by Isadore Rosenfeld, M.D.

Chapter 1

ALZHEIMER'S DISEASE

Remembering!

Any discussion of aging with someone older than fifty invariably makes them anxious about eventually losing their "marbles." Most of the other devastating ailments of mankind, heart trouble, stroke, even AIDS—don't usually produce the kind of terror associated with Alzheimer's disease. Cancer is certainly something to worry about, but it can often be detected early enough to be cured; its symptoms can be controlled, and patients may survive for months or even years.

Everyone knows someone who has "conquered" a malignancy or coped with it for a long time. Stroke is also viewed with more equanimity these days; it can be prevented by effective treatment of high blood pressure; the likelihood of it causing permanent paralysis is not nearly as great as it used to be, thanks to sophisticated new medications and physical rehabilitation techniques. Proper diet, cholesterol-lowering drugs, and aspirin can prevent or delay heart disease. And if these measures don't work, there is a host of new procedures to treat most cardiac conditions: angioplasty, bypass surgery, valve replacement, laser beams directed into heart muscle, and gene therapy that forms new blood vessels. As a last resort, there's the option of a heart transplant. Even the outlook for AIDS has improved. New drugs prolong life and improve its quality among those afflicted, and HIV infections sometimes even disappear spontaneously.

I am not suggesting that these illnesses always end happily, but they rarely have the emotional impact of chronic dementia. When your mind is intact, you retain some control over your life; you can try to cope with adversity; you can make decisions about your care; you can plan; you can still hope. You have your soul. None of this is true for Alzheimer's disease. Most victims eventually end up in a vegetative state, totally estranged from their environment and unable to communicate with or even recognize their closest loved ones. Tragically, many of them are physically strong enough to hang on to "life" for twenty years or more, during which time the strain on family and friends is unrelenting and unbearable.

Close blood relatives of Alzheimer's patients naturally worry about their own long-term outlook, and for good reason. They read into every minor memory lapse the portents of the disease; they panic when they can't remember a name or where they've put their car keys—even though such lapses are experienced now and then by everyone at every age.

Alzheimer's is a terrible disease, for which there is no cure. Although its rate of progress varies, the road is inexorably downhill. However, there are things you can do, and medications you can take, to delay or possibly even prevent its onset. The sooner you start them, the better.

The Alzheimer's Brain

Until the early 1900s, people believed that if they lived long enough they would inevitably develop "senile dementia" and that losing their mind was a normal accompaniment of aging. But in 1906 a German neuropathologist named Alois Alzheimer looked under the microscope at the brains of relatively young "demented" people who had died in their fifties and sixties. He noted that there were areas in which the nerve fibers had lost their normal orderly appearance and become all tangled up. He termed this disarray "neurofibrillary tangles" and believed that they were only present in young persons who were prematurely deranged. So for many years, doctors limited the diagnosis of "Alzheimer's disease" to young people who were demented. We now know that the brains of elderly persons with "senile dementia" also have these twisted fibers. (They are also occasionally present in other neurological disorders such as Lou Gehrig's disease—amyotrophic lateral sclerosis—and Down's syndrome.) In other words, Alzheimer's is a disease that can occur at any age and is not an inevitable accompaniment of aging.

What Causes Alzheimer's Disease?

The cause of Alzheimer's disease—why these neurofibrillary tangles develop in some people and not in others—remains a mystery. Modern methods of analyzing brain tissue have revealed that the neurofibrillary tangles are deposits or pla—ues of abnormal proteins, the most common of which is beta amyloid. An Alzheimer's brain is also deficient in several neurotransmitters (chemicals that allow nerves in different parts of the brain to send messages to each other), the best known of which is acetylcholine. Although replenishing these neurotransmitters has no real impact on dementia, doing so sometimes alleviates symptoms.

There are several interesting theories about the cause of Alzheimer's. One suggests that the culprit is an as yet unidentified virus. Or perhaps the brain may be deficient in nerve growth factor (NGF), a substance that stimulates the formation of new nerve connections (synapses). When the brain is lacking in NGF and can't make enough synapses, memory and intellectual function become impaired. When NGF is administered to rats, new connections form in those areas of the brain that are concerned with memory. Although these and other observations hold out the promise that Alzheimer's will one day be cured, don't hold your breath—at least for the moment.

Who's Vulnerable?

How do you know if you're especially susceptible to Alzheimer's? There are no absolute risk factors, but there are some statistical correlations.

*Age: Full-blown Alzheimer's affects about 4 million Americans, virtually all of whom are older than sixty; the majority are beyond eighty-five. At least half the current residents of nursing homes in this country have Alzheimer's disease; most of the others are there because they have brain damage from recurrent small strokes, Parkinson's disease, and other less common neurological disorders.

*Family History: The risk of getting Alzheimer's in your lifetime is slightly more if any of your close relatives, such as a parent, sibling, or child is, or was, affected. However, the more such relatives you have, the greater your risk. (In-laws don't count.)

*Genetics: A specific gene called ApoE, usually situated on chromosome #19, is a marker of susceptibility to Alzheimer's in about 15 percent of the population. However, if you happen to carry it, don't panic. Most persons who do never develop Alzheimer's, and vice versa. More recently, another gene, this one located on the #12 chromosome, has been found in up to 15 percent of late-onset Alzheimer's (appearing at or beyond age 80). Again, its presence merely indicates that, in combination with certain environmental factors, you may be predisposed to Alzheimer's but are by no means certain to develop it. Although genetic testing is important in the research of Alzheimer's disease, it is not yet precise enough to warrant its routine use. It is not clear why Hispanics and Blacks without these specific genes are at two and four times the risk, respectively, of developing Alzheimer's disease. Some other as yet unidentified gene or genes, or perhaps environmental factors such as diet, occupation, and exposure to toxic substances, may be responsible.

Other possible causes of Alzheimer's that have been suggested but remain unproved include underactivity of the thyroid gland (hypothyroidism) and chronic alcohol excess.

Symptoms of Alzheimer's

Full-blown Alzheimer's impairs virtually every function of the brain: memory, behavior, abstract thinking, personality, judgment, language, movement, and coordination. It's interesting that patients with Alzheimer's lose these abilities in the reverse sequence in which we develop them during childhood. For example, the very first thing babies can do is swallow; then they recognize and respond to the mother or other caregiver; next they begin to repeat words; then they walk; next in the sequence are bladder and bowel control; finally they begin to converse, to exercise their memory, and to demonstrate judgment. In Alzheimer's, the higher thought processes are the first to go. The earliest symptoms are impaired learning and an inability to retain new information, lack of reasoning power, trouble performing complex tasks, a distinctive subtle change in personality, confusion, and a lack of orientation. These are followed by loss of bladder and bowel control, and walking is progressively more difficult. As motor skills become impaired, the Alzheimer's patient cannot walk unassisted, is unable to swallow normally, and often dies from pneumonia due to aspiration of fluid or liquid into the lung.

Make Sure It's Alzheimer's

Dementia is not always due to Alzheimer's. At least 20 percent of older people suffer from other conditions that mimic it, the most important of which are:

*Depression: When you're depressed, you're not terribly concerned with remembering details, learning new facts, mastering new skills, or socializing—criteria by which mental capacity is often judged. Lack of involvement and enthusiasm are often interpreted as evidence of Alzheimer's. In one of my other books, I recounted the story of a man whose children were convinced that he had Alzheimer's because he'd become withdrawn for no apparent reason. He was a widower who lived alone, and the family didn't think he was really able to care for himself. They decided he'd be better off in a "retirement" home. He agreed to move—or, rather, he didn't resist the decision because he couldn't care less where he lived or what he did. A few weeks after moving into the senior citizens' residence that had been chosen for him, he met a woman whose company he enjoyed. They fell in love and—presto—his "personality change" cleared up and his "Alzheimer's" disappeared. The couple married, moved out of the home, rented an apartment in the city, started visiting museums, went to the theater and movies, and developed a close circle of friends. So always think of depression before deciding someone has Alzheimer's.
*Subdural hematoma refers to a pocket of blood that has accumulated on the inside of the skull, usually as a result of a blow or other injury to the head. This damages blood vessels on the inner surface of the skull and makes them bleed. The blood that accumulates exerts pressure on the underlying brain, causing headache, personality changes, and a variety of other neurological symptoms. Because blood vessels are more fragile in older people, they tear more easily so that even a minor knock on the head can cause a subdural hematoma. This condition can be cured by either removing the blood clot with a needle or by shrinking it with steroid drugs.

Subdural hematomas are often unrecognized when the injury that caused them is trivial and not immediately followed by symptoms. Always suspect this possibility in any older person with an unexplained change in behavior or personality or a persistent headache. And when you do, get a CT scan of the brain to confirm the diagnosis. I remember one man who knocked his head on a shelf in his bathroom while looking for some aftershave lotion. The injury had left no bump, scar, or other mark, so he didn't tell anyone about it. A few weeks later his wife noticed that he was drowsy and confused. Probably Alzheimer's, she thought. After all, he was eighty! Yet he had always been so sharp. Why now? And why so suddenly? A CT scan revealed a large subdural hematoma from just this little bang on the head. It was removed with a needle, and the "Alzheimer's" was cured!

The symptoms of stroke (paralysis, impaired speech, blindness, loss of balance, incontinence), and their severity, depend on what caused it—a hemorrhage, a traveling blood clot, or a blockage. Was the involved vessel large or small? How much of the brain and what part of it was damaged or destroyed? Involvement of just a single small blood vessel usually results in only limited injury, and the symptoms are apt to be minor and transient. However, when such little strokes keep recurring, their cumulative effect can cause enough brain damage to produce memory loss and personality change. This train of events is referred to as multi-infarct dementia (infarct means death of tissue). We can often stop the progress of such dementia by preventing these strokes by dietary means, blood pressure control (so that blood vessels are not prematurely clogged by arteriosclerotic plaques), or blood thinning (either with aspirin or other anticoagulants). By contrast, the dementia of Alzheimer's disease usually progresses relentlessly.

Hypothyroidism can occur at any age, and it is not uncommon among the elderly. Unfortunately, even though it is easily diagnosed by means of a simple blood test, doctors and patients don't think of this possibility often enough. You have no idea how many patients I've seen over the years with typical complaints of hypothyroidism—inability to lose weight, constantly feeling cold, constipated, no energy, depressed, even confused—who went untreated for years because their mental sluggishness was mistaken for Alzheimer's. Always suspect thyroid underfunction in any older person who has slowed down both physically and mentally for no apparent reason. It's amazing how thyroid supplements will cure most of their symptoms, including their "dementia."

Sedatives, sleeping pills, tran—uilizers, and painkillers are the agents most likely to affect behavior. However, any drug or combination of drugs taken for any purpose can produce personality changes and memory loss. For example, you wouldn't think that a drug to treat urinary incontinence could impair memory. Yet in one study, 10 milligrams daily of oxybutynin chloride (Ditropan), widely prescribed for this disorder, affected language and mental performance. Since incontinence most commonly occurs in older persons, you can imagine a scenario in which someone using Ditropan might be thought to have early Alzheimer's. Identifying and withdrawing the offending agent, whatever it is, can result in a miraculous cure of "Alzheimer's"!

Diagnosing Alzheimer's

There is no reliable marker that identifies Alzheimer's with certainty during life. Even the most sophisticated scans cannot reveal the neurofibrillary tangles or the amyloid plaques in someone who's still alive. An abnormal protein called Alzheimer's Disease Associated Protein (ADAP) has recently been found only in the brains of persons who have died with Alzheimer's. Hopefully, scientists will one day develop a test that can identify this protein in the spinal fluid or blood during life and so diagnose Alzheimer's clinically. At the present time, however, doctors make the diagnosis only after all other possible causes of dementia have been eliminated.

Because of these limitations, Alzheimer's is the most overdiagnosed and misdiagnosed mental ailment in older people. Whenever this disorder is suspected, a thorough examination must be done to eliminate all other possibilities. This should include, in addition to the physical itself, a careful and detailed history to identify any family predisposition. It's important also to investigate the possibility of poor nutrition, a head injury, the use or abuse of medication, or the presence of other medical problems.

An evaluation of mental status and neuropsychological testing are also in order. Most family doctors are not trained to do so, and even if they are they would usually recommend a specialist, such as a neurologist, psychologist, or psychiatrist. No screening for Alzheimer's is complete without an electroencephalogram (EEG) to analyze the brain waves, and a CT scan of the brain to visualize its physical structure. Magnetic resonance imagining (MRI) and positron emission tomography (PET), which provide data concerning the metabolic activity of the brain and cerebral function, are expensive and rarely necessary. Ask a good neurologist to decide what special procedures, if any, are necessary.

How to Reduce Your Chances of Getting Alzheimer's

Here is another dietary tip: The more fish you eat, the less likely you are to get Alzheimer's. That's because the neurofibrillary tangles and amyloid plaques may, at least in part, be due to inflammation within the brain. The protective effect of fish is probably due to the anti-inflammatory properties of Omega-3 fatty acids, present in highest concentrations in deep-sea, cold-water fish such as mackerel, tuna, halibut, and sardines. Eat at least three to six ounces of these fish every week. If you don't like seafood, or can't afford it, you can obtain Omega-3 fatty acids in capsule form. Make sure to get a "reputable" brand, since some of the commercial preparations can turn rancid. I prefer the fish.

Holistic practitioners believe that several foods are "brain builders." For example, they claim that artichokes increase mental acuity; brewers' yeast makes for better brain function; sardines, rich in coenzyme —10, raise the concentration of cerebral oxygen; lettuce, raw or juiced, which is rich in iron and magnesium, builds brain cells; and parsnip—raw, juiced, or in salad—improves cognition. I know of no scientific documentation for any of these assertions, but why not try them? My mother, who was not a holistic practitioner, always recommended them, as I'm sure yours did too.

A maintenance dose of NSAIDs may slow the progression of Alzheimer's, but it can cause subtle intestinal bleeding, as well as kidney and liver problems. Two other drugs that may work in a similar way are currently being studied. The first, colchicine, is used mainly in the prevention and treatment of acute gout; the other, chloro—uine, is an antimalarial drug. It's too early to recommend either of these agents for the management of Alzheimer's.

Treating Alzheimer's

The symptoms of Alzheimer's disease can remain mild for a long time, so that many of those afflicted can continue to function at home with relatively little care from others. However, as the disease progresses, most patients eventually require total care—feeding, dressing, and constant monitoring.

Although there is no specific treatment for Alzheimer's, every patient should be given a good multivitamin because his or her diet can be so unpredictable. I also recommend at least 120 milligrams of Ginkgo biloba daily. Ginkgo is an herb that is said to increase blood flow to the brain, heart, and extremities. Reports from Europe and Asia have attested to its effectiveness in improving memory in older people. The American medical literature on the efficacy of ginkgo has been sparse—until now. In 1997 doctors at the New York Institute for Medical Research reported in the Journal of the American Medical Association that an extract of ginkgo stabilized, and in some cases improved, the cognitive function and the social behavior of demented persons for six months to a year. This was not the anecdotal type of study criticized by scientifically trained doctors but a double-blind, placebo-controlled, parallel-group multicenter trial.

Ginkgo has few if any side effects and is worth trying. But remember that it interacts with and enhances the effect of blood thinners such as aspirin or Coumadin, and that the dose of these two drugs may have to be reduced if you're also taking ginkgo.

Tacrine (Cognex) and donepezil (Aricept) are now specifically marketed for the treatment of Alzheimer's. They inhibit the enzyme (acetylcholinesterase) that breaks down acetylcholine in the brain. Both these agents can result in some temporary memory improvement. They're worth trying.

What to Remember about Alzheimer's
1. Alzheimer's is a distinct disease of unknown cause that ultimately leads to dementia. It is not an inevitable accompaniment of aging.
2. The diagnosis of Alzheimer's is one of exclusion. There is no test currently available to make the diagnosis during life. This can only be done with certainty by examining the brain after death.
3. A family history of Alzheimer's only slightly increases your risk of developing the disease.
4. Several genes associated with Alzheimer's have been identified. However, people who harbor them may never develop the disease, which may also strike those who don't have them.
5. Alzheimer's is frequently overdiagnosed and misdiagnosed in older people because there are many different diseases and disorders that can mimic its symptoms and cause dementia. Unlike Alzheimer's, some of these other conditions are preventable and curable. The diagnosis of Alzheimer's should never be made without a thorough and complete neurological examination.
6. Lifestyle changes, including a low-fat diet, education, and exercise, can lower the risk of Alzheimer's.
7. Several agents, including antioxidants, anti-inflammatory drugs, hormones, ginkgo, and vitamin E, may reduce the chances of developing Alzheimer's.
8. There is only a handful of drugs on the market for the treatment of the established form of the disease, none of which are very effective. Supportive care remains the basic treatment of Alzheimer's.

© 1999 by Isadore Rosenfeld, M.D.
Excerpt posted with permission from http://www.twbookmark.com

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