New Tools for Taking Control of Alzheimer Disease
Up to 4 million Americans1 in 10 people over
age 65 and nearly half of everyone over age 85develop Alzheimer
disease (AD), the most common cause of dementia. As yet, there
is no cure. But there is hope. Recent advances are so significant
that the American Academy of Neurology (AAN) has recently incorporated
them into new guidelines that are sure to improve the lives of
many AD patientsand their caregiversas soon as they
are integrated into routine medical practice.
Great strides have been made in both diagnosis
and treatment. Once notoriously difficult to identify, early
AD can now be diagnosed with 90% accuracy through regular monitoring
that focuses on specific symptoms and their progression over
time. And recently developed medications can improve mild to
moderate symptoms, thus helping people maintain independence,
delay nursing home admission, and provide more opportunity to
plan for the futurebefore cognitive decline undermines
New risk factor identified
According to the guidelines, people with mild cognitive
impairment (MCI)one of the most common and recently confirmed
precursors of ADshould now be identified and closely monitored
for early AD symptoms. MCI is characterized by persistent, recurrent
short-term memory loss. People who are affected sometimes forget
important social and business matters and may experience confusion.
They also tend to do worse than others of comparable age and
education when performing short-term memory tasks, such as learning
a list of words. These tendencies canand frequently dointerfere
with daily life, though people with the condition are able to
continue caring for themselves. Between 10% and 20% of people
with MCI eventually develop AD, characterized by the progressive
deterioration of memory, reason, and other vital cognitive functions.
After AD occurs, about half of people live just over three years;
however, some survive for as long as two decades.
In contrast, normal age-related changes typically
involve taking longer to recall a name, find a word, or remember
where you put down the house keys. Many older people with perfectly
normal cognitive skills also occasionally forget why they have
walked into a room and must retrace their steps to remember their
intentions. Although these phenomena are sometimes frustrating
or inconvenient, they have no real impact on daily life. Less
than 2% of people who experience such lapses develop AD.
Other risk factors for AD include advanced age,
a family history of dementia, and, possibly, a history of head
injury. There is also a higher than normal incidence of AD in
people with Down syndrome. Scientists have yet to pinpoint the
underlying causes of AD. A number of genetic mutations have been
implicated that carry different degrees of risk, and environmental
factors may also play a role.
The AAN guidelines recommend regular monitoring
by a primary care doctor for signs of AD in anyone with MCI or
other AD risk factors. In addition, people at increased risk,
as well as their friends and family, should be alert for warning
signs that indicate the need for an evaluation. Worsening MCI
is one of the most frequent clues. Other "red flags" include:
completing familiar tasks, such as preparing a meal but forgetting
to serve it.
perhaps becoming lost on your own street without knowing
how you got there or how to get back home.
choices, such as putting on a bathrobe to go outdoors.
abstract thought, particularly difficulty recognizing numbers
or performing basic arithmetic.
items, usually by putting them in inappropriate placessuch
as an iron in the freezerand not recalling how they
arbitrary mood or personality changes, such as going from
affable to angry or fearful for no apparent reason.
of initiative, characterized by persistent lack of interest
or involvement in usual pursuits.
If AD is diagnosed, the guidelines support cholinesterase
inhibitorsgalanthamine (Reminyl), rivastigmine (Exelon),
and donepezil (Aricept)as the treatment of choice for patients
with mild to moderate AD. These medications are thought to act
by increasing the brain's supply of acetylcholine, a neurotransmitter
(chemical that transmits messages between nerve cells). At a
recent American Medical Association conference that introduced
the guidelines, experts noted that cholinesterase inhibitors
appear to stabilize or improve symptoms in up to 80% of patients
with mild to moderate symptoms.
Vitamin E, an antioxidant that is thought to reduce
the cell damage caused by molecules known as free radicals, is
another option. In one two-year study, it slowed the deterioration
of self-care skills, which delayed nursing home admission. However,
the benefit was marginal and the high dose required occasionally
causes excessive bleeding, which could delay wound healing or
lead to a stroke.
Currently, no medications have been shown to improve
memory or reasoning skills in patients with advanced AD, although
the effectiveness of cholinesterase inhibitors is being studied.
However, the behavioral problems and depression that sometimes
develop can often be managed with lifestyle measures, including
walking or other light exercise; listening to music while eating,
bathing, and performing other activities; and establishing and
following a predictable routine. If these methods fail, antipsychotic
medications and antidepressants may be helpful.
Promising preventive therapies
Now that people at increased risk for AD can be
identified, studies are targeting them to see if the onset of
disease can be delayed or even prevented. Reviews of medical
records indicate that AD may be less likely to develop in women
on hormone replacement therapy and people who frequently take
NSAIDsparticularly ibuprofen (Advil and Motrin). However,
all of this information is from retrospective studies that examine
medical records, statistics, or people's recollections, possibly
making it inaccurate. Clinical trials are currently under way
to examine whether early indications are correct and to weigh
potential side effects (such as kidney damage, which can occur
when NSAIDs are taken for too long or at excessive doses). Other
possibilities currently being investigated include an anti-AD
vaccine, antioxidants (especially vitamins A, E, and C), and
statins (the same medications currently used to lower cholesterol).
Results are anticipated beginning in 2005.
For more information
American Academy of Neurology,
St. Paul, MN
Alzheimer's Association, Chicago, IL
From The Johns Hopkins Medical Letter: Health
After 50, August 2002.