It is a simple connection: Alzheimer’s disease = memory loss. A recent report contradicts that notion. Recently published in the journal, Neurology, researchers remind us that those stricken with early-onset Alzheimer’s (below age 60) may paint a very different early picture of decline. Nearly 40% of those stricken at a younger age can show major deficits in four different areas:
- Decline in the ability to carry out tasks (executive functions like planning a trip or decision-making such as avoiding cake when on a diet)
- Language impairment
- Behavior problems
- Vision deficits
Alzheimer’s disease guidelines were recently updated by the Alzheimer’s Association and the National Institute on Aging in Alzheimer’s and Dementia: The Journal of the Alzheimer’s Association (Online publication April 19). Three stages of Alzheimer’s disease are described:
- Preclinical – This stage is based on research that the disease process might start more than 10 years before symptoms show up. Specialized testing like PET scan, APOE e4 genetic studies, and spinal fluid chemistry analysis may help predict Alzheimer’s during this stage. The down side of adding this early stage: would you want to know dementia is coming many years before it hits you? Think of the extra years of distress. Sometimes ignorance is bliss. Is this another example of over-diagnosis like “pre-hypertension” and “pre-diabetes” in which some experts argue that healthy people are needlessly labeled with a disease? Some would suggest that pharmaceutical companies encourage illness labels: more “sick” people means more folks will need the drugs they develop.
- Mild Cognitive Impairment – Mild changes in memory and thinking without functional impairment.
- Dementia Due to Alzheimer’s – Memory, thinking, language, and behavioral deficits impair daily life function. Onset is gradual and brain power declines slowly over years.
Interestingly, of people who have mild cognitive impairment (MCI), about 5 to 15 % will progress to full-blown dementia every year. Some predictors of higher risk for progression to dementia include the following:
- Depression and MCI
- Apathy (No motivation, loss of interest, cannot initiate activity but distinct from depression) and MCI
- Agitation and MCI
- Difficulty performing Activities of Daily Living such as cooking, cleaning, bathing
Review: Types of Long-Term Memory
- Procedural memory: How to do things like tying shoes, dance steps, driving a car, getting dressed. Previous experiences help in doing these tasks without being actively aware of them.
- Semantic memory: Meaning and concept-based knowledge unrelated to personal experience. For example, semantic memory enables you to know that a hammer is a type of tool, not a type of pet.
- Episodic memory: Memory of past and personally experienced events including places, times, emotions and other contextually important information.
- Autobiographical memory: A memory system consisting of episodes recollected from an individual’s life. Interestingly, actress Marilu Henner (TV series Taxi fame) was found to have superior autobiographical memory. She has the rare ability to recall detailed events of nearly every day of her life. This ability requires memory of personal experiences (people, places, date, time, feelings) as well as general knowledge of the world (semantic memory).
- Visual memory: A mental image of people, places, objects, animals. Also known as the “mind’s eye.”
- Topographic memory: The ability to recognize familiar places and to orient oneself in space. Getting lost when traveling alone occurs commonly in those who have dementia.
The most common symptom of Alzheimer’s is an inability to form new memories, manifest as trouble with short-term memory. Early sufferers may be repetitive, misplace objects often, and forget appointments or recent conversations. But dementia is not limited to memory difficulties. Other deficits that develop over time include:
- Cannot perform complex tasks requiring several steps such as cooking or balancing a checkbook.
- Loss of reasoning ability such as responding with a plan for a flooded bathroom or kitchen fire. Disregards rules of social conduct.
- Spatial ability and orientation deteriorate. May lose way in the house or familiar neighborhood. Driving may become a daunting task when it was not before.
- Language impairment becomes more apparent like inability to find the right word and difficulty following conversations.
- Behavior changes develop including:
- May become more passive and less responsive to surroundings
- More irritable, agitated or suspicious than usual
- May misinterpret surroundings: for example, gunfire or screaming on the television may seem real.
A few Practical Tips for Care of those with Dementia
- A reminder is in order about available treatments for dementia. The Alzheimer’s Association lists the following as Myth #8:
Myth: There are treatments available to stop the progression of Alzheimer’s disease
Reality: At this time, there is no treatment to cure, delay or stop the progression of Alzheimer’s disease. FDA-approved drugs temporarily slow worsening of symptoms for about 6 to 12 months, on average, for about half of the individuals who take them.
In addition, a recent meta-analysis of studies of Namenda (memantine) has questioned the effectiveness of this drug for mild and moderate dementia.
- Despite the need for structure at adult care homes and assisted living facilities, frail elders can benefit greatly if allowed to make independent choices and retain control over their schedule. Many older adults simply cannot go to bed at 7 pm, for instance. If they have stayed up past midnight most of their adult years, it can lead to “insomnia” as well as resentment and frustration if forced to have an early bedtime.
- Some dementia sufferers become very anxious and clingy, following caregivers around like a puppy and making constant demands. These folks need extra reassurance and patience. Caregivers or healthcare providers should try to determine if they have unmet needs, or suffer from depression, anxiety, or pain. They should not be scolded, ignored and labeled as a ‘trouble patient’ not to be taken seriously.
- Dealing with very anxious and needy residents who shadow and call out incessantly can be challenging. If there are no unmet needs found and no untreated medical issues, try handing them a broom to sweep or a pile of laundry to fold. Allow opportunity for walking in a safe area free of loose rugs, crowded walkways, uneven ground, or other “banana peels” they can slip or trip on.
- Agitation should never be treated using potent drugs before unmet needs or untreated medical conditions are carefully considered. A healthcare provider should evaluate a frail elder who has sudden outbursts that are unusual for that individual.
- Language deficits can be subtle in early dementia sufferers. Important information to assess include:
- Any word-finding difficulties?
- Is speech broken by round-about explanations or gestures rather than words?
- Any errors in word-production — producing the wrong syllables or using the wrong word?
- Do they understand what is said to them?
- If language deficits are suspected try some simple tests:
- Have them name unfamiliar objects like a reflex hammer or stethoscope
- Have them name specific parts of a familiar object. For example, the hands of a clock or buttons and collar of a shirt.
- Ask the person to generate a word list of words that begin with any letter. Then a list of words in a category such as naming all 4-legged animals they can come up with. “Normal” answers would be about 10 objects in 30 seconds for each list. The list of animals is usually longer than words beginning with a named letter in alzheimer’s sufferers. A large deviation from this should alert the provider to other diagnoses such as frontotemporal dementia.
♦ Gallagher, M., & Long, C.(2011). Advanced Dementia Care: Demystifying Behaviors, Addressing Pain, and Maximizing Comfort. Journal of Hospice & Palliative Nursing, 13(2), 70-78. ♦ News release, American Academy of Neurology. Balasa, M. Neurology, May 17, 2011. ♦ Tomaszewski Farias, S. Cahn-Weiner, D., Reed, B.R., Mungas, D., Kramer, J.H., Chui, H. Longitudinal changes in memory and executive functioning are associated with longitudinal changes in instrumental activities of daily living in older adults. The Clinical Neuropsychologist, 23, 446-461. 2009 ♦ Farias ST, Mungas D, Reed BR, Harvey D, DeCarli C. Progression of mild cognitive impairment to dementia in clinic- vs community-based cohorts. Arch Neurol. 2009 Sep;66(9):1151-7. ♦ http://en.wikipedia.org/wiki/Memory ♦ http://www.medicineclinic.org/AmbulatorySyllabus4/NEW%20dementia.htm ♦http:/www.dementiaguide.com/aboutdementia/understanding/language_difficulties ♦ Maioli F. Conversion of mild cognitive impairment to dementia in elderly subjects: a preliminary study in a memory and cognitive disorder unit. Arch Gerontol Geriatr - 01-JAN-2007; 44 Suppl 1: 233-41. ♦ http://www.alz.org/alzheimers_disease_myths_about_alzheimers.asp ♦ Lon S. Schneider, MD, MS; Karen S. Dagerman, MS; Julian P. T. Higgins, PhD; Rupert McShane, MD. Lack of Evidence for the Efficacy of Memantine in Mild Alzheimer Disease. Arch Neurol. Published online April 11, 2011. doi:10.1001/archneurol.2011.69.