Alzheimer’s disease

Diagnosis

A key component of a diagnostic assessment is self-reporting about symptoms, as well as the information that a close family member or friend can provide about symptoms and their impact on daily life. Additionally, a diagnosis of Alzheimer’s disease is based on tests your doctor administers to assess memory and thinking skills.

Laboratory and imaging tests can rule out other potential causes or help the doctor better characterize the disease causing dementia symptoms.

The entire set of diagnostic tools is designed to detect dementia and determine with relatively high accuracy whether Alzheimer’s disease or another condition is the cause. Alzheimer’s disease can be diagnosed with complete certainty after death, when microscopic examination of the brain reveals the characteristic plaques and tangles.

Tests

A diagnostic work-up would likely include the following tests:

Physical and neurological exam

Your doctor will perform a physical exam and likely assess overall neurological health by testing the following:

• Reflexes
• Muscle tone and strength
• Ability to get up from a chair and walk across the room
• Sense of sight and hearing
• Coordination
• Balance

Lab tests

Blood tests may help your doctor rule out other potential causes of memory loss and confusion, such as a thyroid disorder or vitamin deficiencies.

Mental status and neuropsychological testing

Your doctor may conduct a brief mental status test or a more extensive set of tests to assess memory and other thinking skills. Longer forms of neuropsychological testing may provide additional details about mental function compared with people of a similar age and education level. These tests are also important for establishing a starting point to track the progression of symptoms in the future.

Brain imaging

Images of the brain are now used chiefly to pinpoint visible abnormalities related to conditions other than Alzheimer’s disease — such as strokes, trauma or tumors — that may cause cognitive change. New imaging applications — currently used primarily in major medical centers or in clinical trials — may enable doctors to detect specific brain changes caused by Alzheimer’s.

Imaging of brain structures include the following:

• Magnetic resonance imaging (MRI). MRI uses radio waves and a strong magnetic field to produce detailed images of the brain. MRI scans are used primarily to rule out other conditions. While they may show brain shrinkage, the information doesn’t currently add significant value to making a diagnosis.
• Computerized tomography (CT). A CT scan, a specialized X-ray technology, produces cross-sectional images (slices) of your brain. It’s currently used chiefly to rule out tumors, strokes and head injuries.

Imaging of disease processes can be performed with positron emission tomography (PET). During a PET scan, a low-level radioactive tracer is injected into the blood to reveal a particular feature in the brain. PET imaging may include the following:

• Fluorodeoxyglucose (FDG) PET scans show areas of the brain in which nutrients are poorly metabolized. Identifying patterns of degeneration — areas of low metabolism — can help distinguish between Alzheimer’s disease and other types of dementia.
• Amyloid PET imaging can measure the burden of amyloid deposits in the brain. This imaging is primarily used in research but may be used if a person has unusual or very early onset of dementia symptoms.
• Tau Pet imaging, which measures the burden of neurofibrillary tangles in the brain, is only used in research.

In special circumstances, such as rapidly progressive dementia or very early onset dementia, other tests may be used to measure abnormal beta-amyloid or tau in the cerebrospinal fluid.

Future diagnostic tests

Researchers are working on tests that can measure the biological evidence of disease processes in the brain. These tests may improve the accuracy of diagnoses and enable earlier diagnosis before the onset of symptoms.

Genetic testing generally isn’t recommended for a routine Alzheimer’s disease evaluation. The exception is people who have a family history of early-onset Alzheimer’s disease. Meeting with a genetic counselor to discuss the risks and benefits of genetic testing is recommended before undergoing any tests.

Drugs

Current Alzheimer’s medications can help for a time with memory symptoms and other cognitive changes. Two types of drugs are currently used to treat cognitive symptoms:

• Cholinesterase inhibitors. These drugs work by boosting levels of cell-to-cell communication by preserving a chemical messenger that is depleted in the brain by Alzheimer’s disease. The improvement is modest.Cholinesterase inhibitors may also improve neuropsychiatric symptoms, such as agitation or depression. Commonly prescribed cholinesterase inhibitors include donepezil (Aricept), galantamine (Razadyne) and rivastigmine (Exelon).The main side effects of these drugs include diarrhea, nausea, loss of appetite and sleep disturbances. In people with cardiac conduction disorders, serious side effects may include cardiac arrhythmia.
• Memantine (Namenda). This drug works in another brain cell communication network and slows the progression of symptoms with moderate to severe Alzheimer’s disease. It’s sometimes used in combination with a cholinesterase inhibitor. Relatively rare side effects include dizziness and confusion.

Sometimes other medications such as antidepressants may be prescribed to help control the behavioral symptoms associated with Alzheimer’s disease.

Creating a safe and supportive environment

Adapting the living situation to the needs of a person with Alzheimer’s disease is an important part of any treatment plan. For someone with Alzheimer’s, establishing and strengthening routine habits and minimizing memory-demanding tasks can make life much easier.

You can take these steps to support a person’s sense of well-being and continued ability to function:

• Always keep keys, wallets, mobile phones and other valuables in the same place at home, so they don’t become lost.
• Keep medications in a secure location. Use a daily checklist to keep track of dosages.
• Arrange for finances to be on automatic payment and automatic deposit.
• Carry a mobile phone with location capability so that a caregiver can track its location. Program important phone numbers into the phone.
• Make sure regular appointments are on the same day at the same time as much as possible.
• Use a calendar or whiteboard in the home to track daily schedules. Build the habit of checking off completed items.
• Remove excess furniture, clutter and throw rugs.
• Install sturdy handrails on stairways and in bathrooms.
• Ensure that shoes and slippers are comfortable and provide good traction.
• Reduce the number of mirrors. People with Alzheimer’s may find images in mirrors confusing or frightening.
• Make sure that the person with Alzheimer’s carries identification or wears a medical alert bracelet.
• Keep photographs and other meaningful objects around the house.

Alternative medicine

Various herbal remedies, vitamins and other supplements are widely promoted as preparations that may support cognitive health or prevent or delay Alzheimer’s. Clinical trials have produced mixed results with little evidence to support them as effective treatments.

Some of the treatments that have been studied recently include:

• Omega-3 fatty acids. Omega-3 fatty acids in fish or from supplements may lower the risk of developing dementia, but clinical studies have shown no benefit for treating Alzheimer’s disease symptoms.
• Curcumin. This herb comes from turmeric and has anti-inflammatory and antioxidant properties that might affect chemical processes in the brain. So far, clinical trials have found no benefit for treating Alzheimer’s disease.
• Ginkgo. Ginkgo is a plant extract containing several medicinal properties. A large study funded by the National Institutes of Health found no effect in preventing or delaying Alzheimer’s disease.
• Vitamin E. Although vitamin E isn’t effective for preventing Alzheimer’s, taking 2,000 international units daily may help delay the progression in people who already have the disease. However, study results have been mixed, with only some showing this benefit. Further research into the safety of 2,000 international units daily of Vitamin E in a dementia population will be needed before it can be routinely recommended.

Supplements promoted for cognitive health can interact with medications you’re taking for Alzheimer’s disease or other health conditions. Work closely with your health care team to create a safe treatment plan with any prescriptions, over-the-counter medications or dietary supplements.

Lifestyle and home remedies

Healthy lifestyle choices promote good overall health and may play a role in maintaining cognitive health.

Exercise

Regular exercise is an important part of a treatment plan. Activities such as a daily walk can help improve mood and maintain the health of joints, muscles and the heart. Exercise can also promote restful sleep and prevent constipation.

People with Alzheimer’s who develop trouble walking may still be able to use a stationary bike or participate in chair exercises. You may find exercise programs geared to older adults on TV or on DVDs.

Nutrition

People with Alzheimer’s may forget to eat, lose interest in preparing meals or not eat a healthy combination of foods. They may also forget to drink enough, leading to dehydration and constipation.

Offer the following:

• Healthy options. Buy healthy food options that the person with Alzheimer’s disease likes and can eat.
• Water and other healthy beverages. Try to ensure that a person with Alzheimer’s drinks several glasses of liquids every day. Avoid beverages with caffeine, which can increase restlessness, interfere with sleep and trigger a frequent need to urinate.
• High-calorie, healthy shakes and smoothies. You can supplement milkshakes with protein powders or make smoothies featuring favorite ingredients. This may be particularly important when eating becomes more difficult.

Social engagement and activities

Social interactions and activities can support the abilities and skills that are preserved. Doing things that are meaningful and enjoyable are important for the overall well-being of a person with Alzheimer’s disease. These might include:

• Listening to music or dancing
• Reading or listening to books
• Gardening or crafts
• Social events at senior or memory care centers
• Planned activities with children

Coping and support

People with Alzheimer’s disease experience a mixture of emotions — confusion, frustration, anger, fear, uncertainty, grief and depression.

If you’re caring for someone with Alzheimer’s, you can help them cope with the disease by being there to listen, reassuring the person that life can still be enjoyed, providing support, and doing your best to help the person retain dignity and self-respect.

A calm and stable home environment can help reduce behavior problems. New situations, noise, large groups of people, being rushed or pressed to remember, or being asked to do complicated tasks can cause anxiety. As a person with Alzheimer’s becomes upset, the ability to think clearly declines even more.

Caring for the caregiver

Caring for a person with Alzheimer’s disease is physically and emotionally demanding. Feelings of anger and guilt, stress and discouragement, worry and grief, and social isolation are common.

Caregiving can even take a toll on the caregiver’s physical health. Paying attention to your own needs and well-being is one of the most important things you can do for yourself and for the person with Alzheimer’s.

If you’re a caregiver for someone with Alzheimer’s, you can help yourself by:

• Learning as much about the disease as you can
• Asking questions of doctors, social workers and others involved in the care of your loved one
• Calling on friends or other family members for help when you need it
• Taking a break every day
• Spending time with your friends
• Taking care of your health by seeing your own doctors on schedule, eating healthy meals and getting exercise
• Joining a support group
• Making use of a local adult day center, if possible

Many people with Alzheimer’s and their families benefit from counseling or local support services. Contact your local Alzheimer’s Association affiliate to connect with support groups, doctors, occupational therapists, resources and referrals, home care agencies, residential care facilities, a telephone help line, and educational seminars.

Preparing for your appointment

Medical care for the loss of memory or other thinking skills usually requires a team or partner strategy. If you are concerned about your memory loss or related symptoms, ask a close relative or friend to go with you to a doctor’s appointment. In addition to providing support, your partner can provide help in answering questions.

If you are accompanying someone on a doctor’s appointment, your role may be to provide some history or your perspective on changes you have observed. This teamwork is an important part of medical care for initial appointments and throughout a treatment plan.

Your primary care doctor may refer you to a neurologist, psychiatrist, neuropsychologist or other specialist for further evaluation.

What you can do

You can prepare for your appointment by writing down as much information as possible to share. Information may include:

• Medical history, including any past or current diagnoses and family medical history
• Medical team, including the name and contact information of any current physician, mental health professional or therapist
• Medications, including prescriptions, over-the-counter drugs, vitamins, herbal medications or other dietary supplements
• Symptoms, including specific examples of changes in memory or thinking skills

What to expect from your doctor

Your doctor will likely ask a number of the following questions to understand changes in memory or other thinking skills. If you are accompanying someone to an appointment, be prepared to provide your perspective as needed. Your doctor may ask:

• What kinds of memory difficulties and mental lapses are you having? When did you first notice them?
• Are they steadily getting worse, or are they sometimes better and sometimes worse?
• Have you stopped doing certain activities, such as managing finances or shopping, because these activities were too mentally challenging?
• How is your mood? Do you feel depressed, sadder or more anxious than usual?
• Have you gotten lost lately on a driving route or in a situation that’s usually familiar to you?
• Has anyone expressed unusual concern about your driving?
• Have you noticed any changes in the way you tend to react to people or events?
• Do you have more energy than usual, less than usual or about the same?
• What medications are you taking? Are you taking any vitamins or supplements?
• Do you drink alcohol? How much?
• Have you noticed any trembling or trouble walking?
• Are you having any trouble remembering your medical appointments or when to take your medication?
• Have you had your hearing and vision tested recently?
• Did anyone else in your family ever have memory trouble? Was anyone ever been diagnosed with Alzheimer’s disease or dementia?
• Do you act out your dreams while sleeping (punch, flail, shout, scream)? Do you snore?