Ask an Expert about Alzheimer's Disease

First, visit your regular family physician. The physician will probably do a variety of tests to determine the probability of Alzheimer's. Specialists such as neurologists, gerontologists and geriatric psychiatrists may also be involved in the evaluation process.

Increasing evidence supports the idea that factors such as head injury, activity, social engagement, and diet may influence the development of Alzheimer’s disease. Data regarding the significance of toxic environmental exposures paints a murkier picture. A recent NIH conference addressed the state of current knowledge regarding environmental agents that might cause Alzheimer’s disease, and concluded that too little is known about this topic to provide more than a tentative answer. Limited data are available regarding long-term effects of exposure to solvents, pesticides, lead, aluminum, and electromagnetic fields, each of which has been suspected of increasing the risk for Alzheimer’s. The most convincing association was found for chronic exposure to organophosphate pesticides. If the tenants diagnosed with Alzheimer’s disease shared a pesticide exposure, it’s possible that the exposure was a factor in the development of their diseases. Otherwise, it may be that they shared the most significant risk factor for Alzheimer’s disease, which is advanced age.

The relationship between general anesthesia and Alzheimer’s has been attracting attention for a number of years, given cell culture and animal experiments that suggest several mechanisms by which some anesthetics (particularly the inhaled anesthetic isoflurane) might exacerbate cellular changes associated with Alzheimer’s. Supporters of the connection between isoflurane use and Alzheimer’s point out demonstrated effects on amyloid processing, tau hyperphosphorylation, and apoptosis (cell death). On the other side, some studies have failed to demonstrate a relationship between general anesthesia and a subsequently increased risk for dementia or cognitive decline.

In the case of your father, of course, an effect of anesthesia would be difficult to separate from other risk factors. For example:

1. Progression of the vascular dementia
2. Age
3. Other factors during the operation that might have harmed him independently of anesthesia.

Vascular dementia can be progressive and the vascular risk factors that presumably preceded his dementia may require further attention. Cerebrovascular disease, too, is a risk factor for Alzheimer’s disease and people who have both these conditions are not rare. Age is considered the largest overall risk factor for development of Alzheimer’s disease. Finally, there can be other factors that can occur during an operation (such as temporary hypoxia*) that result in later cognitive symptoms.

* hypoxia occurs when the body or a particular tissue in the body is deprived of adequate oxygen supply.

If you visit a new doctor, bring your medical records; for any doctor, bring a list of over the counter and prescription medicines you are currently taking. If you don't know the names of the drugs, bring the pill bottles with you. A medication or a combination of medications can sometimes cause symptoms that resemble Alzheimer's disease. Also make a list of current medical problems. It's a good idea to show the doctor a list of symptoms, behaviors and any problems carrying out routine activities (for example, paying bills) in yourself or your loved one that concern you.

There are three general stages of Alzheimer's disease:

Stage 1 (Mild): Early in the illness, those with Alzheimer’s tend to be less energetic and spontaneous. They exhibit minor memory loss and mood swings, and are slow to learn and react. They may become withdrawn, avoid people and new places and prefer the familiar. Individuals become confused, have difficulty organizing and planning, get lost easily and exercise poor judgment. They may have difficulty performing routine tasks, and have trouble communicating and understanding written material. If the person is employed, memory loss may begin to affect job performance. They can become angry and frustrated.

Stage 2 (Moderate): In this stage, the person with Alzheimer’s is clearly becoming disabled. Individuals can still perform simple tasks independently, but may need assistance with more complicated activities. They forget recent events and their personal history, and become more disoriented and disconnected from reality. Memories of the distant past may be confused with the present, and affect the person’s ability to comprehend the current situation, date and time. They may have trouble recognizing familiar people. Speech problems arise and understanding, reading and writing are more difficult, and the individual may invent words. They may no longer be safe alone and can wander. As Alzheimer’s patients become aware of this loss of control, they may become depressed, irritable and restless or apathetic and withdrawn. They may experience sleep disturbances and have more trouble eating, grooming and dressing.

Stage 3 (Severe): During this final stage, people may lose the ability to feed themselves, speak, recognize people and control bodily functions. Their memory worsens and may become almost non-existent. Constant care is typically necessary. In a weakened physical state, the patient may become vulnerable to other illnesses and respiratory problems, particularly when bedridden.

Mild forgetfulness and memory delays often occur as part of the normal aging process. Older individuals simply need more time to learn a new fact or to remember an old one. We all have occasional difficulty remembering a word or someone's name; however, those with Alzheimer's disease (AD) will find these symptoms progressing in frequency and severity. Everyone, from time to time will forget where they placed their car keys; an individual with Alzheimer’s may not remember the purpose of the keys.

There has been recent interest in a condition called mild cognitive impairment (MCI). Individuals with MCI have memory impairment (pronounced forgetfulness), but are able to perform routine activities without assistance. However, MCI has been identified as a major risk factor for developing AD. While all patients who develop some form of dementia go through a period of MCI, not all patients exhibiting MCI will go on to develop AD.

Many conditions can contribute to the development of memory problems and dementia; AD is just one of them. A decline in intellectual functioning that significantly interferes with normal social relationships and daily activities is characteristic of dementia, of which AD is the most common form. AD and multi-infarct dementia (a series of small strokes in the brain) cause the vast majority of dementias in the elderly. Other possible causes of dementia-like symptoms include infections, drug interactions, a metabolic or nutritional disorder, brain tumors, depression or another progressive disease like Parkinson's disease.

If memory loss increases in frequency or severity, makes an impression on friends and family, begins to interfere with daily activities (employment tasks, social interactions, and family chores, for example), seek out qualified professional advice and evaluation by a physician with extensive knowledge, experience and interest in dementia and memory problems.

Medicare is a federal health insurance program for people age 65 or older who receive Social Security retirement benefits. To receive assistance from Medicare, a person must meet specific eligibility requirements. Medicare covers some, but not all, of the services a person with Alzheimer's disease may require. For example, the program does not cover long term healthcare. Medicaid is a federal program for certain individuals and families with low incomes and resources, typically administered by state agencies; eligibility and benefits vary from state to state. Medicaid can cover all or a portion of nursing home costs. A person with Alzheimer's can qualify for long term care only if there are minimal income and cash assets. Medicaid may be applied for by calling each state's Department of Human Services or Medicaid Assistance Program.

Dementia is a progressive deterioration of intellectual function due to the death of brain cells. Dementia can be caused by medical conditions such as hypothyroidism or stroke, drug toxicity or brain injury. Some conditions are treatable, and others cause irreversible brain damage. Alzheimer’s disease (AD) is irreversible, and in western countries, it accounts for more than half of dementia cases. Currently, the only way to diagnose AD definitively is through a brain autopsy. However, on living patients, physicians can correctly diagnose AD about 90 percent of the time based on mental and behavioral symptoms, a physical examination, and neuropsychological and laboratory tests.

A physician will normally take a history of mental and behavioral symptoms, using information provided by the patient and the family. In nearly 75 percent of cases, AD starts with the inability to remember recent events and to learn and retain new information. Early stage AD patients experience memory problems that interfere with daily living and steadily worsen. Other early AD symptoms can include difficulty managing money, driving, orientation, shopping, following instructions, abstract (conceptual) thinking and finding the right words. There may also be other problems, such as poor judgment, emotional instability and apathy. AD can be distinguished from other types of dementia in part by the symptoms exhibited, the extent to which these symptoms occur and the speed with which the disease progresses.

A physical examination will be performed to help identify and rule out other potential causes of dementia. This exam will normally include a general physical, blood tests and urinalysis. Through a blood test, for example, the physician can measure thyroid function; hypothyroidism or failure to produce sufficient thyroid hormones is common in the elderly and can cause dementia. Dementia may also be the result of a vitamin B12 deficiency which is common in the elderly, and can be measured through blood tests. Physicians may use brain scans (such as magnetic resonance imaging or MRI) to rule out other possible causes of dementia, including brain tumors, stroke, blood accumulation on the brain surface or other conditions. In addition, brain scans can show characteristic structural changes present in AD. Physicians may administer an electroencephalogram (EEG) to measure the electrical activity in the brain. Occasionally, spinal fluid may be tested through a lumbar puncture.

Neuropsychological tests identify behavioral and mental symptoms associated with brain injury or abnormal brain function. The neuropsychological tests used will depend on the symptoms and the dementia’s state of advancement. Usually, physicians start with a brief screening tool, such as the Mini-Mental Status Examination (MMSE), to help confirm that the patient is experiencing problems with intellectual functions. The MMSE includes tests of memory, attention, mathematical calculation and language. If a patient has severe dementia, further neuropsychological testing beyond the MMSE is usually not necessary. However, for patients with mild intellectual deficits, more tests may be needed to determine whether the patient is simply showing signs of advanced age or is developing AD. The patient may be referred to a neuropsychologist, who will administer a battery of tests to identify more specific deficits.