A. General Considerations

Absent-mindedness and forgetfulness increase as adults get older and may be a part of normal aging. However, signs of persistent memory problems, such as difficulty finding the right word or forgetting recent conversations, may indicate something more serious than normal aging.

Dementia is a syndrome in which there is deterioration in cognitive function beyond what might be expected from the usual consequences of biological ageing.

Although dementia mainly affects older people, it is not an inevitable consequence of ageing. Dementia results from a variety of diseases and injuries that primarily or secondarily affect the brain, such as Alzheimer’s disease or stroke.

Currently more than 55 million people live with dementia worldwide, and there are nearly 10 million new cases every year. As the proportion of older people in the population is increasing in nearly every country, this number is expected to rise to 78 million in 2030 and 139 million in 2050.

Dementia results from a variety of diseases and injuries that primarily or secondarily affect the brain. Alzheimer’s disease is the most common form of dementia and may contribute to 60-70% of cases. Other dementias include Lewy body dementia, frontotemporal disorders, Parkinson’s disease dementia, Korsakoff syndrome and vascular dementia. It is common for people to have mixed dementia — a combination of two or more types of dementia. For example, some people have both Alzheimer’s disease and vascular dementia.

Dementia is currently the seventh leading cause of death among all diseases and one of the major causes of disability and dependency among older people globally.

Dementia has physical, psychological, social and economic impacts, not only for people living with dementia, but also for their carers, families and society at large.

Prevalence studies demonstrated that dementia is indeed a prevalent condition in Arab countries, ranging between 1.1% and 2.3% among age groups of 50 years and older, as well as between 13.5% and 18.5% among age groups of 80 years and above. However, these results are not different from those of many other countries in the world. Moreover, prevalence was found to vary depending on sociodemographic characteristics. Major risk factors of dementia included hypertension, low income, and low education, while the risk of developing dementia is increased by obesity, diabetes mellitus, and cardiovascular risk factors.

Dementia is a syndrome – usually of a chronic or progressive nature – that leads to deterioration in cognitive function (i.e. the ability to process thought) beyond what might be expected from the usual consequences of biological ageing. It affects memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgement. Consciousness is not affected. The impairment in cognitive function is commonly accompanied, and occasionally preceded, by changes in mood, emotional control, behaviour, or motivation.

Alzheimer’s is a disease of the brain that causes problems with memory, thinking and behavior. It is not a normal part of aging.

Alzheimer’s gets worse over time. Although symptoms can vary widely, the first problem many people notice is forgetfulness severe enough to affect their ability to function at home or at work, or to enjoy hobbies.

The disease may cause a person to become confused, get lost in familiar places, misplace things or have trouble with language.

There is no cure for dementia / Alzheimer’s disease and it can cause a great deal of distress for those affected and their families. However, early diagnosis is important because there is a great deal of support as well as medication that can help.

What causes Alzheimer’s?

Alzheimer’s disease is named after Dr. Alois Alzheimer. In 1906, Dr. Alzheimer noticed changes in the brain tissue of a woman who had died of an unusual mental illness. Her symptoms included memory loss, language problems, and unpredictable behavior. After she died, he examined her brain and found many abnormal clumps (now called amyloid plaques) and tangled bundles of fibers (now called neurofibrillary, or tau, tangles).

The exact cause of Alzheimer’s disease is not yet fully understood, although a number of things are thought to increase your risk of developing the condition.

These include:

• increasing age (Alzheimer’s disease is most common in people over the age of 65);
• a family history of the condition: there is a small increased risk if a first-degree family member (father, mother, brother or sister) is affected;
• gender (it is more common in women);
• untreated depression, although depression can also be one of the symptoms of Alzheimer’s disease
• lifestyle factors and conditions associated with cardiovascular disease (smoking, lack of physical exercise, unhealthy diet)
• Additional risk factors include social isolation, low educational attainment, cognitive inactivity and air pollution.

B. Alzheimer’s disease symptoms

Alzheimer’s disease is a progressive condition, which means the symptoms develop gradually over many years and eventually become more severe. It affects multiple brain functions.

The first sign of Alzheimer’s disease is usually minor memory problems. For example, this could be forgetting about recent conversations or events, and forgetting the names of places and objects.

As the condition develops, memory problems become more severe and further symptoms can develop, such as:

• confusion, disorientation and getting lost in familiar places
• difficulty planning or making decisions
• problems with speech and language
• problems moving around without assistance or performing self-care tasks
• personality changes, such as becoming aggressive, demanding and suspicious of others
• hallucinations (seeing or hearing things that are not there) and delusions (believing things that are untrue)
• low mood or anxiety

The first symptoms of Alzheimer’s vary from person to person. For many, decline in nonmemory aspects of cognition, such as word-finding, vision/spatial issues, and impaired reasoning or judgment may signal the very early stages of the disease.

C. DIAGNOSTIC OF ALZHEIMER’S DISEASE

As the symptoms of Alzheimer’s disease progress slowly, it can be difficult to recognise that there’s a problem. Many people feel that memory problems are simply a part of getting older.

Also, the disease process itself may (but not always) prevent people recognising changes in their memory. But Alzheimer’s disease is not a “normal” part of the ageing process.

An accurate and timely diagnosis of Alzheimer’s disease can give you the best chance to prepare and plan for the future, as well as receive any treatment or support that may help.

There’s no single test that can be used to diagnose Alzheimer’s disease. And it’s important to remember that memory problems do not necessarily mean you have Alzheimer’s disease.

A GP will ask questions about any problems you’re experiencing and may do some tests to rule out other conditions. The GP will arrange for blood or urine tests to help exclude other causes of symptoms that can be confused with dementia. The general physician can refer the patient to a neurologist, who is specialized in diseases of the brain and nervous system or to a psychiatrist.

If Alzheimer’s disease is suspected, you may be referred to a specialist service to:

• assess your symptoms in more detail
• organise further testing, such as brain scans if necessary
• create a treatment and care plan

There’s no simple and reliable test for diagnosing Alzheimer’s disease, but the GP or neurologist will listen to the concerns of both patient and the family about his/her memory or thinking. They’ll assess the memory condition and other areas of mental ability and, if necessary, arrange more tests to rule out other conditions.

To rule out other possible causes of your symptoms and look for possible signs of damage caused by Alzheimer’s disease, the specialist may recommend having a brain scan.

This could be a CT scan, an MRI or even SPECT or a PET scan which can be recommended if the result of MRI or CT scans is uncertain. If a specialist is worried that epilepsy may be causing the dementia symptoms, an EEG may be taken to record the brain’s electrical signals (brain activity), but this is rare.

CT scan – several X-rays of your brain are taken at slightly different angles and a computer puts the images together

MRI scan – a strong magnetic field and radio waves are used to produce detailed images of your brain

Researchers are studying biomarkers (biological signs of disease found in brain images, cerebrospinal fluid, and blood) to detect early changes in the brains of people with mild cognitive impairment and in cognitively normal people who may be at greater risk for Alzheimer’s.

C.1. Who develops Alzheimer’s disease?

Most people who develop Alzheimer’s disease are more than 65 years old. However, it can affect younger people – when this occurs, it is called early-onset Alzheimer’s disease. Early-onset Alzheimer’s occurs between a person’s 30s and mid-60s and represents less than 10% of all people with Alzheimer’s. In people with early-onset Alzheimer’s, a genetic mutation may be the cause. Late-onset Alzheimer’s arises from a complex series of brain changes that may occur over decades. The causes probably include a combination of genetic, environmental, and lifestyle factors.

D. TREATMENT FOR ALZHEIMER’S DISEASE

It may take several appointments and tests over many months before a diagnosis of Alzheimer’s disease can be confirmed, although often it may be diagnosed more quickly than this.

It takes time to adapt to a diagnosis of dementia, for both, the patient and his family. As Alzheimer’s disease is a progressive illness, the weeks to months after a diagnosis are often a good time to think about legal, financial and healthcare matters for the future.

There’s currently no cure for Alzheimer’s disease. But there is medicine available that can temporarily reduce the symptoms.

Support is also available to help someone with the condition, and their family, cope with everyday life.

D1. Medicines

A number of medicines may be prescribed for Alzheimer’s disease to help temporarily improve some symptoms.

The main medicines are:

Acetylcholinesterase (AChE) inhibitors

These medicines increase levels of acetylcholine, a substance in the brain that helps nerve cells communicate with each other. Donepezil, galantamine and rivastigmine can be prescribed for people with early- to mid-stage Alzheimer’s disease. The latest guidelines recommend that these medicines should be continued in the later, severe, stages of the disease.

There’s no difference in how well each of the 3 different AChE inhibitors work, although some people respond better to certain types or have fewer side effects, which can include nausea, vomiting and loss of appetite. The side effects usually get better after 2 weeks of taking the medication.

Memantine

This medicine is not an AChE inhibitor. It works by blocking the effects of an excessive amount of a chemical in the brain called glutamate.

Memantine is used for moderate or severe Alzheimer’s disease. It’s suitable for those who cannot take or are unable to tolerate AChE inhibitors.

It’s also suitable for people with severe Alzheimer’s disease who are already taking an AChE inhibitor. Side effects can include headaches, dizziness and constipation but these are usually only temporary.

Medications to treat the underlying Alzheimer’s disease process

Aducanumab is the first disease-modifying therapy approved by the FDA to treat Alzheimer’s disease. The medication helps to reduce amyloid deposits in the brain and may help slow the progression of Alzheimer’s, although it has not yet been shown to affect clinical outcomes such as progression of cognitive decline or dementia. A doctor or specialist will likely perform tests, such as a PET scan or analysis of cerebrospinal fluid, to look for evidence of amyloid plaques and help decide if the treatment is right for the patient.

Several other disease-modifying medications are being tested in people with mild cognitive impairment or early Alzheimer’s as potential treatments.

Medicines to treat challenging behaviour

In the later stages of dementia, a significant number of people will develop what’s known as behavioural and psychological symptoms of dementia (BPSD).

The symptoms of BPSD can include:

• increased agitation
• anxiety
• wandering
• aggression
• delusions and hallucinations

These changes in behaviour can be very distressing for both the person with Alzheimer’s disease and their carer.

If coping strategies do not work, a consultant psychiatrist can prescribe risperidone or haloperidol, antipsychotic medicines, for those showing persistent aggression or extreme distress.

Antidepressants may sometimes be prescribed if depression is suspected as an underlying cause of anxiety.

Treatments that involve therapies and activities

Medicines for Alzheimer’s disease symptoms are only one part of the care for the person with dementia. Other treatments, activities and support – for the carer, too – are just as important in helping people live well with dementia.

Cognitive stimulation therapy – involves taking part in group activities and exercises designed to improve memory and problem-solving skills.

Cognitive rehabilitation – involves working with a trained professional, such as an occupational therapist, and a relative or friend to achieve a personal goal, such as learning to use a mobile phone or other everyday tasks. Cognitive rehabilitation works by getting you to use the parts of your brain that are working to help the parts that are not.

Changes to home environment to make it easier to deal with day-to-day activities.

Other ways to help with anxiety, depression and difficulties with behaviour include aromatherapy, music and dance, using animals as therapy, massage and exercise.

Caring for a person with Alzheimer’s can have significant physical, emotional, and financial costs. The demands of day-to-day care, changes in family roles, and decisions about placement in a care facility can be difficult.

Good coping skills, a strong support network, and respite care are other things that may help caregivers handle the stress of caring for a loved one with Alzheimer’s. For example, staying physically active provides physical and emotional benefits.

Becoming well-informed about the disease is one important long-term strategy. Programs that teach families about the various stages of Alzheimer’s and about ways to deal with difficult behaviors and other caregiving challenges can help.

People with Alzheimer’s disease can live for several years after they start to develop symptoms. But this can vary considerably from person to person.

Alzheimer’s disease is a life-limiting illness, although many people diagnosed with the condition will die from another cause.

There’s increasing awareness that people with Alzheimer’s disease need palliative care.

Contact a specialty consultation or advice from a neurology specialist / Alzheimer’s disease  center: