Alzheimer’s : The disease we dare not forget

What do you mean get off the sidewalk? I don’t have to show you my papers. Who are you to question me?” escalated an exchange between one of our city’s preeminent artists and a New Orleans policewoman. The 80-year-old or so artist was riding a bicycle on a French Quarter sidewalk. He was almost arrested before passers-by intervened and explained that the well-known artist had memory problems.

“You, I know you. Who are you?” had become his standard “hey you” greeting to compadres he knew and had socialized with for decades. Friends and acquaintances including the clerks at Matassa’s Market, a daily stop on his bicycle rounds, whispered among themselves about his declining memory and personal hygiene for years. Several times he became lost on his bicycle outside his protective French Quarter cocoon where those who knew his situation steered him home. Alzheimer’s disease (AD) has surpassed cancer as the most feared and dreaded disease on the planet. A lady in her 70s recently sent her physician this note: “I have been having such bad forgetfulness, really, really bad. I am thinking I should get a CT scan for Alzheimer’s. What do you think about this?”

Minor memory lapses are part of aging. Memory and recent recall normally decline with advancing years. There are easily discernable differences between age-related memory loss and the obvious dementia of the artist. Normal age-related memory loss and AD are very separate biological processes.

The human mind is a complex computer. It normally takes a little longer for an older brain to activate and process memory circuits just as that 2005 computer runs slower than a brand new one. Occasional and even recurring failure of instant and spontaneous recall is more likely due to decades of brain overload than AD.

And who hasn’t forgotten where they parked after an intense few hours shopping at the Lakeside Shopping Center? On the other hand repeating a question or story at the same dinner party or getting lost driving home from the mall is the sort of memory loss that needs a medical evaluation.

I once heard a neurologist say that an unbalanced checkbook is an early clue to the diagnosis of AD. If this is true, most people I know are at risk. But early symptoms do often include new problems with finances, frequent repeating of stories, forgetting names of relatives, poor judgment and driving and becoming lost. Symptoms intensify over time.

“A formal mental status exam is important in evaluating memory loss,” says Dr. Frank Oser, a neurologist known for his thorough bedside neurological examinations. “Are they up on current events? Can they interpret proverbs like ‘what does it mean that Rome was not built in a day’? Can they draw a clock and insert the numbers correctly?”

Such mental status testing, the keystone to proper assessment, often begins with screening questions such as: what city are you in; what are the month and year; and who’s the mayor or president? If those questions present problems, mental impairment is usually obvious. A good clinician can access mental status within minutes.

The diagnosis of AD is based on the history with exclusion of other possible disorders and especially those with effective treatments. A physician who has followed a person for years supported by observations from family and friends is in the best position to access memory changes, evaluate thinking skills, note behavioral changes and judge functional abilities.

Acute or sudden mental changes ring certain bells and call for more extensive testing. A medication inventory is very important as many drugs cause memory problems and confused thinking. Sedatives, sleeping pills and alcohol are the top three classes of problem drugs. Various sleep disorders can also worsen memory problems.

The physical examination gives clues to more treatable causes of dementia, including Parkinson’s disease, thyroid disorders, depression, anxiety, strokes and anemia. Treatment for any coexisting cardiovascular disease needs to be maximized. This means attention to any underlying hypertension, diabetes and cardiac disease/vascular disease. Carefully selected blood tests are usually more important than brain-imaging tests to exclude other medical problems.

Common Alzheimer’s disease myths
Dementia means AD. Nothing could be further from the truth. Dementia is a term that refers to anything that diminishes memory, thinking, reasoning and brain functioning. AD is a common cause of dementia, but dementia can be caused by a multitude of both treatable and untreatable causes.

AD only affects the elderly. While most common in folks older than age 70, a rare specific gene can cause a familial early-onset variant beginning before age 50. Persons with Down’s syndrome develop AD at early ages. Dr. Alois Alzheimer first described the scrambled clumps and tangles of brain tissue in microscopic sections from a woman who died with dementia, memory loss and poor judgment in 1906. She was only 51 years old. Scientists honored Alzheimer by pinning his name to the disease.

A CT scan of the brain is the only way to diagnose AD. With the exception of an autopsy, there’s no single test to diagnose Alzheimer’s disease. An astute clinician rarely needs a brain-imaging study to make the diagnosis. If there’s confusion about a diagnosis, an MRI is usually the preferred test. However, MRI results rarely alter the treatment or outcome of a person with AD and are mostly ordered to satisfy patient or family expectations.
There are effective drugs that can prevent the progression of AD. Aricept, Exelon and Namenda are three promoted drugs based on industry designed and sponsored clinical trials. It isn’t uncommon for internists and neurologists to prescribe these. What is uncommon, however, is for one of these drugs to actually help a person with AD. No drug to date can cure AD or prevent its progression.

Even if drugs for AD have minimal, if any real benefits, why not take them anyway? There is no downside. Currently available drugs deliver false hope coupled with adverse effects. Family members often ask for these well-advertised drugs. A pill is an easy answer that often distracts from more important non-drug interventions that can encourage intellectual stimulation and social interactions. Caretaker education and interventions can extend the time a patient can safely remain in their own home.

Gingko biloba will prevent AD. Believe this, and I have a bridge to sell you. The health food lobby always seems to have a new gimmick supplement that fails muster once tested. Five years of daily ginkgo biloba didn’t reduce the risk of progression to AD compared to placebo in a study of almost 3,000 persons over age 70 with reported memory problems. Vitamin E flunked an earlier test.

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