September 6, 2021
The month of September is dedicated to creating awareness about one of the devastating forms of Dementia, caused by Alzheimer’s disease. Named after Dr Alois Alzheimer, who was the first to recognize the symptoms and write about it, AD is progressive and irreversible, meaning the symptoms worsen over time and the damage done cannot be rectified.
Alzheimer’s Disease (AD) is a neuro-degenerative condition which gradually damages brain cells causing problems in memory and thinking. It has been estimated that more than 50million people are diagnosed with AD worldwide and it is the most common cause of Dementia accounting for 60-70% of all dementia cases.
As we advance in age, some amount of cognitive decline is part of the normal ageing process. During stressful times when there are too many things weighing on one’s mind, everyone experiences ‘senior moments.’ It has to be borne in mind that occasional losing of car keys, glasses or misplacing your wallet does not necessarily mean you have Alzheimer’s Dementia. The drastic cognitive decline that occurs in AD is colossal affecting all executive functions of the brain including memory, thinking, judgement, decision making, concentration and so on. Although symptoms of AD commonly manifest in people above 65 years, in rare instances those below 50 may develop the disease.
In the beginning stages of AD, the person may be aware of their inability to remember but family and caregivers notice it when the person keeps repeating the same story or asking the same questions over and over. They may forget appointments, conversations they have just had or even events. They may repeatedly misplace their glasses, keys or other valuables and start looking for them in wrong places.
Changes in memory are one of the early symptoms of AD and the person is likely to have difficulty registering and recalling new information, forgetting recent events and conversations. Short-term and immediate memory are the first to be affected wherein a person may forget what was just said and hence tends to repeat. For example, they may forget that they have eaten, had a shower or locked the door. This lapse in memory often results in altercations with family as the person may accuse the loved ones of not feeding them, stealing their valuables and so on. Eventually, as the disease progresses, the person may develop severe memory impairment thereby finding it problematic to carry out simple daily tasks or even recognize loved ones.
People with AD may wander aimlessly, get lost in familiar surroundings, or forget where the bathroom is. They may even wander away from home and not be able to trace their steps back. The family caregivers have to be alert all the time and ensure they do not walk away from their comfort zones.
Thinking and making decisions
Due to changes in the areas of the brain which are directly responsible for thought processing, people with AD have difficulty finding words to identify things, or hold meaningful conversations. They have difficulty with numbers and find it challenging to handle money, pay bills or balance their chequebooks. Simple everyday tasks that we take for granted like turning off the stove, dressing, bathing or grooming may be confusing for them. Because of their inability to communicate with clarity, family caregivers have to make extra efforts to understand what they want- whether they are hungry, thirsty, want to use the washroom or if they are in pain and respond accordingly.
Changes in personality and behaviour
Behavioural and personality issues may develop over time in those with AD. Temporal lobe involvement leads to emotional reactions like anxiety, sadness, and apathy, lack of trust, anger and aggression. Some may experience what is called as the “Sun down Syndrome” wherein, they are more agitated and irritable after the sun goes down, i.e., in the late evening hours. Their sleep patterns change drastically and they feel comfortable sleeping during the day and are awake at night.
Psychotic symptoms like delusions are sometimes seen in people during the later stages of AD. They may accuse loved-ones/care-givers of poisoning their food, stealing their valuables, plotting to harm them and so on. The persecutory content of their thought processes may mislead others into believing the accusations if they are unfamiliar with the symptoms.
Hoarding paper cuttings, fruit peels, match sticks or other junk and treating them as items of immense value is seen in some. When family caregivers take them away, they become very agitated or aggressive. On rare occasions they may become violet if others do not go with their thinking and argue otherwise. Sometimes it is best to leave them alone and not monitor every move of theirs as long as they do not harm themselves or others. Losing their inhibitions, undressing in public, urinating or defecating in the living room are noticed in the advanced stages of AD.
What causes AD?
There are a number of speculations about what causes Alzheimer’s Disease and the exact causes are not yet understood. However, autopsy studies have strongly implicated interference of brain proteins in the functioning of brain cells or neurons which are not able to connect with each other and eventually die. Cell damage initially occurs in the area of the brain that controls memory years before the onset of symptoms.
There is scientific evidence that AD is caused by a combination of genetic, environmental and lifestyle factors. It has been found that the risk of developing AD is slightly higher if there is family history. Women are diagnosed with AD more often than men as they live longer but there is no significant gender difference when it comes to the development of AD. It has also been found that brain injury or head trauma increases risk of dementia. Exposure to environmental pollutants has been implicated in expediting cognitive decline. Excessive use of alcohol, lack of exercise, Type II diabetes, high blood pressure, high cholesterol levels, sleep problems, smoking are some of the other risk factors.
Diagnosis, Treatment and Prevention
Physical and neurological examination consists of checking reflexes, balance, motor coordination, muscle tone and strength. A mental status examination will determine the extent of attention, concentration, memory, judgement and thinking deficits.
If the confusion or disorientation is of sudden onset, a simple blood test -serum electrolytes will help rule out electrolyte imbalance (low sodium/potassium levels). Delirium caused by metabolic or organic issues of the brain also needs to be ruled out before a diagnosis of AD is made.
Magnetic Resonance Imaging (MRI) will assist in getting a clearer picture of brain functioning and detect shrinkage if any. PET Scans are sometimes used to measure amyloid deposits, neurofibrillary tangles and nutrient metabolism in the brain.
Unfortunately, as of today, there is no cure for AD but there are medications which are beneficial in slowing down the progression of dementia by addressing the symptoms. Medications help by improving the quality of life of the person and enhancing their day-to-day functioning. Donepezil, Galantamine and Memantine are commonly prescribed medications for revitalizing cell connections and curtailing behavioural issues like aggression and mood changes. Additionally, anti-depressants and anti-psychotics are advised when behavioural symptoms are severe and disruptive.
Keeping oneself socially and mentally active is a well-known protective factor. Some studies have shown that dietary changes and exercise regimen which helps reduce the risk of heart diseases may also lower the risk of AD or other disorders that cause dementia. Eating healthy-foods low in saturated fats, plenty of fruits and vegetables, staying away from alcohol and quitting smoking is advisable. Blood sugar, blood pressure and cholesterol levels have to be monitored regularly.
Improving the quality of life
Dancing, singing, playing an instrument, handicrafts, reminiscing (telling stories) are some of the skills which are preserved for a longer time and by keeping the person with AD engaged and cognitively occupied, it is possible to slow down cognitive decline to a great extent. Research evidence suggests that the above-mentioned skills are controlled by parts of the brain which are not affected by Alzheimer’s Disease till the end.
Tips for family caregivers
Caring for a person with AD is not easy and can be quite overwhelming. Each day poses new challenges as the disease progresses. Each person is unique and the families have learn how to deal with certain behaviours by trial and error. The following tips are for family caregivers:
• Keep clocks, calendars handy so they can ascertain for themselves what time/day/month it is. If they think it is Monday, and you know it is not, just go with their reality. You don’t have to prove you’re right and they are wrong.
• Place the belongings where they can easily find them.
• Keep emergency contact numbers on them so someone can contact you if they wander away. Identify cards, Bracelets with phone number etched on them also help.
• Remove excess furniture, clutter from the rooms. It is very confusing when there are too many pieces of furniture. Rearranging furniture could be very confusing for them.
• Most people with AD have problems with balance. Comfortable footwear with good traction will help in mobility.
• Handrails are useful in corridors and bathrooms. Bath time is sometimes a challenge and it is important to schedule a bath according to their convenience and not yours. If they don’t feel like stepping into the bathroom it is okay, try when they are in a better frame of mind.
• Remove mirrors from the rooms as the images are sometimes frightening to them.
• Keep medications out of their reach to prevent overdosing by mistake.
• Communicate in short, simple clear sentences, keeping in mind their abilities to grasp and understand. Avoid arguments and distract them when they are stubborn.
• Finally, do not ask them repeatedly if they know who you are and what your relationship with the person is. They have dementia, you don’t. If they fail to recognize you, it is okay as long as you know who you are!