Ask an Expert about Alzheimer's Disease

Alzheimer's disease affects short term memory, so it is not uncommon for persons with this disease to completely forget, for example, why they walked into a particular room or what they were about to do with the checkbook they just retrieved. Similarly, Alzheimer's patients can experience a disconnect between the name of an object and the actual physical object, or what the object is supposed to be used for. For instance, your husband may recognize that he needs to do something in the bathroom involving the razor, but he can’t remember what it is. Sometimes patients get “stuck” in the middle of performing a task (or have difficulty starting the task altogether), and need a little help to remind them what to do or how to do it. In these cases, a simple prompt such as “your razor and your shaving cream for shaving your face are on the bathroom sink” could be used to aide your husband. If he still seems “stuck,” then break the task into smaller steps such as: “Lather up a small amount of shaving cream to put on your face, and use the razor to shave the stubble.” Then tell him that you’ll be in the next room if he needs any further assistance. Some gentle reminders such as these can greatly help your husband in his daily activities.

A sudden change in behavior along with memory lapses, confusion, and difficulty with decision making can be early indicators of dementia, but there are many other conditions that cause similar problems. For example, head injuries, infections of the brain or central nervous system, thyroid hormone imbalances, depression, drug interactions, alcoholism, and even certain vitamin deficiencies can all cause symptoms similar to the early stages of dementia. Also, if your husband’s angry temper is something that has always been present instead of something that has started recently, then his temper may not be a symptom per se, but rather just his “normal” behavior. Only a thorough examination by his doctor will be able to determine if this behavior is the result of a medical condition such as dementia.

It may be difficult, but try to persuade your husband to go see his physician, perhaps by scheduling annual physicals for both of you during the same visit. Rather than telling your husband that you want the doctor to assess his behavior (which very well may anger your husband), you can say that with advancing age it is a good idea to get regular medical check-ups, and therefore both of you are going to the doctor. He may feel less threatened if you are having a physical as well. Prior to his examination, you can discuss your concerns with his doctor and/or your doctor.

Regardless, you may also benefit from talking to a counselor about your husband and his angry outbursts. The Alzheimer's Disease Education Referral Center (ADEAR), for example, has professionals who can help with issues such as this, as well as generally providing advice on immediate caregiver questions, referring patients and caregivers to help in their area. ADEAR is available 24 hours a day, 7 days a week, and can be reached at 1-800-272-3900. Other useful agencies can also be found under “Helpful Organizations.”

There is a test currently available that can identify which forms of apolipoprotein (ApoE) are present in the blood. One form, ApoE4, is associated with an already well-studied condition, heart disease, and appears to increase the risk of developing Alzheimer’s as well. However, this blood can only detect whether ApoE4 is present, not if and when the person will develop Alzheimer's.

In 2007, researchers at Stanford University published some promising study results in which 18 blood proteins (and resultant chemical signals) were tested to determine the risk of advancement from mild cognitive impairment (MCI) to Alzheimer’s disease. In the study, the scientists were able to predict whether the subjects would progress to Alzheimer’s with 90% accuracy. However, this study tested a relatively small number of people, and larger studies will need to be undertaken.

Apolipoprotein E or ApoE genotype is a genetic factor that has been shown to affect risk for development of cognitive decline and Alzheimer’s disease. Each of us inherits two versions (alleles) of the gene for ApoE, one from father and one from mother, and there are 3 main types of this gene (E2 E3, and E4). We can inherit two E4 alleles, two E3 alleles, two E2 alleles, or any combination of 2 types. The ApoE3 genotype is considered neutral so far as this risk is concerned, while ApoE2 appears protective and ApoE4 increases the risk for developing cognitive decline and Alzheimer’s disease. It’s important to emphasize that not everyone with Alzheimer’s disease has an ApoE4 allele and not everyone with an ApoE4 allele develops Alzheimer’s disease.

As you mention, your research has turned up the important influence that ApoE genotype has on the effects of other risk factors for Alzheimer’s disease and even perhaps on the effects of treatments, though much remains to be learned about these topics. One possible explanation for ApoE genotype influence is that the brains of people with the higher-risk ApoE genotypes (one or two of the ApoE4 alleles) may have less capacity to repair wear and tear on the brain associated with the other risk factors. For example, it appears that possession of an ApoE4 genotype reduces the benefits otherwise associated with light to moderate alcohol consumption.

NSAIDS (non-steroidal anti-inflammatory drugs), believed on the basis of epidemiologic studies to reduce the risk for Alzheimer’s disease, have not consistently been shown to do so in treatment trials (and there is even evidence of increased risk associated with these medications in some trials). In one observational study that reported a decreased Alzheimer’s disease risk with midlife use of NSAIDs (Hayden et al. Neurology 2007;69:275-82), the protective effect of NSAIDs was actually greater in those with one or more ApoE4 alleles.

Oxidative stress is suspected to be one contributor to the pathologic brain changes associated with Alzheimer’s disease, and ApoE4 genotype is associated with reduced capacity to repair oxidative damage. This would suggest that antioxidants might be more rather than less beneficial in people with the ApoE4 genotype, yet overall the findings regarding high levels of antioxidant intake have not provided a consistent basis for recommendations, according to the very comprehensive evidence review recently published by the NIH.

Exercise has convincingly been shown in both observational studies and treatment trials to benefit the brain (as well as other parts of the body). Nichol and colleagues (Alzheimers Dement 2009;5:287-94) reported that the effect of “wheel-running” on ApoE4 mice was even greater than on mice without that genotype in improving cognition and hippocampal plasticity. In humans, too, aerobic exercise may be even more important when ApoE4 alleles are present, as concluded by Etnier and colleagues (Med Sci Sports Exerc 2007;39:199-207). They reported an association between aerobic fitness and cognitive performance that was larger when E4 alleles were present.

Regarding hormone replacement therapy (HRT), this remains a confusing area with some conflicting pieces of data. Estrogen use alone has not consistently been related to Alzheimer’s disease risk, though the Women’s Health Initiative Study reported an increased risk for Alzheimer’s disease in women treated with the combination of estrogen and progesterone. ApoE genotype does seem to interact with the effects of HRT, and one observational study (Burkhardt et al. J Alzheimers Dis 2004;6:221-8) reported an association of HRT with better cognitive performance in women without the ApoE4 genotype.

Clearly, more needs to be learned about the interaction between the ApoE genotype and other Alzheimer’s disease risk factors, but as you can see the relationship is not the same for all the factors.

Immobility and muscle rigidity are occasionally seen in advanced Alzheimer’s disease, but there are also many other potential causes of these symptoms. If your husband’s diagnosis is Dementia with Lewy Bodies (DLB) or one of the other dementias with Parkinsonian features, for example, periods of muscle rigidity (called catatonia) can be part of the basic disease itself. For some patients, medications result in unwanted muscle rigidity. Certain types of strokes can produce catatonia as well, and Alzheimer’s disease in some cases is complicated by the addition of strokes. Also, medications induce changes in muscle tone, and the antipsychotic medications, in particular, can produce this problem. The combination of antipsychotic medications with DLB is especially prone to inducing muscle rigidity. A review of your husband’s diagnosis and medications may suggest a way to reduce or alleviate these episodes, so I suggest that you work with your husband’s clinicians to and discuss the options.

Your question is an important one that concerns individuals with a family history of dementia, clinicians who wish to advise their patients accurately, and researchers seeking to understand the course of dementia’s development in order to improve our understanding of its various causes. Although early signs of dementia can be variable, one frequently used summary of dementia’s stages was published by Dr. Reisberg and colleagues in 1982 and is still commonly used. You may want to seek out the article, which is in the American Journal of Psychiatry (1982;139:1136-9). They described the earliest manifestations of dementia, particularly Alzheimer’s, as including memory lapses with names or words and misplacing of objects, but recognized that these behaviors also can occur in normal cognitive aging. Don’t let yourself get alarmed if these are your experiences, since they are not strong predictors of dementia. At the next stage, early signs of dementia may be apparent as “mild cognitive decline” consisting of memory or concentration problems that can be objectively demonstrated on neuropsychological testing. It becomes more difficult to remember the names of newly introduced people. Performance in work or social settings may show some signs of decreased function and declining organization or planning ability. At this stage, friends or family may have noticed changes in an individual’s memory or behavior. If you are experiencing symptoms such as these, there are still many possible explanations other than dementia that should be explored. It would be sensible to seek evaluation with a clinician experienced in assessing the presence of cognitive impairment such as a behavioral neurologist, neuropsychologist, or geriatric psychiatrist.

Alzheimer’s patients generally do not like surprises or unexpected changes, and may become frightened, stressed or agitated if their routines are suddenly altered without warning. So by all means prepare your mother-in-law for the move to the new facility by describing what will happen before, during and after the move. Mark the date of the move on a calendar that she can see, and be sure to talk about the moving process frequently beforehand.

In order to make her transition less stressful, try to make her feel welcome at the new facility. Have some of her possessions or personal effects already waiting for her in the new facility. Do not leave anything to the last minute for the move – try to have all the necessary paperwork and provisions in place. Also, Alzheimer's disease patients can get stressed if they feel as though they are being rushed, so be sure to leave plenty of extra time for the journey to the new facility. Finally, immediately following the move, try to get your mother-in-law back on her regular schedule as soon as possible.

Many investigators and clinicians suspect that diet may have a connection to Alzheimer’s disease, though it is unlikely that diet is a primary cause. A recent National Institutes of Health conference on “Preventing Alzheimer’s Disease and Cognitive Decline” reviewed current data on this issue and concluded that there is preliminary evidence to support the idea that the Mediterranean diet, which is high in vegetables, fish, fiber, and healthy oils, may be associated with a decreased risk for cognitive decline or Alzheimer’s disease. By contrast, there was a suggestion that high intake of saturated fats and trans-fats might increase this risk. Some investigators have explored the idea that a “ketogenic diet” might benefit Alzheimer’s disease by providing the brain with an energy source other than the usual glucose (which is handled less effectively by the brain in Alzheimer’s disease). A prescribed “medical food” that induces ketosis is available but further studies are needed to fully assess its safety and effectiveness. In general, there is no rigorously documented prevention strategy for Alzheimer’s disease in humans; however, some preliminary data from animal studies show exiting promise. Much further research is necessary to confirm these findings.