Alzheimer's disease

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Editor(s)-in-Chief: C. Michael Gibson, M.S.,M.D. [1] Phone:617-632-7753; Peter Pressman, M.D. [2], Northwestern Memorial Hospital, Department of Neurology

Dr. Pressman has nothing to disclose.

Synonyms and keywords: AD; Alzheimer disease; senile dementia of the Alzheimer type; SDAT; Alzheimer's

Overview

Historical Perspective

Classification

Pathophysiology

Epidemiology and Demographics

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms | Physical Examination | Lab Studies | Electrocardiogram | Chest X Ray | MRI | CT | Echocardiography | Other imaging findings

Treatment

Medical: Medical Therapy | Prevention | Future or Investigational Therapies
Surgical: Surgery

Background

Alzheimer's disease (AD), also called Alzheimer disease, Senile Dementia of the Alzheimer Type (SDAT) or simply Alzheimer's, is the most common form of dementia.

Although each sufferer experiences Alzheimer's in a unique way, there are many common symptoms.[1] The earliest observable symptoms are often mistakenly thought to be 'age-related' changes, or manifestations of stress.[2] The most commonly recognized symptom of early Alzheimer's disease is memory loss, usually the forgetting of recently learned facts. As the disease advances, symptoms include confusion, irritability and aggression, mood swings, language breakdown, long-term memory loss, and the general withdrawal of the sufferer as their senses decline.[2][3] Gradually, bodily functions are lost, ultimately leading to death.[4] When a doctor or physician has been notified, and AD is suspected, the diagnosis is usually further supported by behavioral assessments and cognitive tests, often followed by a brain scan if available.[5] Individual prognosis is difficult to assess, as the duration of the disease varies. AD develops for an indeterminate period of time before becoming fully apparent, and it can progress undiagnosed for years. The mean life expectancy following diagnosis is approximately seven years.[6] Fewer than three percent of individuals live more than fourteen years after diagnosis.[7]

The cause of Alzheimer's disease is poorly understood. Research indicates that the disease is associated with plaques and tangles in the brain.[8] Currently-used treatments offer a small symptomatic benefit. No treatments to halt the progression of the disease are yet available. As of 2010, more than 700 clinical trials were investigating possible treatments for AD, but it is unknown if any of them will prove successful.[9] Many measures have been suggested for the prevention of Alzheimer's disease, but the value of these measures is unproven in slowing the course and reducing the severity of the disease. Mental stimulation, exercise, and a balanced diet are often recommended as both a possible prevention and a sensible way of managing the disease.[10]

Because AD cannot be cured, management of patients is essential as the disease progresses. The role of the main caregiver is often taken by a spouse or a close relative.[11] Alzheimer's disease is known for placing a great burden on caregivers; the pressures can be wide-ranging, affecting social, psychological, physical, and economic components of the caregiver's life.[12][13][14] In developed countries, AD is one of the most economically costly diseases to society.[15][16]

Management

There is no known cure for Alzheimer's disease. Available treatments offer relatively small symptomatic benefit but remain palliative in nature. Current treatments can be divided into pharmaceutical, psychosocial and caregiving.

Psychosocial intervention

A specifically designed room for sensory integration therapy, or snoezelen; an emotion-oriented psychosocial intervention for people with dementia

Psychosocial interventions are used as an adjunct to pharmaceutical treatment and can be classified within behavior, emotion, cognition or stimulation oriented approaches. Research on efficacy is unavailable and rarely specific to Alzheimer's disease, focusing instead on dementia as a whole.[17]

Behavioral interventions attempt to identify and reduce the antecedents and consequences of problem behaviors. This approach has not shown success in the overall functioning of patients,[18] but can help to reduce some specific problem behaviors, such as incontinence.[19] There is still a lack of high quality data on the effectiveness of these techniques in other behavior problems such as wandering.[20][21]

Emotion-oriented interventions include reminiscence therapy, validation therapy, supportive psychotherapy, sensory integration or snoezelen, and simulated presence therapy. Supportive psychotherapy has received little or no formal scientific study, but some clinicians find it useful in helping mildly impaired patients adjust to their illness.[17] Reminiscence therapy (RT) involves the discussion of past experiences individually or in group, often with the aid of photographs, household items, music and sound recordings, or other familiar items from the past. Although there are few quality studies on the effectiveness of RT it may be beneficial for cognition and mood.[22] Simulated presence therapy (SPT) is based on attachment theories and is normally carried out playing a recording with voices of the closest relatives of the patient. There is preliminary evidence indicating that SPT may reduce anxiety and challenging behaviors.[23][24] Finally, validation therapy is based on acceptance of the reality and personal truth of another's experience, while sensory integration is based on exercises aimed to stimulate senses. There is little evidence to support the usefulness of these therapies.[25][26]

The aim of cognition-oriented treatments, which include reality orientation and cognitive retraining is the restoration of cognitive deficits. Reality orientation consists of the presentation of information about time, place or person in order to ease the the patient's understanding of their surroundings. On the other hand, cognitive retraining tries to improve impaired capacities by exercising mental abilities. Both have shown some efficacy improving cognitive capacities,[27][28] although in some works these effects were transient. Negative effects, such as frustration, have also been reported.[17]

Stimulation-oriented treatments include art, music and pet therapies, exercise, and any other kind of recreational activities for patients. Stimulation has modest support for improving behavior, mood, and, to a lesser extent, function. Nevertheless, as important as these effects are, the main support for the use of stimulation therapies is the improvement in the patient's daily life, as opposed to improving the underlying disease course.[17]

Caregiving

Further information: [[:Caregiving and dementia]]

Since there is no cure for Alzheimer's, caregiving is an essential part of the treatment. Due to the eventual inability for the sufferer to self-care, Alzheimer's has to be carefully care-managed. Home care in the familiar surroundings of home may delay onset of some symptoms and delay or eliminate the need for more professional and costly levels of care.[29] Many family members choose to look after their relative,[30] but two-thirds of nursing home residents have dementias.[31]

Modifications to the living environment and lifestyle of the Alzheimer's patient can improve functional performance and ease caretaker burden. Assessment by an occupational therapist is often indicated. Adherence to simplified routines and labeling of household items to cue the patient can aid with activities of daily living, while placing safety locks on cabinets, doors, and gates and securing hazardous chemicals can prevent accidents and wandering. Changes in routine or environment can trigger or exacerbate agitation, whereas well-lit rooms, adequate rest, and avoidance of excess stimulation all help prevent such episodes.[32][33] Appropriate social and visual stimulation can improve function by increasing awareness and orientation. For instance, boldly colored tableware aids those with severe AD, helping people overcome a diminished sensitivity to visual contrast to increase food and beverage intake.[34]

Society and culture

Social costs

Because the median age of the industrialised world's population is gradually increasing, Alzheimer's is a major public health challenge. Much of the concern about the solvency of governmental social safety nets is founded on estimates of the costs of caring for baby boomers, assuming that they develop Alzheimer's in the same proportions as earlier generations. For this reason, money spent informing the public of available effective prevention methods may yield disproportionate benefits.[35]

Caregiving burden

Further information: [[:Caregiving and dementia]]

The role of family caregivers has become more prominent in both reducing the social cost of care and improving the quality of life of the patient. Home-based care also can have economic, emotional, and psychological costs to the patient's family. Although family members in particular often express the desire to care for the sufferer to the end,[36] Alzheimer's disease is known for effecting a high burden on caregivers.[30]

Alzheimer's disease can incur a variety of stresses on the caregivers: typical complaints are stress, depression, and an inability to cope. Reasons for these complaints can include: high-demands on the caregiver's concentration, as Alzheimer's sufferers have a decreasing regard for their own safety (and can wander when unattended, for example); the lack of gratitude received when the sufferer is unaware of the help being given; and the lack of satisfaction when the sufferer's condition does not abate. Alzheimer's sufferers can be verbally and physically aggressive, and can stubbornly refuse to be helped. Aggression in particular can lead to a temptation to retaliate, which can put both the sufferer and carer at risk. It is additionally stressful for caregivers who are friends and family to witness a sufferer lose his or her identity, and eventually be unable to recognise them.[30]

Family caregivers often give up time from work and forego pay to spend 47 hours per week on average with the person with AD. From a 2006 survey of US patients with long term care insurance, direct and indirect costs of caring for an Alzheimer's patient average $77,500 per year.[37]


References

  1. ↑ "What is Alzheimer's disease?". Alzheimers.org.uk. 2007. Retrieved 2008-02-21. Unknown parameter |month= ignored (help)
  2. ↑ 2.0 2.1 Waldemar G, Dubois B, Emre M; et al. (2007). "Recommendations for the diagnosis and management of Alzheimer's disease and other disorders associated with dementia: EFNS guideline". Eur. J. Neurol. 14 (1): e1–26. doi:10.1111/j.1468-1331.2006.01605.x. PMID 17222085. Unknown parameter |month= ignored (help)
  3. ↑ Tabert MH, Liu X, Doty RL, Serby M, Zamora D, Pelton GH, Marder K, Albers MW, Stern Y, Devanand DP (2005). "A 10-item smell identification scale related to risk for Alzheimer's disease". Ann. Neurol. 58 (1): 155–160. doi:10.1002/ana.20533. PMID 15984022.
  4. ↑ "Understanding stages and symptoms of Alzheimer's disease". National Institute on Aging. 2007-10-26. Retrieved 2008-02-21.
  5. ↑ "Alzheimer's diagnosis of AD". Alzheimer's Research Trust. Retrieved 2008-02-29.
  6. ↑ Mölsä PK, Marttila RJ, Rinne UK (1986). "Survival and cause of death in Alzheimer's disease and multi-infarct dementia". Acta Neurol. Scand. 74 (2): 103–7. PMID 3776457. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  7. ↑ Mölsä PK, Marttila RJ, Rinne UK (1995). "Long-term survival and predictors of mortality in Alzheimer's disease and multi-infarct dementia". Acta Neurol. Scand. 91 (3): 159–64. PMID 7793228. Unknown parameter |month= ignored (help)
  8. ↑
  9. ↑ "Alzheimer's Disease Clinical Trials". US National Institutes of Health. Retrieved 2008-08-18.
  10. ↑ "Can Alzheimer's disease be prevented" (pdf). National Institute on Aging. 2006-08-29. Retrieved 2008-02-29.
  11. ↑ "The MetLife study of Alzheimer's disease: The caregiving experience" (PDF). MetLife Mature Market Institute. 2006. Retrieved 2008-02-12. Unknown parameter |month= ignored (help)
  12. ↑ Thompson CA, Spilsbury K, Hall J, Birks Y, Barnes C, Adamson J (2007). "Systematic review of information and support interventions for caregivers of people with dementia". BMC Geriatr. 7: 18. doi:10.1186/1471-2318-7-18. PMC 1951962. PMID 17662119.
  13. ↑ Schneider J, Murray J, Banerjee S, Mann A (1999). "EUROCARE: a cross-national study of co-resident spouse carers for people with Alzheimer's disease: I—Factors associated with carer burden". International Journal of Geriatric Psychiatry. 14 (8): 651–661. doi:10.1002/(SICI)1099-1166(199908)14:8<651::AID-GPS992>3.0.CO;2-B. PMID 10489656. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  14. ↑ Murray J, Schneider J, Banerjee S, Mann A (1999). "EUROCARE: a cross-national study of co-resident spouse carers for people with Alzheimer's disease: II--A qualitative analysis of the experience of caregiving". International Journal of Geriatric Psychiatry. 14 (8): 662–667. doi:10.1002/(SICI)1099-1166(199908)14:8<662::AID-GPS993>3.0.CO;2-4. PMID 10489657. Unknown parameter |month= ignored (help)
  15. ↑ Bonin-Guillaume S, Zekry D, Giacobini E, Gold G, Michel JP (2005). "Impact économique de la démence (English: The economical impact of dementia)". Presse Med (in French). 34 (1): 35–41. ISSN 0755-4982. PMID 15685097. Unknown parameter |month= ignored (help)
  16. ↑ Meek PD, McKeithan K, Schumock GT (1998). "Economic considerations in Alzheimer's disease". Pharmacotherapy. 18 (2 Pt 2): 68–73, discussion 79–82. PMID 9543467.
  17. ↑ 17.0 17.1 17.2 17.3 "Practice Guideline for the Treatment of Patients with Alzheimer's disease and Other Dementias" (PDF). American Psychiatric Association. October 2007. doi:10.1176/appi.books.9780890423967.152139. Retrieved 2007-12-28.
  18. ↑ Bottino CM, Carvalho IA, Alvarez AM; et al. (2005). "Cognitive rehabilitation combined with drug treatment in Alzheimer's disease patients: a pilot study". Clin Rehabil. 19 (8): 861–869. doi:10.1191/0269215505cr911oa. PMID 16323385.
  19. ↑ Doody RS, Stevens JC, Beck C; et al. (2001). "Practice parameter: management of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology". Neurology. 56 (9): 1154–1166. PMID 11342679.
  20. ↑ Hermans DG, Htay UH, McShane R (2007). "Non-pharmacological interventions for wandering of people with dementia in the domestic setting". Cochrane Database Syst Rev (1): CD005994. doi:10.1002/14651858.CD005994.pub2. PMID 17253573.
  21. ↑ Robinson L, Hutchings D, Dickinson HO; et al. (2007). "Effectiveness and acceptability of non-pharmacological interventions to reduce wandering in dementia: a systematic review". Int J Geriatr Psychiatry. 22 (1): 9–22. doi:10.1002/gps.1643. PMID 17096455.
  22. ↑ Woods B, Spector A, Jones C, Orrell M, Davies S (2005). "Reminiscence therapy for dementia". Cochrane Database Syst Rev (2): CD001120. doi:10.1002/14651858.CD001120.pub2. PMID 15846613.
  23. ↑ Peak JS, Cheston RI (2002). "Using simulated presence therapy with people with dementia". Aging Ment Health. 6 (1): 77–81. doi:10.1080/13607860120101095. PMID 11827626.
  24. ↑ Camberg L, Woods P, Ooi WL; et al. (1999). "Evaluation of Simulated Presence: a personalised approach to enhance well-being in persons with Alzheimer's disease". J Am Geriatr Soc. 47 (4): 446–452. PMID 10203120.
  25. ↑ Neal M, Briggs M (2003). "Validation therapy for dementia". Cochrane Database Syst Rev (3): CD001394. doi:10.1002/14651858.CD001394. PMID 12917907.
  26. ↑ Chung JC, Lai CK, Chung PM, French HP (2002). "Snoezelen for dementia". Cochrane Database Syst Rev (4): CD003152. doi:10.1002/14651858.CD003152. PMID 12519587.
  27. ↑ Spector A, Orrell M, Davies S, Woods B (2000). "WITHDRAWN: Reality orientation for dementia". Cochrane Database Syst Rev (3): CD001119. doi:10.1002/14651858.CD001119.pub2. PMID 17636652.
  28. ↑ Spector A, Thorgrimsen L, Woods B; et al. (2003). "Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia: randomised controlled trial". Br J Psychiatry. 183: 248–254. doi:10.1192/bjp.183.3.248. PMID 12948999.
  29. ↑ Gaugler JE, Kane RL, Kane RA, Newcomer R (2005). "Early community-based service utilization and its effects on institutionalization in dementia caregiving". Gerontologist. 45 (2): 177–85. PMID 15799982. Retrieved 2008-05-30. Unknown parameter |month= ignored (help)
  30. ↑ 30.0 30.1 30.2 Selwood A, Johnston K, Katona C, Lyketsos C, Livingston G (2007). "Systematic review of the effect of psychological interventions on family caregivers of people with dementia". Journal of Affective Disorders. 101 (1–3): 75–89. doi:10.1016/j.jad.2006.10.025. PMID 17173977.
  31. ↑ "Practice Guideline for the Treatment of Patients with Alzheimer's disease and Other Dementias" (PDF). American Psychiatric Association. October 2007. doi:10.1176/appi.books.9780890423967.152139. Retrieved 2007-12-28.
  32. ↑ "Treating behavioral and psychiatric symptoms". Alzheimer's Association. 2006. Retrieved 2006-09-25.
  33. ↑ Wenger GC, Burholt V, Scott A (1998). "Dementia and help with household tasks: a comparison of cases and non-cases". Health Place. 4 (1): 33–44. doi:10.1016/S1353-8292(97)00024-5. PMID 10671009.
  34. ↑ Dunne TE, Neargarder SA, Cipolloni PB, Cronin-Golomb A (2004). "Visual contrast enhances food and liquid intake in advanced Alzheimer's disease". Clinical Nutrition. 23 (4): 533–538. doi:10.1016/j.clnu.2003.09.015. PMID 15297089.
  35. ↑ Sloane PD, Zimmerman S, Suchindran C, Reed P, Wang L, Boustani M, Sudha S (2002). "The public health impact of Alzheimer's disease, 2000–2050: potential implication of treatment advances". Annual Review of Public Health. 23: 213–231. doi:10.1146/annurev.publhealth.23.100901.140525. PMID 11910061.
  36. ↑ O’Donovan ST. "Dementia caregiving burden and breakdown" (PDF). Forum of Consultant Nurses, Midwives and Allied Health Professionals. Retrieved 2008-02-29.
  37. ↑ "The MetLife Study of Alzheimer's Disease: The Caregiving Experience" (PDF). MetLife Mature Market Institute. August 2006. Retrieved 2008-02-12.


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