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Last Updated Tuesday October 17 2017 07:30 AM IST

Heal Thy Self | Could it be Alzheimer's?

Nirmala  Ferrao
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Long before he refused to take a bath and fought his male nurse to the bathroom floor, long before he failed to recognize his wife, his children and his grand-children, long before his mind and his family’s happiness slipped away, one plaque and one tangle at a time, long before all this, my aunt’s late husband was doing things that she and her children found vaguely disturbing, but which doctors dismissed as nothing to be concerned about.

There were the times when he (a retired chartered accountant who had taken on home-based assignments to keep himself busy) would make the kind of mistakes that might be expected from a primary-school student – and this happened on a number of occasions.

There was the time he misplaced his wallet thrice in two days.

His memory for names also seemed to be “slipping”, as my aunt put it.

The first time she went with him to the family doctor, she mentioned these occurrences and voiced her concerns. The doctor spoke briefly to my uncle – who interfaced with him lucidly – and then he told my aunt, “These are called ‘senior moments’. It happens with age. Go home and stop worrying.”

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But she couldn’t. My uncle was withdrawing into himself, and when that wasn’t happening, he was flying off into sudden rages. My aunt returned to the doctor. It was moodiness and irritability, he pronounced, brought on by advancing age, and he would prescribe a sedative which would “settle him down”. My aunt requested a referral to a neurologist. He saw the grim and determined look on her face, and with visible reluctance he gave her the referral.

Following the history-taking, the neurologist administered the cognitive tests that are commonly used to assess the possibility of dementia.

The “Test Your Memory” questions, such as:

Why is a carrot like a potato?

Name four creatures whose names begin with ‘S’.

20-4 = __

Dementia

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The clock-drawing test (drawing the face of a clock with all the numbers put in, and the hands drawn in to indicate a specific time, say, 5.30 p.m).

The sentence-copying test.

The paired series test: A-1; B-2; C-3…. and so forth.

My uncle aced all the tests.

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The neurologist mentioned that a number of other health conditions could mimic the symptoms of dementia; so my uncle was tested for brain tumour, diabetes, stroke, AIDS, thyroid imbalance, vitamin deficiencies. All the tests were clear. The neurologist said there was nothing to worry about; the lapses the family had noticed could be put down to “age-related memory decline.” And he prescribed an anti-depressant.

My aunt’s doubts should have been given a decent burial. But, when you have lived with someone for a good part of your lifetime, you just know them. And my aunt, seeing the very specific changes in the behaviors and mood of the man she had lived with for over half a century, knew at the gut level that he was not himself, and the knowledge was driving her crazy. Confiding in only a few relatives, she would detail the growing list of her observations:

Alzheimer's care

“He asks the same questions over and over.”

“There are days when he forgets the names of our grand-children.”

“Sometimes he paces the floor for half an hour at a time.”

“His answer to most questions is: ‘You’ll have to ask my wife’.”

Most of the relatives who visited said they could not see anything very wrong, and my aunt should not be too hard on him, he was in his late 70s, and she should expect a bit of “slowness”.

But at their wedding anniversary celebration, when he stood up to respond to the toast, he remained frozen in silence and found he couldn’t say anything, couldn’t even remember the name of the toast-master (a close family friend).

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Alzheimer's care

And on his next visit to the neurologist, when he sat down to the clock-drawing test, he drew the face of the clock all right, but put all the numbers on the outside. Then he looked across at my aunt, searching for some sign that he was doing it right. “My heart sank,” she told us later. “I felt so unbearably sad. I knew I been right all along to be worried. And I would give anything not to have been right.”

The trajectory that my uncle’s illness took is far from being an uncommon one. Family members are generally the first to see that “something’s wrong”, but if they take their fears to a physician, even if these fears are taken seriously (and they are not fobbed off with a prescription for an anti-depressant or a sedative), the clinical examination for Alzheimer’s can come up with a reasonably firm diagnosis only when the disease has progressed to the stage where symptoms are beyond doubt.

But this is not good enough. We don’t have a cure for Alzheimer’s, a degenerative disease of the brain; and the drugs in current use only slow down the progression of the disease for a limited period.

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What we need is early diagnosis. This is crucial to effective treatment. The research on Alzheimer drugs is a long history of failed efforts, and that – health scientists say – is because these drugs are being tested at too late a stage of the disease.

That is why there has been a paradigm shift in the focus of research efforts – the spotlight now is increasingly on tests that will give us a definite early diagnosis. These are predominantly brain imaging tests. The Alzheimer’s brain is defined by plaques (abnormal clusters) and tangles of proteins. Amyloid PET scans, now in advanced human trials, for the first time enable the detection of such plaques in living persons, and are likely to prove a game-changer. A positive result on such a scan would be a strong indicator of an Alzheimer’s diagnosis. A negative result would suggest that factors other than Alzheimer’s could be causing the symptoms of cognitive difficulty. (Some of these other causes – like vitamin or thyroid deficiency – are reversible).

Alzheimer's disease

But, apart from this cutting-edge diagnostic tool which is currently being used only in research trials, we already do have one clinical marker – an early warning sign at least for a high proportion of those who go on to develop Alzheimer’s.

The red flag- "Mild Cognitive Impairment"

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MCI (Mild Cognitive Impairment) is a condition that has long been known to the research community, but the knowledge is now becoming more available to the general community. It is a condition that causes a slight but noticeable decline in cognitive abilities, including memory and thinking skills. These changes are serious enough to be noticed by the person experiencing them or by those in regular touch with the person; but they are not severe enough to interfere with daily life or independent function.

MCI is today considered a strong precursor to Alzheimer’s, falling as it does neatly between the normal “age-related decline” in mental skills and the more serious decline of dementia.  It is a natural part of aging to sometimes take longer to think of a word or to recall a person’s name. But if you often lose your train of thought or the thread of conversations, these kind of lapses in mental functioning go beyond what’s expected with normal aging, and may indicate possible MCI.

Research has shown that MCI significantly increases a person’s risk of developing Alzheimer’s disease within a few years, compared to people with normal cognitive function. Reportedly, 60 to 100 % of MCI cases convert to Alzheimer’s or other dementia in 5 to 10 years.

Alzheimer's disease

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Current evidence also indicates that MCI often, but not always, arises from a lesser degree of the same kind of brain changes seen in Alzheimer’s. Some of these changes have been identified in autopsy studies of people with MCI.

So, how do you recognize the signs that you or someone you know may need to be evaluated for MCI? Here’s a fairly comprehensive checklist that may indicate the possibility of MCI (all of them do not have to be present for an MCI diagnosis):

Alzheimer's disease

» You forget important events – example., appointments or social engagements.

» Overall, you forget things more often.

» You lose your train of thought or the thread of conversations, books or movies.

» You feel it increasingly difficult to make sound decisions, plan the steps or sequence to accomplish a task (example., starting the washing machine).

» You start to have trouble finding your way around familiar environments.

» You become more impulsive or show increasingly poor judgment.

» Your family and friends notice any of these changes.

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If you have MCI, you may also experience:

Alzheimer's care

» Depression

» Irritability and aggression

» Anxiety

An important caveat: Although someone with MCI may go on to develop Alzheimer’s, this is not always the case. In some people, MCI never gets worse. In others, it eventually gets better.

MCI- How early intervention helps

Since the diagnosis of MCI is a strong predictor of an eventual Alzheimer’s diagnosis, it also constitutes a window of opportunity during which drugs are more likely to have a benefit. In fact, drugs specifically targeted to treat MCI may get to us faster than drugs to treat full-fledged Alzheimer’s. For instance, Johns Hopkins researchers have found that low doses of levetiracetam, a drug more commonly used to treat epilepsy, can improve memory performance and calm hyperactivity in the brain, both well-documented symptoms in people with amnestic MCI. The research now moves into large-scale human trials to find whether long-term treatment with this drug will prevent further cognitive decline, and either delay or stop progression to Alzheimer’s.

In addition, there are lifestyle interventions (example, controlling high blood pressure and depression) that are likely to be beneficial if they are brought into play at the MCI stage rather than after Alzheimer’s has taken root.

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Exercise for Alzheimer's patience

Red flags- Early stage Alzheimer's

What if you (or someone you know) have missed the window of opportunity provided by MCI, and now feel you’re further down the road? There are still benefits to catching Alzheimer’s in its beginning stage. This early stage affects people differently, but certain signs may be commonly expected:

» Forgetting recently learned information. This kind of memory loss – the kind that disrupts daily life, in stark contrast to the milder memory lapses of MCI – is one of the most common signs of Alzheimer’s, especially in the early stages. What is affected is called “day-to-day memory”. You may have an especially hard time remembering newly-learned information and may repeatedly
ask the same question.

» Difficulty with problem-solving, complex tasks and sound judgments. Planning a family event or even preparing a meal may become overwhelming. There may be lapses in judgment, such as when making financial decisions.

» Confusion in orientation – losing track of the day or date, or becoming confused about where you are.

Exercise for Alzheimer's patience

» Having visual or space difficulties, such as not understanding distance (e.g., when climbing stairs, or while driving), getting lost or misplacing items, or having problems seeing objects in three dimensions.

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» Language difficulties, such as finding the right word, or following a conversation.

» Mood Swings. You may experience rapid mood swings for no apparent reason. Alternatively, you may show less emotion than was usual previously.

Early Alzheimer's- How intervention helps

It’s true that if you have Alzheimer’s, doctors can’t offer a cure. Which may make you wonder: is there any point in a diagnosis if there’s no cure?

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But getting an early diagnosis can be beneficial. Knowing what you can do is just as important as knowing what you can’t do. Some possible interventions:

» If you have another treatable condition that’s somehow complicating the impairment caused by Alzheimer’s, then a doctor can start treatment for that corollary condition, which will result in improvements in thinking and memory.

» Drugs may slow the decline in memory and other cognitive skills for a period of time.

» Also, doctors and your care-givers can help you develop strategies to enhance your living environment, establish routines, plan activities and manage changes in skills to minimize the effect of the disease on your everyday life.

Alzheimer's care

» Importantly, an early diagnosis also helps you and your care-givers plan for the future. You’ll have the chance to make informed decisions on a number of issues, such as:

» financial and legal matters

» developing support networks

» deciding on options for institutional or at-home care

» expectations for future care and medical decisions

(The author, a former editor of 'Health & Nutrition' magazine, works as a counseling therapist)

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