Wednesday, October 31, 2012

Alzheimer's Disease

     Alzheimer's Disease is a progressive dementia that causes a steady, virtually irreversible loss of social skills and intellectual skills, and eventually impairs the sufferer's ability to carry out the ordinary activities of daily living. There have been many studies purporting to show an external cause, or successful drug treatment or beneficial  interactive treatment, but no clinical intervention has been demonstrated to make a permanent difference in the course or incidence of the disease. Since the disease can only be definitely diagnosed by autopsy of the brain, it remains a diagnosis of exclusion, and since the diagnosis is a horrific one for the patient and his/her family, every effort should be made to look for a reversible cause of the person's dementia. The best book of which I know that discusses the stresses of being an Alzheimer's caregiver is "The 36 Hour Day", which describes what it is like to be the caregiver on a 24/7 basis of someone who's mind is being progressively ravaged. .

     It has been my experience that AD patients fall into one of two categories. Some (like my father who had it for five years) appear to be unaware of their condition. They slowly develop a childlike dependence on the caregivers, and cause little or no fuss as they regress to a point where they lie in bed all day and are unable to feed themselves. Others are aware that something is wrong and get frustrated, angry and paranoid and become hostile to caregivers. They are therefore much more difficult to nurse, because they are usually inaccessible to gentle reason.  Drug treatment of this latter  condition usually involves major tranquilizers, is seldom successful in the long run, and can have unacceptable side effects. On occasion physical restraints are necessary. Their caregivers are under major stress, and usually are mentally holding their breath, hoping that the latest outburst will be the last one. A special problem arises when the AD patient tells a relative that the aide has physically abused him/her, and the relative cannot tell if the patient is speaking the truth or succumbing to paranoid ideation. I know several families who have changed aides monthly.

     One problem that arises is guilt on the part of the immediate family members, especially a spouse or a child. They may feel that they have not done enough, or been sufficiently perceptive or supportive. They feel guilty if they cannot be with the AD patient 24/7, and I have to reassure them that caregivers need rest also, and that there is a reason that interns, truck drivers, and airline crews have strict limits on the number of consecutive hours that they are allowed to serve. An early point of stress is the family decision to remove driving privileges from the AD patient. The primary caregiver also often feels uncomfortable about  being more than one or two hours from the AD patient in case "something happens", let alone taking a weekend trip or an extended vacation.

     Then there are the well-meaning friends and relatives who bombard the caregiver with forceful suggestions about taking the AD patient to a special diagnostic or treatment center, or to a geriatric specialist. Again, the reversible causes of dementia are well-known to all competent internists, family doctors and neurologists, and are diligently looked for. One diagnosis that is occasionally overlooked is the pseudo-dementia of depression. And there is no good clinical evidence that intellectual interaction and stimulation affects the course of the disease. The main advantage of a day-care center for the AD patient is that it gives the caregiver a well-needed rest.

     All AD patients have some degree of memory loss and impairment, most commonly in short-term memory. As we get older, the transfer of information from short-term to long-term memory becomes less automatic and requires more effort,so that while in our 20's we remember our friends' phone numbers and addresses automatically, as we get older we write it down more and more often or log it into our smartphones. If you walk into a room in your 20's and say "where did I put my car keys", you curse yourself for being an idiot, but the same activity in your 60's immediately makes you concerned about AD, It has been my experience that a significant sign of serious memory loss is the inability to find one's way home after a walk or a drive, especially if the person  took an unfamiliar route to get someplace. And if you want to find something after you put it down, you will be most successful if you place it at eye level.


  1. An MRI of the brain is part of the evaluation of any patient with dementia. Many patients have UBO's, or Unidentified Bright Objects seen in their brain on MRI. UBO's are precisely what their name implies: we have absolutely no idea what they signify.

  2. There is a new PET scan out which can detect amyloid plaques in the brain. The problem is that 25-30% of elderly patients who were shown to have these plaques did not develop AD. The cost of the test, as yet not paid for by Medicare, is $3,000, largely because of the expense of producing the radioactive injection. I believe that if the results of a test will not change the treatment plan for the patient, then there is no need to do the test. (And the absence of the plaques does not predict the future behavior of the brain.)