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New Tools for Taking Control of Alzheimer Disease

Up to 4 million Americans—1 in 10 people over age 65 and nearly half of everyone over age 85—develop 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 patients—and their caregivers—as 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 future—before cognitive decline undermines decision-making skills.

New risk factor identified

According to the guidelines, people with mild cognitive impairment (MCI)—one of the most common and recently confirmed precursors of AD—should 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 can—and frequently do—interfere 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.

Red flags

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:

Difficulty completing familiar tasks, such as preparing a meal but forgetting to serve it.

Disorientation, perhaps becoming lost on your own street without knowing how you got there or how to get back home.

Inappropriate choices, such as putting on a bathrobe to go outdoors.

Poor abstract thought, particularly difficulty recognizing numbers or performing basic arithmetic.

Misplacing items, usually by putting them in inappropriate places—such as an iron in the freezer—and not recalling how they got there.

Rapid, arbitrary mood or personality changes, such as going from affable to angry or fearful for no apparent reason.

Loss of initiative, characterized by persistent lack of interest or involvement in usual pursuits.

Effective treatment

If AD is diagnosed, the guidelines support cholinesterase inhibitors—galanthamine (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 NSAIDs—particularly 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
(800-879-1960)
Alzheimer's Association, Chicago, IL
(312-335-8700)


From The Johns Hopkins Medical Letter: Health After 50, August 2002.


 

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