WHAT IS ALZHEIMER’S DISEASE?

Alzheimer's disease is a neurological disorder in which the death of

brain cells causes memory loss and cognitive decline. A
neurodegenerative type of dementia, the disease starts mild and gets
progressively worse.

CAUSES
Like all types of dementia, Alzheimer's is caused by brain cell death.3 It
is a neurodegenerative disease, which means there is progressive brain
cell death that happens over a course of time.
The total brain size shrinks with Alzheimer's - the tissue has
progressively fewer nerve cells and connections.3,4

Nerve cells (neurons) in the brain. In Alzheimer's, there are microscopic

'plaques' and 'tangles' between and within brain cells.
While they cannot be seen or tested in the living brain affected by
Alzheimer's disease, postmortem/autopsy will always show tiny
inclusions in the nerve tissue, called plaques and tangles:3,4
 Plaques are found between the dying cells in the brain - from the
build-up of a protein called beta-amyloid (you may hear the term
"amyloid plaques").
 The tangles are within the brain neurons - from a disintegration of
another protein, called tau.
For a detailed visualization of what goes on in the Alzheimer's disease
process, progressing from the normal brain to increasing dementia
changes, the Alzheimer's Association has produced a journey of 16
slides.

The abnormal protein clumps, inclusions, in the brain tissue are always
present with the disease, but there could be another underlying
process that is actually causing the Alzheimer's - scientists are not yet
sure.3
This sort of change in brain nerves is also witnessed in other
disorders,3 and researchers want to find out more than just that there
are protein abnormalities - they also want to know how these develop
so that a cure or prevention might be discovered.

Symptoms of Alzheimer's disease

The information in this section connects closely to some of that about

tests and diagnosis below because symptoms noticed by patients, or
people close to them, are exactly the same signs that healthcare
professionals look for during testing.
Symptoms can be diagnosed at any stage of Alzheimer's dementia and
the progression through the stages of the disease is monitored after an
initial diagnosis, too, when the developing symptoms dictate how care
is managed.

Of course, the very nature of the symptoms can be confusing for both a
patient and the people around them, with different levels of severity.
For this reason, and because symptoms could signal any of a number of
diagnoses, it is always worthwhile seeing a doctor.
 For doctors to make an initial diagnosis of Alzheimer's disease, they
must first be satisfied that there is dementia - guidelines spell out what
dementia consists of. It involves cognitive or behavioral symptoms that
show a decline from previous levels of "functioning and performing"
and interfere with ability "to function at work or at usual activities."11
The cognitive decline is in at least TWO of the five symptom areas listed
below (from guidelines jointly produced by the National Institute on
Aging and the Alzheimer's Association):11
1. Worsened ability to take in and remember new information, for
example:
 "Repetitive questions or conversations

 Misplacing personal belongings

 Forgetting events or appointments
 Getting lost on a familiar route."
2. Impairments to reasoning, complex tasking, exercising judgment:
 "Poor understanding of safety risks

 Inability to manage finances

 Poor decision-making ability
 Inability to plan complex or sequential activities."
3. Impaired visuospatial abilities (but not, for example, due to eye
sight problems):
 "Inability to recognize faces or common objects or to find objects in
direct view
 Inability to operate simple implements, or orient clothing to the
body."
4. Impaired speaking, reading and writing:
 "Difficulty thinking of common words while speaking, hesitations

 Speech, spelling, and writing errors."

 5. Changes in personality and behavior, for example:
 Out-of-character mood changes, including agitation; less interest,
motivation or initiative; apathy; social withdrawal
 Loss of empathy
 Compulsive, obsessive or socially unacceptable behavior.
Once the number and severity of these example symptoms confirm
dementia, the best certainty that they are because of Alzheimer's
disease is given by:
 A gradual onset "over months to years" rather than hours or
days (the case with some other problems)
 A marked worsening of the individual person's normal level of
cognition in particular areas.11
The most common presentation marking Alzheimer's dementia is
where symptoms of memory loss are the most prominent, especially in
the area of learning and recalling new information. But the initial
presentation can also be one of mainly language problems, in which
case the greatest symptom is struggling to find the right words.11
If visuospatial deficits are most prominent, meanwhile, these would
include inability to recognize objects and faces, to comprehend
separate parts of a scene at once (simultanagnosia), and a type of
difficulty with reading text (alexia). Finally, the most prominent deficits
in "executive dysfunction" would be to do with reasoning, judgment
and problem-solving.11

Stages of Alzheimer's disease

The progression of Alzheimer's can be broken down into three basic

stages:12
 Preclinical (no signs or symptoms yet)

 Mild cognitive impairment

 Dementia.
The Alzheimer's Association has broken this down further, describing
seven stages along a continuum of cognitive decline based on symptom
severity - from a state of no impairment, through mild and moderate
decline, and eventually reaching "very severe decline."
The association has published the seven stages online.13 It is not usually
until stage four that a diagnosis is clear - here it is called mild or early-
stage Alzheimer's disease, and "a careful medical interview should be
able to detect clear-cut symptoms in several areas."

How common is Alzheimer's disease?

In the US, the most recent census has enabled researchers to

give estimates of how many people have Alzheimer's disease. In 2010,
some 4.7 million people of 65 years of age and older were living with
Alzheimer's disease in the US.1
The 2013 statistical report from the Alzheimer's Association gives a
proportion of the population affected - just over a tenth of people in
the over-65 age group have the disease in the US. In the over-85s, the
proportion goes up to about a third.2
 As our dementia page outlines, there is a handful of different types, but
Alzheimer's disease is the problem behind most cases of memory loss
and cognitive decline:2
 The Alzheimer's Association says it accounts for between 60% and
80% of all cases of dementia.
Vascular dementia, which is caused by stroke not Alzheimer's, is the
second most common type of dementia.

Alzheimer's disease risk factors

Some things are more commonly associated with Alzheimer's disease -

not seen so often in people without the disorder. These factors may
therefore have some direct connection. Some are preventable or
modifiable factors (for example, reducing the risk of diabetes or heart
disease may in turn cut the risk of dementia).
If researchers gain more understanding of the risk factors, or
scientifically prove any "cause" relationships for Alzheimer's, this could
help to find ways to prevent it or develop treatments.
Risk factors associated with Alzheimer's disease include:5,6
Unavoidable risk factors
 Age - the disorder is more likely in older people, and a greater
proportion of over-85-year-olds have it than of over-65s.2
 Family history (inheritance of genes) - having Alzheimer's in the
family is associated with higher risk. This is the second biggest risk
factor after age.7
 Having a certain gene (the apolipoprotein E or APOE gene) puts a
person, depending on their specific genetics, at three to eight times
more risk than a person without the gene.6 Numerous other genes
have been found to be associated with Alzheimer's disease, even
recently (see developments below).7
 Potentially avoidable or modifiable factors
 Factors that increase blood vessel (vascular) risk - including diabetes,
high cholesterol and high blood pressure. (These also increase the
risk of stroke, which itself can lead to another type of dementia.)
 Low educational and occupational attainment.
 Prior head injury. (While a traumatic brain injury does not necessarily
lead to Alzheimer's, some research links have been drawn, with
increasing risk tied to the severity of trauma history.)8
 Sleep disorders (the breathing problem sleep apnea, for example).

Early-onset Alzheimer's disease

Genetics are behind early-onset familial Alzheimer's disease, which

presents typically between the ages of 30 and 60 years and affects
people who have a family history of it.
Due to one of three inherited genes, it is also known as young-onset,
and it is uncommon - accounting for under 5% of all Alzheimer's
cases.6,9
The Alzheimer's Association says in its early-onset information that it
can sometimes be "a long and frustrating process" to get this diagnosis
confirmed since doctors do not expect to find Alzheimer's in younger
people. For the younger age groups, doctors will look for other
dementia causes first.
Healthcare professionals, the nonprofit says, may also "incorrectly
attribute" symptoms to stress and so on, or may not agree on the
diagnosis.10

Recent developments in understanding causes and risk factors from MNT news

Exposure to environmental toxin may lead to Alzheimer's

Chamorro villagers living on the Pacific Island of Guam - a territory of
the US - have led scientists to an important discovery; an
environmental toxin present in some soils and lakes of the island may
increase the risk for Alzheimer's disease and other neurodegenerative
disorders.

Alzheimer's brain plaques discovered in people with brain injuries

A new study, published in Neurology, finds plaques in the brains of

middle-aged people who have experienced head injuries. These
amyloid plaques match those found in Alzheimer's, but their spatial
distribution differs.

Gum disease may worsen cognitive decline for Alzheimer's patients

Gum disease is an unpleasant condition, causing bad breath, bleeding

and painful gums, ulcers and even tooth loss. But people with
Alzheimer's disease might fare worse, after a new study suggests gum
disease may speed up cognitive decline.

Alzheimer's risk higher in people with rosacea

People with rosacea appear to have a slightly higher risk of developing

dementia, and Alzheimer's disease in particular, compared with people
without the common chronic inflammatory skin condition.

ests and diagnosis for Alzheimer's disease

Alzheimer's disease is not simple to diagnose - there is no single test for

it. For this reason, the first thing doctors do is to rule out other
problems before confirming whether mental signs and symptoms are
severe enough to be a kind of dementia or something else.11,14
Doctors may:3
 Take a history (ask about symptoms and daily activities)
 Do a physical examination to find any signs of, for example, a stroke,
heart condition or kidney disease, and
 Check neurological function, e.g. by testing balance, senses and
reflexes.
Depending on what the doctor thinks could need checking, other
diagnostics are:3
 Sending off for tests of blood and urine samples

 Arranging brain scans (possibly including CT, MRI and EEG).

Sometimes dementia symptoms are related to an inherited disorder
such as Huntington's disease, so genetic testing may be done. For
some, an assessment for things such as depression can also be carried
out.3
Again though, the above early tests are not for diagnosing Alzheimer's
disease itself, but for ruling out other problems before starting to
narrow down to dementia caused by AD. Central to this is checking
memory loss and mental performance (cognitive testing).
There must be memory loss and an impairment in one other area of
cognition for a diagnosis of dementia such as Alzheimer's to be made.
These criteria also need to be progressive (a worsening compared
with how the person has been before), and severe enough to affect
daily activities.11
Because of this common route to a diagnosis for all kinds of dementia,
there is more detailed information about this from the Medical News
Today dementia page; the following summary also gives links straight
to particular sections on that page.
Cognitive tests have changed little since being established by work
from the likes of Professor Henry Hodkinson in the 1970s. The following
example list of questions reveals the types of memory loss and areas of
cognition that are tested and may indicate Alzheimer's.15
The "abbreviated mental test score" (AMTS):
 What is your age?
 What is the time, to the nearest hour?
 Repeat an address at the end of the test that I will give you
now (e.g. "42 West Street")
 What is the year?
 What is the name of the hospital or town we are in?
 Can you recognize two people (e.g. the doctor, nurse, home
help, etc.)?
 What is your date of birth?
 In what year did World War 1 begin? (Other widely known
dates in the past can be used.)
 Name the president/prime minister/monarch.
 Count backwards from 20 down to 1.
The general practitioner assessment of cognition (GPCOG) test is a
website-based assessment designed to be an early reliable indicator for
use in initial consultations with GPs.16,17
The mini mental state examination (MMSE) is a fuller cognitive test to
help diagnose Alzheimer's disease. It is also sensitive to the severity of
the disorder and helps to indicate when drug treatment could ease
symptoms appearing later in the course of the disease:17,18
 Normal cognitive health - score above 26

 Mild-to-moderate Alzheimer's - below 26

 Moderate - below 20 but above 10
 Severe - score under 10.
It is always worthwhile for people with concerns about their own or
someone else's possible dementia to get the problem thoroughly
checked by a doctor, both because of the mental confusion created by
the symptoms and because they may be due to something else that
needs checking and treating.17,19

Is there a biological test for Alzheimer's disease?

There is no simple biological test specifically for Alzheimer's disease

that can be used by doctors, which is why all the diagnostic options
are designed to rule out other explanations for the dementia before
confirming Alzheimer's as the cause.11,14
A genetic test is possible in some settings to indicate the likelihood of
someone having or developing the disease but this is controversial and
not entirely reliable.11,14 A gene known as the APOE-e4 is associated
with higher chances of people over the age of 55 years developing
Alzheimer's.20
The question of future biological tests is being intensely investigated by
medical research. A lot of clues as to the biological changes in the brain
have been uncovered by neuropathology work on brains examined at
autopsy after death.12 This and other types of research may result in
future tests to measure new biomarkers.
Genetic testing may become a more realistic option, too - so long as
researchers continue to find reliable links as they discover new gene
associations.
Genetic testing is not always a welcome idea though. The Alzheimer's
Association's position on APOE-e4 testing for example, is that it should
not be used routinely and that there should not be prejudiced
treatment in terms of insurance and so on when it is used as an
indication.20
In research studies, any genetic results used as indicators of disease
would not be identifiable by individual - they would be anonymized.

Recent developments in tests and diagnosis from MNT news

Peanut butter may help diagnose Alzheimer's disease

A small study published in August 2013 in the Journal of the

Neurological Sciences found interesting differences in ability to smell
peanut butter between people with Alzheimer's disease versus those
with different kinds of dementia.

Could a simple saliva test detect Alzheimer's?

A person's risk of Alzheimer's disease could be predicted through a

simple saliva test, according to the results of a new study.

New way of looking at age could help prevent Alzheimer's

A team of researchers at King's College London in the UK has

announced the development of a "gene signature" that could help
predict conditions such as Alzheimer's disease years before symptoms
arise.

Changes in humor may be early indicator for dementia

According to new research, a noticeable change in what makes us laugh

may not be a good sign for cognitive health: it may be an early indicator
for dementia.

Alzheimer's-related brain changes occur 2 decades before symptom

onset

Inflammatory brain changes related to Alzheimer's disease may occur

as many as 20 years before onset of symptoms, according to new
research - a finding that could pave the way for early interventions that
could halt disease development.
Treatment and prevention of Alzheimer's disease

America's national plan sets out to improve the quality of care and
support for people with Alzheimer's disease and their families.
There is no known cure for Alzheimer's disease - the death of brain cells
in the dementia cannot be halted or reversed.
There is, however, much backing for therapeutic interventions to help
people live with Alzheimer's disease more ably.2,21
The Alzheimer's Association includes the following as important
elements of dementia care:22
 Effective management of any conditions occurring alongside the
Alzheimer's
 Activities and/or programs of adult day care
 Support groups and services.
America has created a national plan to address Alzheimer's disease,
making it a medical priority for the country.
In January 2011, President Obama signed the National Alzheimer's
Project Act into law, stating:
"Alzheimer's disease burdens an increasing number of our nation's
elders and their families, and it is essential that we confront the
challenge it poses to our public health."
Along with an aim to improve research into prevention and treatment,
the goals of the plan also include measures for present interventions:23
"Enhance care quality and efficiency
Expand supports for people with Alzheimer's disease and their
families, and
Enhance public awareness and engagement."

Drug therapy

There are no disease-modifying drugs available for Alzheimer's disease

but some options may reduce its symptoms and help improve quality of
life. There are four drugs in a class called cholinesterase inhibitor
approved for symptomatic relief in the US:24
 Donepezil (brand name Aricept)

 Alantamine (Reminyl)
 Rivastigmine (Exelon)
 Tacrine (Cognex).
A different kind of drug, memantine (Namenda), an NMDA receptor
antagonist, may also be used, alone or in combination with a
cholinesterase inhibitor.24

Other therapy

As with other types of dementia and neurodegenerative disease, a

major part of therapy for patients with Alzheimer's comes from the
support given by healthcare workers to provide dementia quality-of-
life care, which becomes more important as needs increase with
declining independence.

Recent developments in treatment and prevention from MNT news

Alzheimer's treatment clue found in brain inflammation

Until recently, scientists thought Alzheimer's disease disturbed the

immune system - but a new study of mice adds to mounting evidence
that it could be inflammation in the brain that drives Alzheimer's. It
suggests blocking a protein that regulates immune cells could be a way
to stop the brain-wasting disease.

Keep moving to halve the risk of Alzheimer's

A new study, published in the Journal of Alzheimer's Disease, finds that

any kind of exercise can improve brain volume and cut the risk of
Alzheimer's disease by 50%.

Blueberries could be used to fight Alzheimer's, researchers suggest

Blueberries are a popular fruit, easily added to cereals, salads and

desserts or eaten as a sweet treat in their own right. They are also
known by some as a "superfood," containing a wide variety of nutrients
that offer protection against conditions such as cancer and heart
disease. Now, researchers believe that they may have a part to play in
the fight against Alzheimer's disease.

'Lost' memories retrieved in mice with early Alzheimer's

It may one day be possible to restore memories for people with early
Alzheimer's, according to a new study published in Nature, in which
researchers reveal how they did just that in mice with early symptoms
of the disease.

Implantable capsule shows promise for Alzheimer's prevention

There is currently no way to prevent or slow Alzheimer's disease, but a
new study details the creation of an implantable capsule that
researchers say could stop the condition in its tracks.

Prevention

There is a lot of research into risk factors associated with Alzheimer's

disease, so there may be lifestyle measures we can take to potentially
reduce our risk and enjoy a healthier life more generally. Medical News
Today has a page compiling ideas from researchers on how to prevent
Alzheimer's disease and dementia - including information about heart
health, diet, exercise and keeping an active brain.