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Alzheimer’s Early and Accurate Diagnosis: Normal Aging vs. Alzheimer’s Disease

(Editor’s Note: I recently came across an excellent book and resource, The Alzheimer’s Alzheimer's Disease Action PlanAction Plan: The Experts’ Guide to the Best Diagnosis and Treatment for Memory Problems, just released in paperback. Dr. Murali Doraiswamy, one of the authors and leading Alzheimer’s expert, kindly helped us create a 2-part article series to share with SharpBrains readers advice on a very important question, “How can we help the public at large to distinguish Alzheimer’s Disease from normal aging — so that an interest in early identification doesn’t translate into unneeded worries?” What follows is an excerpt from the book, pages 3-8).

Jane, fifty-seven, managed a large sales force. She prided herself on being good at names, and introductions were easy for her—until last spring when she referred to Barbara as Betty at a meeting and had to correct herself. She started noticing that her memory wasn’t as dependable as it once was—she had to really try to remember names and dates. Her mother had developed Alzheimer’s in her late seventies, so Jane entertained a wide array of worries: Is this just aging? Is it because of menopause? Is it early Alzheimer’s? Did her coworkers or family notice her slips? Should she ask them? Should she see a doctor, and if so, which doctor? Would she really want to know if she was getting Alzheimer’s? Would she lose her job, health insurance, or friends if she did have Alzheimer’s?

As it turns out, Jane did not have Alzheimer’s. She consulted a doctor, who, in docspeak, told her that the passage of time (getting older) had taken a slight toll on her once-superquick memory. She was slowing down a little, and if she relaxed, the name or date or other bit of information she needed would come to her soon enough. She was still good at her job and home life. She had simply joined the ranks of the worried well.

Normal brain aging, beginning as early as the forties in some people, may include:

  • Taking longer to learn or remember information
  • Having difficulty paying attention or concentrating in the midst of distractions
  • Forgetting such basics as an anniversary or the names of friends
  • Needing more reminders or memory cues, such as prominent appointment calendars, reminder notes, a phone with a wellstocked speed dial

Although they may need some assistance, older people without a mental disorder retain their ability to do their errands, handle money, find their way to familiar areas, and behave appropriately.

How does this compare to a person with Alzheimer’s? When Alzheimer’s slows the brain’s machinery, people begin to lose their ability to

  • remember recent events or conversations, yet they retain old memories. They may remember where they were born or their first job, but they won’t remember that they told you about both in some detail a few minutes earlier.
  • plan, start, or organize tasks
  • find the right words or name everyday things, such as a clock or a stove
  • comprehend or follow even simple directions
  • keep track of the time and where they are

The severity and the speed of the memory loss distinguishes aging from Alzheimer’s, yet the line between where normal aging ends and Alzheimer’s begins is as unclear as the memories of a person with Alzheimer’s. Even the changes that occur in the brain during Alzheimer’s are just a more severe version of the changes we see in the aging brain. Indeed, some scientists argue that Alzheimer’s is a form of accelerated but otherwise normal aging.

But to the family members of someone with Alzheimer’s, the differences between normal aging and Alzheimer’s are real and in their face. In contrast to their healthy older friends, people in the early stage of Alzheimer’s have more problems with shopping, handling money, or getting to familiar places. If someone has become a little uneasy driving and finds alternative routes to avoid major highways, that’s not a sign of Alzheimer’s. If a person avoids being alone in the car because he or she is getting lost, that could very well be Alzheimer’s.

Alzheimer’s is more than memory loss. People with the disease have trouble behaving appropriately. Even though they desperately want to appear like their normal selves, their brains aren’t up to it. Healthy individuals without Alzheimer’s or other forms of dementia still have that choice.

DEMENTIA VERSUS ALZHEIMER’S

Dementia is the broad general diagnosis given to a person whose thinking, particularly memory, is so impaired it affects day-to-day functioning. Not all dementia is due to Alzheimer’s, but everyone with Alzheimer’s has dementia. However, the term Alzheimer’s is often used incorrectly to refer to different types of dementia that impair memory and occur in older individuals. More than a hundred different disorders cause dementia, and their different symptoms depend on what parts of the brain they attack.

WHAT CHANGES IN ALZHEIMER’S?

Alzheimer’s is about change. If you are wondering if a family member has Alzheimer’s, think about how he has changed. It’s the decline that is telling. For example, your father may remember all sorts of interesting facts or stories, but when you think about it, you realize he’s actually become forgetful for him. Some people never knew the name of their senators, but a lobbyist forgetting a senator’s name could be a sign of serious memory loss. If your mother loves to read, has always forgotten the name of the author, and now finds the name slipping more often, she’s probably fine. If she is losing her interest in reading, she’s not.

Alzheimer’s is gradual, but not as gradual as normal aging. It comes on more slowly than some kinds of dementias. If you ask family members when they noticed the changes, they will have difficulty saying. If there is a sudden onset of memory loss or confusion, it is likely due to another cause, such as a stroke, medication side effects, or an infection that is disturbing the person’s thinking or mood. When these conditions are treated, memory sometimes improves as well.

Personality and mood shift as well in people with Alzheimer’s.We aren’t talking about normal changes in response to events or big decisions, such as retiring, falling in love, or losing a loved one.We mean, “Have you noticed how Dad is so sullen all the time?” or “What has gotten into Dad?” or “Why is he so irritable and suspicious?” Not all Alzheimer’s-induced mood and personality changes are for the worse. Some people become more accepting or spontaneous.

It’s not unusual for a person with Alzheimer’s to seem almost fine one day and do something quite out of character the next day. Symptoms seem to come and go. As the disease progresses, the variability continues, but the good days become less frequent and less good.

Eventually, Alzheimer’s can become quite intrusive. If a person doesn’t get proper help, Alzheimer’s can seem to undermine all aspects of life at work and at home.

WHAT DEFINES ALZHEIMER’S

To be diagnosed with the disease, there have to be signs that the person’s memory has declined along with one other cognitive or “thinking” function, such as language, sense of time, judgment, reasoning, or executive function, which includes the ability to plan, organize, and start or stay on task.The defining characteristics of Alzheimer’s are:

  • A subtle onset followed by a slow decline in memory (not caused by reversible conditions such as thyroid imbalance)
  • A slow decline in one other mental function, such as language
  • Having problems in daily functioning as a result of the mental changes

These and other criteria are what doctors use to make a clinical diagnosis that someone has “probable Alzheimer’s.” If the person only partially meets these criteria, he or she has “possible Alzheimer’s.” A definitive diagnosis of Alzheimer’s is usually made only during an autopsy, by examining the brain tissue.


DEMENTIA SCREENING INTERVIEW

If you are worried about whether your relative is developing Alzheimer’s, answer the following questions. Put a yes by the ones that describe a change that you’ve seen in your relative in the last several years, if you think the change is caused by thinking and memory problems. So if he has always had trouble remembering appointments but hasn’t gotten any worse, it’s not a yes. Or if he now has trouble with his financial affairs because he is losing his eyesight and is too stubborn to get someone to read him his financial documents, it’s not a yes, either (yes, it’s annoying; no it’s not necessarily dementia). Try to answer the questions quickly, without dwelling on the accuracy of your answers.

1. Problems with judgment (e.g., problems making decisions, bad financial decisions, problems with thinking)
2. Less interest in hobbies/activities
3. Repeats the same things over and over (questions, stories, or statements)
4. Trouble learning how to use a tool, appliance, or gadget (e.g., VCR, computer, microwave, remote control)
5. Forgets correct month or year
6. Trouble handling complicated financial affairs (e.g., balancing checkbook, income taxes, paying bills)
7. Trouble remembering appointments
8. Daily problems with thinking and/or memory

Scoring: If you put a yes next to none or just one, your relative probably does not have any kind of dementia. The questionnaire can’t rule out cases of very early dementia, nor is it perfect, so don’t hesitate to get help for your relative if he or she continues to worry you. If you answer yes to two or more, you do need to get your relative assessed promptly by a specialist.

Source: Adapted with permission from J. E. Galvin et al., “The AD8, a Brief Informant Interview to Detect Dementia,” Neurology 65 (2005): 559–64.

Murali Doraiswamy Dr. Murali Doraiswamy is the Head of the Division of Biological Psychiatry at Duke Alzheimer's Disease Action PlanUniversity’s School of Medicine, and co-author of The Alzheimer’s Action Plan: The Experts’ Guide to the Best Diagnosis and Treatment for Memory Problems, just released in paperback. Next month he will share an additional excerpt from the book to introduce us to The Best Memory Tests, explaining the roles of the  Mini-Mental State Exam (MMSE), clock-drawing test, Language Skills, Delayed Recall Tests, Daily  Living, Depression, Computerized Neuropsychological Tests.

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