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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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