Alzheimers Dementia
(AD) Diagnosis
Guidelines for diagnosis state that people must have memory impairment plus at least one other cognitive dysfunction (listed below). These impairments must be significant enough to affect daily functions. In addition, the physician should rule out other causes for memory impairment or functional impairment prior to making the diagnosis.
Cognitive Function
• Aphasia is a disturbance in language (understanding as well as speaking). ie trouble with word finding.
• Apraxia is an inability to perform previously learned tasks like cooking or following a recipe.
• Agnosia is a failure to recognize objects.
• Disturbance in executive functioning relates to planning and sequencing. ie trouble paying the bills or planning a trip.
Ten to 15 percent of patients with Mild Cognitive Impairment annually progress to Alzheimer’s Dementia. Progression occurs when the person develops deficits in multiple areas of cognitive functioning.
Late Stage AD is devastating for the patient and family. Early education for all is critical. In advanced dementia the elder may experience hallucinations, or delusions (thinking people are stealing their clothes or putting things in their house that are not theirs as they no longer recognize them). This may lead to some paranoia and can be very frightening for the patient and family. Incontinence becomes prevalent as the person doesn’t realize that they may have to go to the bathroom or may forget how to actually get to the bathroom. Mobility is often affected, and in very advanced states many elders become bed bound, increasing risk for bed sores, pneumonia, decreased appetite, and dehydration. Language is often impaired to the point that the elder doesn’t understand what’s being told and is unable to express himself.
Goals of Care discussions are key to honoring the elder. The patient will want to voice his opinions regarding what he wants to happen as functional loss becomes more severe. Ask the elder about his values regarding independence, living alone, continuing hobbies despite risks, etc. Nobody ever wants to have these conversations as it’s emotionally difficult to accept the gradual loss of independence. However, it’s important for the elder to be able to contribute to the decisions while he may still have capacity. This makes it easier for the family when the time comes to make difficult decisions such as placement, what to do when the elder is failing to thrive, becoming dehydrated from not eating, and how aggressive care should be. Primary care physicians can help with these discussions and in preparing for the complications ahead.
Seeking Help
Families always wonder when to seek help. Physicians recommend evaluation right away to treat potentially reversible causes of dementia such as Vitamin B1, Folate, and B12 deficiency, or hypothyroidism. The most common forms of reversible dementia are due to depression (Pseudodementia), medication side effects, substance abuse, infection, and hearing or vision impairment. HIV, neurosyphilis, and brain tumors are less common causes. Neurocognitive studies, evaluation with a Neuropsychiatrist, a Geriatrician, or at a Dementia Center are all great places to start. It is important to rule out other types of dementia such as Parkinson’s, Huntington’s, or vascular dementia (due to multiple strokes). The American Academy of Neurology also recommends MRIs of the brain to rule out some of the above causes.
Preventative Measures
Higher level of education or continued learning is shown to be protective against progression. The elder should be encouraged to get involved in book clubs, crossword puzzles, etc. Exercise is also shown to be a protective factor. Research is being performed into anti-inflammatory medications such as NSAIDs (Ibuprofen, Aleve), and antioxidants such as Vitamin E. Music, art, and pet therapy can be emotionally beneficial as well.
Treatment options
Medications like Donezepil (Aricept) work to increase chemicals in the brain shown to be involved in cognitive function. In studies, Donezepil has been shown to improve quality of life and extend the amount of functional time someone has, as well as to delay need for facility placement. This medication is intended for patients with mild cognitive impairment or early Alzheimer’s to slow progression. In late stages of Alzheimer’s; however, medications have not been shown to be effective. Twenty-four hour supervision becomes necessary and families must come together to discuss at home care versus requiring placement in a facility. To prevent safety hazards, plan ahead regarding who will help with paying bills or paperwork, who can take over driving, help with cooking, cleaning, bathing, etc. Redirecting the elder can be a very effective method for avoiding arguments. Simple things like disguising the front door or hiding the keys work great. Choosing your battles makes life much easier for the elder and the family. If grandpa is convinced that it is snowing inside and wants to wear his winter jacket indoors, let him.
For More Information: alz.org