Ask an Expert about Alzheimer's Disease

Both behaviors you describe are typical of an Alzheimer’s patient. Issues with personal hygiene, especially bathing, are a common manifestation in early stages of Alzheimer’s. Your mother-in-law may feel uncomfortable with the prospect of bathing, as she may feel a loss of a sense of privacy. She may also be confused about what to once in the bath. Vision problems can confuse patients as well, as they may have difficulty judging the depth of water or may be confused by mirrors or other reflective objects in the bathroom. You want to make sure that her bath is comfortable (adjust water temperature, make sure the room is warm, etc.), safe (make sure there are handrails, anti-slip mats and good footing), and to the best of your ability, provide her with some privacy. For more tips, please see our section on bathing.

Because Alzheimer's disease affects each person uniquely, it is impossible to predict what else your mother-in-law might do (or not do) in the future. Sometimes patients can become belligerent and argumentative, others may stay passive or even become non-communicative. Make the most of every lucid moment she may have, and appreciate the fact that she can still communicate with you.

It's not possible to diagnose early Alzheimer's disease from your description of memory slips that could result from so many different possible causes. Normal aging is associated with some "senior moments" and these are worse and more frequent when people are stressed or depressed. Some antidepressant medications can affect memory, as can a thyroid imbalance or morphine. My suggestion is that you review your medications and conditions with the clinicians helping you, aim for consistency in your use of the proper medications, and ask your clinicians whether formal neuropsychological testing (in a memory clinic, for example) would be appropriate at this time.

Niacinamide, also called nicotinamide, was reported in 2008 to improve cognitive functioning in mice genetically engineered to have a disease similar to Alzheimer's disease. The nicotinamide was thought to work by inhibiting the hyperphosphorylation of tau protein that creates "neurofibrillary tangles" (one of the hallmarks of Alzheimer’s disease) and destroys the internal structure of brain cells. The results of human studies are still awaited. Though related to niacin, niacinamide doesn't produce the uncomfortable "flush" that niacin often does. On occasion, in high doses, it can sometimes cause liver toxicity.

Aricept (donepezil) is a well-known medication indicated by the FDA for treatment of mild, moderate, and severe Alzheimer's disease.

Lithium aspartate does not carry an "indication" for Alzheimer’s disease and lithium has potential side effects, but is also believed to have some chemical properties that might be "neuroprotective." The small dose of lithium aspartate you mention may be unlikely to cause harm but should (like all medications) be reviewed with the clinicians treating your wife.

Exelon (rivastigmine) is one of the cholinesterase inhibitors and is FDA indicated for treatment of mild to moderate Alzheimer's disease. Namenda (memantine) works on a different neurotransmitter system (glutamate) and is FDA indicated for use in moderate to severe Alzheimer's disease. It is common practice to combine any of the cholinesterase inhibitors with memantine and there are research findings to support that approach. Several studies have tried to look specifically at the combination of rivastigmine with memantine and most (but not all) support using both medications together. The likelihood of the combination being less tolerable than rivastigmine alone is small. Some studies have reported an additional benefit from adding memantine to rivastigmine, but these studies are of the type called "open label." That means both the subject and investigator knew what experimental drug was being taken, which is a potential source of bias. It would be more convincing to have "double blind" studies that compare subjects on rivastigmine with a placebo added, to subjects who are taking rivastigmine with memantine added, under conditions in which neither subjects nor investigators know who is taking which drug.

This apparently straightforward question turns out to be an area of real uncertainty and even controversy. Among studies that try to find a connection between dietary folate and cognitive decline, some (but not all) find that low self-reported dietary folate or low measured plasma folate levels are linked with greater cognitive decline. Similarly, low folate serum levels have been linked specifically with an increased risk of Alzheimer's disease in more than one (but not in every) observational study. Whether this means that taking folic acid is a good idea is less clear, because studies in which folic acid was given to people with Alzheimer's disease as a way of trying to improve cognitive functioning have not shown impressive or consistent results.

For people with low dietary folic acid, the supplementation might be more clearly beneficial. One study done in the Netherlands (where food is not supplemented with folate as it is in the United States) found that older adults without dementia benefited in global cognitive function and memory when they received supplemental folate. Scientists reviewing this study point out that the high baseline homocysteine levels in these subjects suggest that many were folate deficient to start.

An authoritative systematic review of this question (Cochrane Database Syst Rev. 2008 Oct 8;(4):CD004514) reported that no consistent benefit of folate has been found in cognitively impaired older adults but that one pilot study of people with Alzheimer's disease found that the addition of folic acid (1 milligram per day) seemed to improve the response to cholinesterase inhibitors.

The bottom line, in my opinion, is that a diet naturally high in folate would be advisable, and that folate supplementation might help cognitively if your fasting homocysteine level is elevated or if you are taking a cholinesterase inhibitor. It is always prudent to review any supplementation with your personal physician, who is aware of your medical conditions and medication regimen. Further research will provide a more definitive answer to your question.

Alzheimer's disease can sometimes cause patients to repeat certain behaviors, such as asking a question, pacing back and forth, opening and closing drawers, etc. Therefore, your wife may be scratching herself more out of “habit” then because she actual feels itchy. If this is the case, no amount of ointments or anti-itch medications may help, as you have probably now learned.

You can try making your wife wear thick gloves so that she cannot scratch herself, assuming she will keep them on. If this does not work, you can try a more drastic measure to discourage this behavior: special clothing designed for Alzheimer's patients that prevent them from removing their clothes (and thus getting access to their skin.) These anti-strip jumpsuits and pajamas have back zipper closures, and therefore the clothes cannot be removed by the wearer. If the patient cannot remove her clothes, then she may not be able to scratch at her skin either. Some websites that carry this type of clothing include: Silvert's, Adaptive Clothing, and Nurnia. Or just search for “Alzheimer anti-strip suit” in your web browser to find other sites and/or related products.

A study performed in 2003 found that, in women, the longer the period of time that a person went untreated for depression, the greater the observed shrinkage of brain areas involved in memory (such as the hippocampus). Because these women then had smaller “reserves” of neurons in areas of the brain that are commonly affected by AD, they are believed to be at a higher risk for later developing dementia.

More recent studies in both men and women have suggested that depression may be a risk factor for cognitive decline in elderly patients, and this cognitive decline is associated with a higher likelihood of developing dementia. For example, several studies have indicated a correlation between depression and Alzheimer's disease, wherein a history of depression (particularly in patients under the age of 60) is associated with a greater risk of developing Alzheimer's disease. Researchers believe that depression—particularly long-term untreated depression—may change the brain’s overall chemistry, making it more vulnerable to insults and neurodegeneration. Further research is clearly needed to confirm these conclusions.

Alzheimer's disease typically does not cause gastrointestinal problems by itself. However, some of the more commonly reported side effects of the cholinesterase inhibitor drugs (such as donepezil (Aricept), rivastigmine (Exelon), galantamine (Razadyne), or tacrine (Cognex)) prescribed to Alzheimer's disease patients include nausea and vomiting. If your wife is currently taking a cholinesterase inhibitor, please check with your wife’s prescribing physician to see if her medications can be adjusted. Even if your wife is not taking one of these medications, you should consider consulting her doctor to rule out other medical issues that may be causing her symptoms.