Ask an Expert about Alzheimer's Disease

Social gatherings, even if there are only a handful of people, can be overwhelming and sometimes frightening for a person with Alzheimer’s disease. The person can become confused and over-stimulated by the noise and commotion, which can lead to anxiety and agitation. While social interaction in general is good, it is best to try to tailor the interaction to suit your mother-in-law’s condition. Therefore, perhaps going to fewer such events would be warranted, or only attending those events with smaller gatherings. Before you accept an invitation on behalf of your mother-in-law, make sure the event is at a time that is good for her (i.e., it does not interfere with naps, or is too late at night). Typically, Alzheimer’s patients are better in the morning and early afternoon, so an evening event may be more challenging for them.

When you arrive at the event, find a quiet place where you can take your mother-in-law. This will be her little sanctuary away from the noise and confusion of the party, particularly if there are children present. If the event is at someone’s home, for example, ask in advance if a separate room or secluded area can be made available for your mother-in-law to sit in. If people want to visit with your mother-in-law, bring them to her a few at a time. Even if you think that your mother-in-law will know who these visitors are, be sure to introduce each one and provide some details or a brief description of who they are. For example, you can say “This is Cathy, your niece. We stayed at her house last summer and had a good time swimming in the lake.” Not only will this help to jog your mother-in-law’s memory about who the person is, but it can also make for an easy conversation starter.

Alzheimer’s disease can often cause a person to become apathetic or depressed, which can also lead to the person becoming lethargic and easily tired. It is possible, for instance, that your mother is mildly depressed, and therefore prefers to sit in this position. It is equally possible that your mother simply finds this position peaceful or calming, and may rest her head on the table as a way to relax or even “meditate,” sort of like a coping mechanism. Maybe if there are people or commotion around her and she does not feel like being social, she may just put her head down as a way to communicate her desire to be left alone. Sometimes, however, Alzheimer’s disease simply causes people to have odd behaviors that they did not have before the disease—this may be one of those unexplained behaviors.

Try talking to your mother when she is in the head-on-table position. Does she communicate with you readily or is she non-responsive? Does she keep her head on the table or pick it up when you start talking? Ask her about it. Is it something that is enjoyable to her (the smoothness or coolness of the table) or is it because she is bored, tired, afraid, etc.? She may not tell you directly, but there may be some emotion underlying her response which can help you determine why she does this.

If you think that she seems depressed or apathetic, speak to her primary care physician. A doctor’s evaluation could help to determine whether or not she is truly depressed, and whether she could benefit from anti-depressant or anti-anxiety medication.

Depressive symptoms and depression are common among people with dementia, and some studies have suggested that depression is a predictor or even risk factor for the onset of Alzheimer’s disease. Several studies, though not all, support the value of using antidepressants in individuals who suffer simultaneously from both Alzheimer’s disease and depression. Also, many clinicians have wondered whether addressing depressive symptoms might also aid cognitive functioning in individuals who already impaired. No consistent evidence, however, supports the intriguing suggestion that antidepressant treatment will forestall Alzheimer’s disease in previously depressed people. Among the several observational studies that have looked into this possibility, findings have differed and at present the value of using an antidepressant for this purpose remains speculative.

Whether or not to withdraw memory medications is often discussed during the course of Alzheimer’s disease, especially in the more advanced stages of the disease. Within weeks after withdrawal of the cognitive enhancing medications such as Namenda or Aricept, the benefits will mostly be gone. Earlier in the course of Alzheimer's disease, the result of medication withdrawal may be a cognitive decline. Later, cognitive decline may be more difficult to recognize but there is a possibility that functional or behavioral symptoms that were helped by the medication(s) might increase. It is not clear whether medication withdrawal shortens life. Determining the effect of medication withdrawal on the patient's quality of life is complicated, but in cases where behavioral symptoms increase there may certainly be a deleterious effect on both patient and caregiver quality of life. On the other hand, the cholinesterase inhibitors can produce gastrointestinal side effects and other medical symptoms that will go away if the medication is discontinued, and memantine (though typically associated with minimal side effects) can also produce side effects such as constipation or confusion that will subside with medication discontinuation. The decision to discontinue cognitive enhancers must be individualized, and should take into account the balance between the benefits of discontinuation (reduced expense, simplified management, elimination of side effects) and the drawbacks (potential for more rapid or severe cognitive and behavioral decline).

Alzheimer's disease (AD) is like frontotemporal dementia (FTD) in that both are dementias. Both affect memory and language among other cognitive faculties, and both can result in behavioral disturbances. These two dementias differ in important ways, including the following:

• Prevalence (AD is around six times as frequent as FTD among older adults)
• Etiology (the pathology of AD includes the famous "plaques and tangles," while a variety of other changes characterize FTD)
• Location of pathology (FTD is associated with very significant frontotemporal atrophy*, while brain atrophy in AD is located more in the temporoparietal areas)
• Age of onset (FTD starts at an earlier age)
• Effects on behavior (FTD is adversely affected earlier with such symptoms as disinhibition)
• Medication treatment (AD is treated with cholinesterase inhibitors and/or memantine, while FTD currently has no FDA-approved medications)

*atrophy is the wasting away or decrease in size of a body organ or tissue

You may be referring to a small pilot study performed by Dr. Alan B. MacDonald in 2006, who found DNA for Borrelia burgdorferi, the Lyme disease spirochete, in seven of ten autopsied Alzheimer's disease brains obtained from the McLean Hospital Brain Bank of Harvard University. Because of the similarity in pathology observed in the brains of patients with Alzheimer's disease patients and those having viral infections of the brain or central nervous system (CNS), Dr. MacDonald proposed a hypothesis that chronic infections caused by viruses or bacteria (as in the case of Lyme disease) may underlie Alzheimer's disease.

However, other studies with a larger number of subjects have not found a connection between Lyme disease and Alzheimer's disease. For example, one study found no evidence of Borrelia antibodies (antibodies are an indicator that the body has been exposed to a foreign pathogen, which in this case would be the Lyme disease pathogen) in patients with Alzheimer's disease. Clearly, further research needs to be performed in order to determine if spirochetes can in any way influence the development of Alzheimer's disease or other neurodegenerative disorders.

At present, the only way to truly confirm a diagnosis of Alzheimer's disease is through autopsy of a patient’s brain at death. Because the symptoms of Alzheimer's disease (AD)—including memory problems, cognitive deficits, and changes in mood or behavior—can occur in a number of other diseases and disorders, sometimes it is difficult to distinguish AD from other conditions. Some people in the medical community say that Alzheimer's disease may be over-diagnosed (or misdiagnosed), and that there are other, under-diagnosed dementias that have been lumped into the AD camp.

Particularly if your doctor did not perform extensive medical and psychological tests on you, it is possible that your diagnosis may be incorrect, but that does not mean that there is nothing wrong at all. You probably presented with at least some symptoms of AD for your doctor to have arrived at this diagnosis. So, you may either have AD and are very fortunate that it has not progressed very rapidly (perhaps you are on medications and they have helped to slow the progress of the disease symptoms?), or you may not have AD, but some other condition with symptoms very similar to it. It would be helpful to speak to your doctor and ask him how he came to the diagnosis of AD. In other words, what criteria were used to arrive at this diagnosis? Additionally, if possible, it wouldn’t hurt to obtain a second opinion.

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