Alzheimer's Disease

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Definition/Description

Alzheimer's Disease is characterized by cortical atrophy and loss of neurons, particularly in the parietal and temporal lobes. Also with loss of brain mass there is an enlargement of the ventricals of the brain.² The changes in the brain tissue slowly cause changes in the person. Often it results in Alzheimer's dementia, however some people progress differently.

Prevalence

Approximately 4 - 4.5 million people have Alzheimer's Disease in the United States and about 8 million affected around the world. It is expected that by 2050 that number will have increased almost three fold to around 13.2 million. The known prevalence is 6% in people over the age of 65, 20% in people over the age of 80, and more than 95% in those 95 years of age.¹ Alzheimer's disease is the fourth leading cause of death in adults, and the period from onset to death is usually 7 to 11 years.¹

Characteristics/Clinical Presentation

The progression of Alzheimer's Disease is continuous and generally does not fluctuate or improve. Often times the early symptoms can be missed or overlooked because they can be misinterpreted as signs of the natural aging process.¹ There are some key risk factors that need to be considered with Alzheimer's Disease. The Primary Risk Factors: age; family history; genetic markers such as apolipoprotein E4 gene; trisomy 21; mutations in presenilin 1 and 2; female gender after 80 years of age; cardiovascular risk factors such as hypertension, diabetes, obesity, and hypercholsterolemia. The Possible Risk Factors: head injury; depression; progression of Parkinson-like signs in older adults; lower thyroid - stimulating hormone (TSH) level within the normal range; hyperhomocysteinemia; folate deficiency; hyperinsulinemia; low educational attainment. There are also some factors that can help to defend a person against developing Alzheimer's disease. The Possible Protective Factors: apolipoprotein E2 gene; regular fish consumption; regular consumption of omega - 3 fatty acids; high education level; regular exercise; nonsteroidal antiinflammatory drug therapy; moderate alcohol intake; adequate intake of vitamins C,E, B6, and B12, and folate.¹ There are also 10 warning signs that people need to be aware of to help with the early diagnosis of Alzheimer's disease.

1. Memory changes that disrupt daily life. One of the most common signs of Alzheimer’s, especially in the early stages, is forgetting recently learned information. Others include forgetting important dates or events; asking for the same information over and over; relying on memory aides (e.g., reminder notes or electronic devices) or family members for things they used to handle on their own. What's typical? Sometimes forgetting names or appointments, but remembering them later.
2. Challenges in planning or solving problems. Some people may experience changes in their ability to develop and follow a plan or work with numbers. They may have trouble following a familiar recipe or keeping track of monthly bills. They may have difficulty concentrating and take much longer to do things than they did before. What's typical? Making occasional errors when balancing a checkbook.
3. Difficulty completing familiar tasks at home, at work or at leisure. People with Alzheimer’s often find it hard to complete daily tasks. Sometimes, people may have trouble driving to a familiar location, managing a budget at work or remembering the rules of a favorite game. What’s typical? Occasionally needing help to use the settings on a microwave or to record a television show.
4. Confusion with time or place. People with Alzheimer's can lose track of dates, seasons and the passage of time. They may have trouble understanding something if it is not happening immediately. Sometimes they may forget where they are or how they got there. What's typical? Getting confused about the day of the week but figuring it out later.
5. Trouble understanding visual images and spatial relationships. For some people, having vision problems is a sign of Alzheimer's. They may have difficulty reading, judging distance and determining color or contrast. In terms of perception, they may pass a mirror and think someone else is in the room. They may not recognize their own reflection. What's typical? Vision changes related to cataracts.
6. New problems with words in speaking or writing. People with Alzheimer's may have trouble following or joining a conversation. They may stop in the middle of a conversation and have no idea how to continue or they may repeat themselves. They may struggle with vocabulary, have problems finding the right word or call things by the wrong name (e.g., calling a "watch" a "hand-clock"). What's typical? Sometimes having trouble finding the right word.
7. Misplacing things and losing the ability to retrace steps. A person with Alzheimer’s disease may put things in unusual places. They may lose things and be unable to go back over their steps to find them again. Sometimes, they may accuse others of stealing. This may occur more frequently over time. What's typical? Misplacing things from time to time, such as a pair of glasses or the remote control.
8. Decreased or poor judgment. People with Alzheimer's may experience changes in judgment or decision-making. For example, they may use poor judgment when dealing with money, giving large amounts to telemarketers. They may pay less attention to grooming or keeping themselves clean. What's typical? Making a bad decision once in a while.
9. Withdrawal from work or social activities. A person with Alzheimer's may start to remove themselves from hobbies, social activities, work projects or sports. They may have trouble keeping up with a favorite sports team or remembering how to complete a favorite hobby. They may also avoid being social because of the changes they have experienced. What's typical? Sometimes feeling weary of work, family and social obligations.
10. Changes in mood and personality. The mood and personalities of people with Alzheimer's can change. They can become confused, suspicious, depressed, fearful or anxious. They may be easily upset at home, at work, with friends or in places where they are out of their comfort zone. What's typical? Developing very specific ways of doing things and becoming irritable when a routine is disrupted.⁴

Stages of Alzheimer's Disease²

Stage 1

• memory loss
• lack of spontaneity
• subtle personality changes
• disorientation to time and date

Stage 2

• impaired cognition and abstract thinking
• restlessness and agitation
• wandering, "sundown syndrome"
• inability to carry out activities of daily living
• impaired judgment
• inappropriate social behavior
• lack of insight, abstract thinking
• repetitive behavior
• voracious appetite

Stage 3

• emaciation, indifference to food
• inability to communicate
• urinary and fecal incontinence
• seizures
  
  

Associated Co-morbidities

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Medications

Below is a list of some commonly used medications use in the treatments of the symptoms of Alzheimers. There is also the use of other treatments such as antioxidants, anti-inflammatory agents, and estrogen replacement therapy in women to prevent or delay the onset of the disease.²

Commonly Used Medications for Alzheimer's Disease¹

Donepezil - (Aricept) has only modest benefits, but it does help slow loss of function and reduce caregiver burden. It works equally in patients with and without apoipoprotein E4. It may even have some advantage for patients with moderate to severe Alzheimer's Disease.

Rivastigmine - (Exelon) targets two enzymes (the major one, acetylcholinesterase, and butyrylcholinesterase). This agent may be particularly beneficial for patients with rapidly progressing disease. This drug has slowed or slightly improved disease status even in patients with advanced disease. (Rivastigmine may cause significantly more side effects than donepezil, including nausea, vomiting, and headache.)

Galantamine - (Reminyl) Galantamine not only protects the cholinergic system but also acts on nicotine receptors, which are also depleted in Alzheimer's Disease. It improves daily living, behavior, and mental functioning, including in patients with mild to advanced-moderate Alzheimer's Disease and those with a mix of Alzheimer's and vascular dementia. Some studies have suggested that the effects of galantamine may persist for a year or longer and even strengthen over time.

Tacrine - (Cognex) has only modest benefits and has no benefits for patients who carry the apolipoprotein E4 gene. In high dosages, it can also injure the liver. In general, newer cholinergic-protective drugs that do not pose as great a risk for the liver are now used for Alzheimer's.

Memantine - (Namenda) targeted at the N-methyl-dasparate receptor, is used for moderate to severe Alzheimer's.

Selegiline - (Eldepryl) is used for treatment of Parkinson's disease, and it appears to increase the time before advancement to the next stage of disability.

Diagnostic Tests/Lab Tests/Lab Values

There are no lab values or tests that can be used to give the diagnosis of Alzheimer's. It is a diagnosis of exclusion essentially and the diagnosis can only be truely confirmed by a cerebral biopsy, or autopsy. The presence of dementia is needed for the diagnosis, and is established by the results of a Mini - Mental State Examination, Blessed Dementia Test, or a similar mental status test. Also there should be no disturbance in consciousness, onset between ages 40 and 90 years, most often after the age of 65, and absence of systemic or brain disorders that could account for the memory or cognitivie deficits. To determine that there are no other diseases that can be causing the symptoms some tests can be done such as brain imaging, CT scan, and MRI.²

Causes

There is no know cause of Alzheimer's Disease.

Systemic Involvement

The most noticabel symptoms inititally are the cognitive and memory related symptoms. However Alzheimer's disease can affect other parts of the body causing symptoms other than those effecting the memory and cognition. Often abnormal motor signs can be apparent depending on the area of the brain affected by the disease.THe presence of tremors can be associated with increased risk for cognitive decline, presence of bradykinesia wiht increased risk for functional decline, and presence of postural-gait impairments with increased risk of institutionalization and death. Also patients may develop disorders of sleeping, eating, and sexual behavior.¹

Medical Management (current best evidence)

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Physical Therapy Management (current best evidence)

Often times when a physical therapist sees an Alzheimer's patient they are in a structured living environment because they have progressed to a stage in the disease where their caregivers can not give the patient the proper attention that they need. Physical therapy can provide the Alzheimer's patient with an activity that they can succeed at and it also can help to improve their breathing, mobility, and endurance. Since restlessness and wandering can be typcial of the Alzheimer's patient physical therapy can help to reduce those symptoms by releasing some of the energy through exercises. These exercises can help to reduce the night time wanderings called sundowning.¹

Alternative/Holistic Management (current best evidence)

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Differential Diagnosis

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Case Reports

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Recent Related Research (from Pubmed)

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References

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1. Goodman C, Fuller K. Pathology Implications for the Physical Therapist. St. Louis, Missouri: Saunders Elsevier; 2009.

2. Porth C. Pathopysiology Concepts of Altered Health States. Philadelphia PA: Lippincott & Wilkins; 2005.

3. Goodman C, Snyder T. Differential Diagnosis for Physical Therapists Screening for Referal. St. Louis, Missouri: Saunders Elsevier; 2007.

4. Alzheimer's Association. 2010. Available at: http://www.alz.org/index.asp . Accessed March 1, 2010.

5. Alzheimer's Disease Fact Sheet. U.S. National Institutes of Health National Institute on Aging. 2010. Available at: http://www.nia.nih.gov/Alzheimers/Publications/adfact.htm . Accessed March 1, 2010.