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Alzheimer's disease is an illness that kills neurons in the brain, robbing people of important functions, including memory and the ability to perform activities of daily living, such as eating, drinking, and grooming. It may also cause apathy and depression and behavioral problems such as wandering.

Some 4 million people in the United States are affected by Alzheimer's disease—one in every ten people over 65 and close to half of all people over 85. More women than men are affected. Some people with a family history of Alzheimer's disease may be at greater risk of experiencing the disease.

A diagnosis of Alzheimer's disease has a huge impact on family and friends. Everyone who cares for a person with Alzheimer's feels the effects of the disease, emotionally, physically, and even financially. Society in general is strongly affected. The U.S. cost of dealing with Alzheimer's disease approaches 100 billion dollars every year. It's the third most costly disease, just behind heart disease and cancer.

Some change in memory is normal as we grow older, but the symptoms of Alzheimer's disease are more than simple lapses in memory. People with Alzheimer's experience difficulties communicating, learning, thinking, and reasoning—problems severe enough to have an impact on an individual's work, social activities, and family life.

The Alzheimer's Association has developed a checklist of common symptoms.

1. Memory loss. One of the most common early signs of dementia is forgetting recently learned information. While it's normal to forget appointments, names, or telephone numbers, those with dementia will forget such things more often and not remember them later.
2. Difficulty performing familiar tasks. People with dementia often find it hard to complete everyday tasks that are so familiar we usually do not think about how to do them. A person with Alzheimer's may not know the steps for preparing a meal, using a household appliance, or participating in a lifelong hobby.
3. Problems with language. Everyone has trouble finding the right word sometimes, but a person with Alzheimer's disease often forgets simple words or substitutes unusual words, making his or her speech or writing hard to understand. If a person with Alzheimer's is unable to find his or her toothbrush, for example, the individual may ask for "that thing for my mouth."
4. Disorientation to time and place. It's normal to forget the day of the week or where you're going. But people with Alzheimer's disease can become lost on their own street, forget where they are and how they got there, and not know how to get back home.
5. Poor or decreased judgment. No one has perfect judgment all of the time. Those with Alzheimer's may dress without regard to the weather, wearing several shirts or blouses on a warm day or very little clothing in cold weather. Individuals with dementia often show poor judgment about money, giving away large amounts of money to telemarketers or paying for home repairs or products they don't need.
6. Problems with abstract thinking. Balancing a checkbook may be hard when the task is more complicated than usual. Someone with Alzheimer's disease could forget completely what the numbers are and what needs to be done with them.
7. Misplacing things. Anyone can temporarily misplace a wallet or key. A person with Alzheimer's disease may put things in unusual places: an iron in the freezer or a wristwatch in the sugar bowl.
8. Changes in mood or behavior. Everyone can become sad or moody from time to time. Someone with Alzheimer's disease can show rapid mood swings—from calm to tears to anger—for no apparent reason.
9. Changes in personality. People's personalities ordinarily change somewhat with age. But a person with Alzheimer's disease can change a lot, becoming extremely confused, suspicious, fearful, or dependent on a family member.
10. Loss of initiative. It's normal to tire of housework, business activities, or social obligations at times. The person with Alzheimer's disease may become very passive, sitting in front of the television for hours, sleeping more than usual, or not wanting to do usual activities.

Early diagnosis of Alzheimer's disease or other disorders causing dementia is an important step in getting appropriate treatment, care, and support services.

Healthcare professionals use several tests to assess a person's symptoms and determine if AD may be the cause. The process begins with a thorough physical exam and questions about medical history and current medications. Doctors ask about the person's ability to perform daily activities such as: eating, bathing, walking, dressing, shopping, cooking and using the phone.

Physical symptoms can include impaired movement or coordination, muscle rigidity, shuffling or dragging feet while walking , insomnia or disturbances in sleep patterns and weight loss.

Doctors test cognitive abilities such as memory, attention, language, judgment, and problem solving. Lab tests and brain scans, such as CT scans and MRIs, are also used to support a correct diagnosis and rule out other possible factors. This approach of using several tests is about 80 to 90 percent accurate in correctly diagnosing AD in an office setting.

Alzheimer's might be suspected when in fact a person is experiencing bouts of confusion resulting from the temporary deprivation of brain cells of energy, oxygen, vitamins or hormones. Some common causes of confusion are:

• Heart failure, "silent" myocardial infarction
• Respiratory problems such as Chronic Obstructive Pulmonary Disease
• Infections
• Stroke, head injury
• Drugs that act on the central nervous system (e.g. tranquilizers)
• Nutritional problems, fluid and electrolyte imbalance
• Hyperthermia (overheating) and hypothermia (chilling)
• Diabetes (through hypoglycemia)
• Alcohol abuse, drug overdose, adverse effects of medicines
• Self-neglect

Confusion, which is a reduced level of arousal, is often mistaken for dementia. This can have serious consequences because the correct treatment can only be given once the underlying problem, e.g. oxygen starvation (anoxia), has been accurately diagnosed.

In Alzheimer's disease, neurons in the cortex (where thinking takes place), the hippocampus (which is involved in learning and memory), and other areas of the brain mysteriously die. Some of these areas are invaded by intracellular growths resembling snarls of wire—they're called tangles—while others become surrounded by "plaques" that look like gobs of dried glue. What causes this process remains largely a mystery, but by investigating how tangles and plaques are produced and studying genes that might be involved, researchers are working to prevent or slow the disease.

The symptoms of Alzheimer's disease are measured by a system called the Alzheimer Disease Assessment Scale-Cognitive Subscale (ADAS-Cog), which was introduced about 15 years ago. It covers the following items: spoken language, comprehension of spoken language, recall of instructions, difficulty in word-finding, following commands, naming objects, drawing, complex movements awareness of time and place, word recall, and word recognition. Scoring allows one to follow progress in the disease—good or bad. The average patient will deteriorate by between 6-10 points a year on this scale. An improvement of 3 to 4 points equals a recognizable clinical improvement in the patient.

Currently Available Medication
Thirty years ago scientists found that the activity of a chemical in certain parts of the brain, called acetylcholine, was decreased in people with Alzheimer's disease. It made sense to see if replacing this substance would improve the symptoms of the disease. Giving acetylcholine as a medicine was not helpful, as it didn't get into the brain. However, two enzymes—substances that break down complex chemicals—are known to inactivate acetylcholine, and recently medicines that inhibit these enzymes have been introduced. Inhibiting the action of these enzymes allows acetylcholine to increase in the brain. Orally active forms of these medicines, called cholinesterase inhibitors, have been developed and tested clinically. Researchers are continuing to study the effectiveness and safety of the four cholinesterase inhibitors available to AD patients in the United States today. These are: tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl).

Effectiveness
All four of the cholinesterase inhibitors were shown to have beneficial effects on the ADAS-Cog scale. At their highest doses given for an adequate time period the following improvements in score (compared with placebo) were seen: tacrine—more than 3 points, donepezil—nearly 3 points, rivastigmine—4 points, and galantamine—more than 3.3 points. The size of these benefits meant a clearly decreased likelihood of the subject being put in a nursing home within the following two years.

With all 4 drugs, initial dosing is typically low, with gradual increases because of unpleasant gastrointestinal side effects. While each person responds differently to this class of medicines, memory and thinking processes are most likely to be improved, and 'activities of daily living' can be maintained for a longer period. However, there will probably be only a temporary delay in the onset of behavioral problems. Nevertheless, the benefits of delaying the inevitable decline are considerable, both for the patient and the family members. Starting medication early is obviously therefore better.

Other medications
Some studies have suggested that a number of medications may prevent the development of Alzheimer's disease: nicotine (cigarette smoking), estrogens, non-steroid anti-inflammatory drugs (NSAIDs), and anti-oxidants (e.g. vitamin E), and some substances made from plants, such as gingko biloba. So far, there are no convincing results from comprehensive studies that show that any of these approaches improve the symptoms or course of established Alzheimer's. However, some pilot studies support the use of high-dose estrogen (as a patch) and a 'statin' drug with anti-inflammatory properties. Intensive research into the way the disease is caused is likely to provide drugs with more impressive results in the future. In the meantime, the cholinesterase inhibitors give the best chance of at least delaying progress of this distressing disease.

Though the symptoms of AD can be treated, there is no cure for the disease. Many symptoms associated with AD, such as forgetfulness, disorientation, language difficulties, depression, agitation, anxiety, aggression, and insomnia, can moderate—temporarily with medications and other forms of therapy can help treat the symptoms of mild to moderate AD, such as memory loss or trouble with daily functioning. Individual responses to treatment vary and individual ability to tolerate the medication also varies widely. Scientists are continuing to study other possible treatments and prevention strategies for AD.

When someone sees a doctor about complaints of memory loss, the first thing the doctor will do is take a complete history, including a family medical history. This information will help the doctor determine whether anyone else in the family has had Alzheimer's disease (AD) or if the disease is due to other neuropsychological diseases, such as depression or schizophrenia.

If AD is a concern, the doctor will assess memory and function through a series of cognitive and memory tests, perform a physical examination, and take laboratory tests. During the exam, the doctor may ask some questions about behavioral symptoms. The doctor will also need information about lifestyle, nutrition, and environment, so you should be as open and detailed as you can. Honesty is very important because it will help the doctor make the right diagnosis.

After the initial examination, some doctors may choose to use an imaging study, such as magnetic resonance imaging (MRI), positron emission tomography (PET scan), or X-ray computerized tomography (CT scan). These tests give doctors a detailed image of the brain and are used if there is a chance that another disorder, such as a stroke, may be causing the signs and symptoms you've described. There is no single test that can tell a doctor for certain that a patient has AD. With the tests mentioned above, however, physicians can arrive at the correct diagnosis most of the time.

Discussing the Diagnosis
If the physician diagnoses AD, he or she may initially choose to talk to a caregiver or family member in private before giving the diagnosis to the patient. Though this approach is less than empowering for the patient, and sometimes controversial, it is done to ensure that the diagnosis is given in the most sensitive manner. This two-stage approach is very effective when discussing diagnosis and treatment.

Patients with Alzheimer's disease (AD) generally go through three stages. People experience the three stages at different rates, and there is overlap in symptoms from one stage to another.

Stage 1: Mild AD
The mild stage of AD can last from two to four years or longer. Those in this phase of the disease may:

• Say the same thing over and over
• Lose interest in things they once enjoyed
• Have trouble finding names for common items
• Lose things more often than normal
• Undergo personality changes

Mild AD patients are usually alert, sociable, and enjoy life, but their forgetfulness interferes with daily living and may frustrate them. They may be overly emotional and temperamental, or apathetic.

Stage 2: Moderate AD
The moderate stage of AD is often the longest, lasting from two to ten years. In this stage, a person may:

• Get lost easily, even in places they know well
• Become more confused about recent events
• Experience difficulty with simple daily activities such as dressing
• Argue more than usual
• Believe things are real when they are not
• Pace about
• Often require close supervision
• Display anxiety or depression

Moderate AD patients often require close supervision. Thinking, logic, and behavior may deteriorate and you may find that adult day services or home care become necessary.

Stage 3: Severe AD
The severe stage can last from one to three years or longer. Patients with severe AD cannot do things on their own anymore. They may not be able to:

• Use or understand words
• Recognize who they are when they look in the mirror
• Recognize family members
• Care for themselves

Most people suffering with severe AD are extremely confused and have lost most of their long-term memory. Caregivers should be aware that loved ones with AD might hallucinate, suffer from delusions, and be paranoid. Constant care, 24 hours a day, 7 days a week, is necessary.

On average, a person with AD lives for about eight to ten years after symptoms begin, although some people may live for as long as 20 years. During this time, the disease will progress. It is important that the person with AD and his or her family prepare for all stages of the disease.

Repeating yourself in conversation, losing things, or becoming more forgetful is just a natural part of getting older. At times, though, increasing memory loss may be an early sign of Alzheimer's disease (AD). Old age does not cause memory loss, and when memory loss starts to interfere with everyday life, it could be time to get help. As with many conditions, treatment for AD is most effective when the disease is diagnosed early. AD is a progressive disease that causes the brain to lose nerve cells. This leads to problems with memory, thinking, feeling, and everyday living.

If you or someone you care about is experiencing some or all of these symptoms, talk to your doctor. Early diagnosis and treatment can slow the symptomatic progression of the disease.

Brain without Alzheimer's disease:
Red, orange, and yellow areas show brain activity.

According to researchers, AD causes significant, progressive changes in the brain. A normal brain sends messages or commands through a network of neurons, or nerve cells. These nerve cells communicate through biochemical signals. Billions of these signals go through the brain every moment.

Brain with late-stage Alzheimer's disease:
The absence of red, orange, and yellow shows loss of brain function.

AD impacts neurons and the connections between them by:

• Breaking down the chemical connections between neurons
• Causing neurons to function improperly
• Destroying neurons

AD also attacks a part of the brain called the hippocampus. First, AD damages the hippocampus and hinders short-term memory. Eventually the disease makes all kinds of memory function more difficult. Remembering how to do simple, everyday tasks or the names of family members becomes a challenge, or even impossible. Another area of the brain damaged by AD is its outer layer, the cerebral cortex, which controls our ability to use language and to think logically.

Scientists are exploring theories about the cause of AD. In one theory, damage starts inside the nerve cell and results in tangles. In the second theory, damage occurs outside of the nerve cell and forms plaques. No one currently knows whether plaques and tangles are causes or effects of AD.

Recent studies seem to show that people diagnosed as having Alzheimer's disease were generally older, had less formal education, weighed more, and, most importantly, had high systolic blood pressure and serum total cholesterol levels when they were examined in midlife.

Both high systolic blood pressure and high serum cholesterol in midlife were significant risk factors for Alzheimer's disease in later life. A systolic blood pressure over 160 mm Hg, or a total cholesterol of over 250 mg/dL (6.5 mmol/l) meant the subject was 2-3 times as likely to develop Alzheimer's disease in later life, varying slightly according to the method used.

High midlife diastolic blood pressure did not prove to be a risk factor in this analysis, although some other studies have indicated that it might be.

Subjects in midlife who had both a high systolic blood pressure and a high serum cholesterol level had an even greater risk of developing Alzheimer's disease—between 2.5 and 3.5 times that of those with normal values for both measurements. Even borderline high systolic blood pressure (140-159 mm Hg) proved to have a higher risk.

Those who had had circulatory problems during the interval between the two examinations, such as heart attacks or strokes, also had a greater risk of developing Alzheimer's disease. However, patients who consumed alcohol were found to be less likely to get Alzheimer's.

Often the subjects in the study had been treated for high blood pressure and high cholesterol levels. The way the study was carried out doesn't exclude the possibility that treatments for these conditions may have influenced the outcome. Nevertheless, the results were consistent with other studies of elderly Finnish men.

An obvious study question is whether the two main risk factors identified (high blood pressure and increased cholesterol levels) in fact produce degenerative changes in the blood vessels supplying the brain (arteriosclerosis), which then cause so-called 'vascular dementia'. The authors point out, however, that analyzing the results after taking into account cardiovascular events (such as a heart attack or stroke) provided the same results. They also felt that genetic factors did not play a role, as cholesterol changes are known to be independent of the "Alzheimer" gene (apolipoprotein E) type.

Finnish scientists are convinced that high blood pressure and high cholesterol levels in midlife are independent risk factors for Alzheimer's disease. Support for this comes from a clinical study of the effects of treating elderly people with 'isolated systolic hypertension', which resulted in a decrease in the occurrence dementia. Ironically, the authors found that the midlife patients who did not participate and take the later re-examination had, on average, higher blood pressure and higher cholesterol levels than those who were in the study group. They also point out that patients with mental difficulties are less likely to participate in clinical studies. Both these facts reinforce their findings.

Studies do show the importance of identifying and treating high blood pressure and high serum cholesterol levels at an early age, or as soon as possible. In this way the risk of getting Alzheimer's disease may be lowered, which is particularly important as the population becomes proportionally older. Exercise, diet, stress reduction and appropriate medication are useful tools for lowering blood pressure and cholesterol levels.

Useful Web-based information can be found at the following sites:

AARP LifeAnswers
Consultation Service
(877) 217-7800
www.aarplifeanswers.com

Alzheimer's Association
919 North Michigan Avenue, Suite 1000
Chicago, IL 60611
(800) 272-3900
www.alz.org

Alzheimer's Disease Education and Referral Center
National Institute on Aging
P.O. Box 8250
Silver Spring, MD 20907-8250
(800) 438-4380
www.alzheimers.org

American Health Assistance Foundation
22512 Gateway Center Drive
Clarksburg, Maryland 20871
(800) 437-2423, (301) 948-3244, Fax: (301) 258-9454
www.ahaf.org/alzdis/about/adabout.htm

Info about Alzheimer's and Driving:
www.thehartford.com/alzheimers/