia specialist, such as a neurologist, geriatric psychiatrist, geriatrician, or neuropsychologist. The doctor will administer some tests by asking you questions; other tests require you to make drawings, solve special puzzles, or answer questions in written form. Depending on your symptoms, your doctor may order laboratory tests. Again, the purpose is to rule out causes other than Alzheimers disease, tightening the circle of diagnosis until it zeroes in on the probable cause. Blood tests can identify anemia, liver disorders, thyroid problems, nutritional deficiencies, and infections. In recent years, there has been a wave of news reports on the latest and greatest brain scanning techniques for the detection of early Alzheimers disease. These high-tech tests go by a variety of acronyms: MRI; fMRI; SPECT; PET; and CAT. Of the imaging tests mentioned above, your doctor is most likely to consider a CAT scan or MRI to check for physical brain abnormalities associated with Alzheimers disease, or to rule out some other cause of the symptoms. These brain scans may detect small strokes, which can cause problems in the brains blood supply and lead to vascular dementia. So-called functional scans, such as positron emission tomography

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Diagnosing Alzheimers Disease

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(PET), are increasingly being used in the diagnosis of Alzheimers disease. They reveal information about the level of activity (function) in various areas of the brain that might be affected by Alzheimers disease. Why Pursue Diagnosis? When people notice mental slips and fear dementia, they may be reluctant to push for testing. There is, after all, no cure for Alzheimers disease. But a positive diagnosis, while frightening, offers some positive opportuni-

ties. Medications can slow the progression of the Alzheimers disease, giving you more time to enjoy with friends and family. If Alzheimers disease is caught early enough, it allows people to participate in their own healthcare decisions. Early diagnosis provides time to prepare psychologically, spiritually, and financially for the inevitable consequences of the disease. And it also gives a potential caregivertypically a family membermore time to obtain the education and training needed to provide a dignified and healthy life for their loved one.

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Rely on Expert Health Advice From Johns Hopkins

Ranked Americas #1 Hospital for the 18th year in a row by U.S. News & World Report Memory White Paper
Memory

A dramatic increase in the number of people affected by Alzheimers disease has heightened the urgency of the research into Alzheimers and other dementias. The Memory White Paper brings you state-of-the-art information on how to tell the difference between Alzheimers, another form of dementia, or ordinary age-related memory loss, and the best ways to keep your memory sharp as you get older. You will also learn about important new research in identifying, treating, and preventing memory disorders, as well as new drugs for Alzheimers and other dementias that can help slow memory decline.

Edited by Dr. Peter V. Rabins, Professor of Psychiatry at the Johns Hopkins University School of Medicine and co-author of the best-selling guide for caregivers, The 36-Hour Day, The Johns Hopkins Memory Bulletin brings timely, in-depth information for anyone facing Alzheimers disease, dementia, or another memory problem. In each quarterly issue, youll read about the latest scientific breakthroughs, research findings from the worlds foremost medical journals and conferences, medications, caregiver support and relief, plus breakthrough medical discoveries for safeguarding your brain against aging and memory loss. Subscribe today at the special web-only discount and get 4 FREE special reports to download instantly.

The Johns Hopkins Memory Bulletin

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The Johns Hopkins Prostate Bulletin is an indispensable quarterly journal for men with prostate cancer, and the other prostate health concerns: Benign Prostatic Hyperplasia (BPH), prostadynia, and the various forms of prostatitis. It also deals with side effects and related conditions, such as Lower Urinary Tract Symptoms (LUTS), overactive bladder (OA), and erectile dysfunction (ED). Written by Dr. Jacek L. Mostwin and his esteemed colleagues at the world-renowned James Buchanan Brady Urological Institute, The Johns Hopkins Prostate Bulletin goes beyond the basics to report on the latest therapeutic treatments, advanced news of clinical trials, inHealthAfter50 depth reports, new medications, plus detailed answers to subscribers Helping Alzheimers Patients Sleep concerns about all aspects of your prostate health.
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Since 1988 this acclaimed monthly newsletter has delivered cutting-edge information on treating the major medical conditions affecting those over 50. Each eight-page issue delivers important news and research on womens health, mens health, nutrition, weight control, arthritis, COPD, colon cancer, dementia and much more. Friendly, easy-to-read, and written in plain English (without any advertising), Health After 50 speaks directly to your personal health concerns.

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1A study of 23,887 elective (nonemergency) angioplasty patients found only 44% underwent a stress test to look for insufficient blood flow to the heart (ischemia) prior to their procedure. Illness or disability may have kept some people from doing the treadmill test. But even capable patients didnt always get a test, and it might have shown they didnt need angioplasty.
Journal of the American Medical Association, vol. 300, p. 1765.

Many people with Alzheimers have trouble sleeping, which can leave them exhausted during the day. Fatigue takes a toll on both patients and their caregivers, and irregular sleeping is a major reason why families move relatives with Alzheimers into long-term care. Light therapy is one of the latest treatments under investigation for people with dementia who struggle with sleep.

set the bodys circadian rhythmsregular mental and biological changes that occur over a 24-hour cycle and regulate important functions, like preparing the body for sleep at night.

1Researchers at Johns Hopkins

examined 197 rheumatoid arthritis patients and found that increased body fat and decreased lean muscle mass, particularly in the arms and legs, were linked to greater disability, like trouble walking and rising. Exercise can help keep muscles strong and body fat low.
Arthritis & Rheumatism, vol. 59, p. 1407.

1A 5-year study of 5,011 participants found that a diet low in dairy fat and packed with nuts, seeds, fruits, leafy green vegetables, and whole grains was linked to a 15% lower diabetes risk than a diet rich in red and processed meats, refined grains, tomatoes, beans, regular soda, and high-fat foods. Although tomatoes and beans are healthy foods, these vegetables were often paired with less nutritious options.
Diabetes Care, vol. 31, p. 1777.

1Stereotactic radiosurgery (SRS), which aims radiation at a tumor to spare surrounding tissue, was found to improve survival in people 75 and older with metastatic cancer in the brain, according to researchers who examined records of 44 SRS patients.
Cancer, vol. 113, p. 834.

FIXING SLEEP Alzheimers patients who have trouble sleeping should first be evaluated for underlying sleep disorders and medical conditions that cause sleep trouble. Also, stopping medications that affect sleep or switching to more tolerable drugs may help. No studies have found that conventional sleep aids, like Ambien (zolpidem) and Sonata (zaleplon), or sedative antidepressant medications like trazodone (Desyrel) effectively treat disturbed sleep in Alzheimers patients. And supplements that boost levels of melatonin (a hormone that makes people feel tired) have limited effect, perhaps because Alzheimers patients have fewer melatonin receptors in the brain than people without dementia. Light therapyregular exposure to sunlight or special bright lamps that mimic natural lightis another option. Its often recommended for people with jet lag, insomnia, or seasonal affective disorder (a depressive condition that occurs during the winter months, when there is less sunlight). Exposure to bright light signals to the brain that it is daytime and helps

HOW WELL DOES LIGHT WORK? In a three-week study from the University of North Carolina at Chapel Hill, 66 adults with dementia living in long-term care facilities were exposed for varying amounts of time to bright ceiling lights installed in common areas. Compared with participants who did not spend time under the lights, those who were exposed to light therapy for two and a half hours in the morning slept 16 minutes longer; those who were exposed for about eight and a half hours off and on throughout the day slept 14 minutes longer. The morning group was also able to fall asleep 29 minutes earlier, which is important since Alzheimers patients often cant fall asleep until late at night. But not all studies have produced positive results, and there are questions about the appropriate dosage. The amount of light prescribed for other conditions may not be sufficient for older patients with dementia; eyes transmit less light with age, and visual problems are particularly common in continued on next page

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