Diagnosing Dementia

Millions of Americans live in fear of developing Alzheimer's disease. Yet only a relatively small proportion, surprisingly, ever get an...

The look of Alzheimer's: tissue from the brain of a 69-year-old man, riddled with a large, dark protein plaque surrounded by damaged nerve fibers and by neurofibrillary tangles (the smaller dark blobs). Healthy aged adults exhibit these structures to a much lesser extent.

Millions of Americans live in fear of developing Alzheimer's disease. Yet only a relatively small proportion, surprisingly, ever get an accurate diagnosis; some studies indicate that only one in five people with dementia is properly diagnosed. Older people and their families often go through years of torment before seeking an Alzheimer's diagnosis, fearing the implications of decline, isolation, and death. ing an Alzheimer's diagnosis, fearing the implications of decline, isolation, and death. Convinced that there is nothing they can offer besides emotional support, family physicians often hesitate along with their older patients, and avoid seeking a clear explanation for memory problems and personality changes.

Our ability to diagnose Alzheimer's disease has improved significantly in the past five years. Although there is still no conclusive laboratory test, many clinicians now have enough firsthand experience to allow them to distinguish Alzheimer's from other apparently similar conditions with 85 to 90 percent accuracy.

"We have a heightened awareness of the nuances of the disease," explains professor of neurology Dennis Selkoe, who sees many Alzheimer's patients. "One of the things that marks these patients is the preservation of alertness. You can see that something is wrong with their thinking, but they're still bright-eyed and perky. That's very different from the way someone acts who has a blood clot, tumor, angioma, or Parkinson's disease, all of which may be confused with Alzheimer's."

But why bother getting the diagnosis? Memory provides the only purchase we have against time, and as recollections crumble under the attack of Alzheimer's, the possession of place, time, and identity also erode. That vertiginous prospect terrifies older people and their families, and the result is that many people coping with the early stages of Alzheimer's disease find it hard to admit the reality of their situation. Why acknowledge that you have an untreatable condition?

In fact, there are many good reasons to do so. First, the cause of memory loss may not be Alzheimer's disease. Other disorders, including depression, reactions to certain drugs, a series of small strokes (called multi-infarct dementia), hearing problems, vitamin deficiencies, and certain tumors and infections may look just like Alzheimer's disease to friends and relatives, yet submit much more readily to treatment. An accurate diagnosis and appropriate treatment may spell the difference between living in a fog or thinking clearly.

And even if Alzheimer's disease is at the root of a memory problem--there are about 360,000 new cases each year--two drugs, Cognex and Aricept, appear to slow the course of the disease, allowing patients at least a few more months of clearer thinking and better memory. Neither drug is a cure, but most experts believe that the best time to take them is early in the course of the disease, while there is still some thinking ability to preserve. (For more information about these drugs, see the Alzheimer's Association website: www.alz.org/medical/rtcognitive.htm.) And although evidence to date is hardly conclusive, some research indicates that nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen may prevent or slow the progress of Alzheimer's disease. Daily doses of vitamin E, selenium, or other antioxidants may have a similar effect, but you should consult your doctor before taking any of these regularly.

If the available drugs merely palliate symptoms, they may also provide a bridge for some patients to a new generation of therapies that researchers hope will attack the disease more directly. According to Selkoe, two of the more promising are beta gamma secretase and a so-called "amyloid vaccine." Each is designed to prevent the formation of beta-amyloid, an abnormal protein that forms sheet-like deposits in the brains of people with Alzheimer's. Although amyloid has not been shown conclusively to cause the mental deficits of Alzheimer's disease, these drugs represent the best hope we have at the moment for fighting this disorder.

The prospect of such new drugs makes the early diagnosis of Alzheimer's all the more vital, stresses instructor in neurology Dorene Rentz, who reports that by the time most people are diagnosed with Alzheimer's, the disease has probably done irreversible brain damage. A behavioral neurologist at Brigham and Women's Hospital, Rentz is currently involved in a large-scale study of community-dwelling older people aimed at finding ways to identify Alzheimer's sufferers earlier in the course of the disease than it is now commonly diagnosed. "If we can begin detecting it early," she says, "we can start to intervene in the disease process and maybe slow it down or halt it."

And there are other reasons to strive to diagnose the disease early. Even though remembering things may be a problem for early Alzheimer's patients, their thinking may still be clear enough to create or revise a will or to make arrangements for their healthcare when they are no longer capable of making decisions. Simple legal documents that either set out wishes for care or legally appoint a person to be responsible for healthcare can be downloaded from the Internet (see www.agingwithdignity.org for the "Five Wishes" document).

The vast majority of Americans with Alzheimer's disease are cared for at home. Renovations and accomodations can help patients avoid the wandering, pacing, rummaging, and other behaviors that often result from the disease, and if done early on can help patients avoid accident and injury. Antidepressant drugs like Prozac can give people with Alzheimer's disease considerable help, and some psychologists run therapy groups specifically for people coping with the early stages of Alzheimer's disease.

No one has a perfect memory, and many people suspect their memories are failing them as they get older. Don't assume that someone has Alzheimer's just because the dishes aren't put away. But if the dishes in the cupboard are still covered with spaghetti sauce, it may be time to think about testing. If you suspect that you or someone you know has Alzheimer's, look for these 10 warning signs, developed by the Alzheimer's Association:

1. Is memory loss affecting job skills?
2. Does it affect the ability to perform familiar tasks?
3. Are there problems with language, such as finding the right words for familiar objects?
4. Is there frequent disorientation as to where one is and what time of day it is?
5. Is judgment poor or decreased?
6. Are there consistent problems with abstract thinking?
7. Are familiar objects frequently misplaced?
8. Are there noticeable changes in mood or behavior?
9. Are there noticeable changes in personality?
10. Is there a loss of initiative?

Finding out whether you or someone you love has Alzheimer's disease may seem a frightening path to take. But taking that first step--getting an accurate diagnosis--may lead to a much less stressful future.

Contributing editor John F. Lauerman writes from Brookline, Massachusetts.

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