Prevention and Wellness

Alzheimer’s Disease 

Larry Lawhorne, MD, of Wright State Physicians and Premier Health, answers Frequently Asked Questions about Alzheimer’s disease and how to live with and manage the condition.

What is Alzheimer's disease?

Dr. Larry Lawhorne discusses Alzheimer’s disease. Click play to watch the video or read the transcript.

 

Alzheimer's disease is one of the most common forms of dementia. Dementia is really the umbrella term for lots of different problems that people have with memory and thinking, but Alzheimer's is the most common. It’s almost always characterized by memory loss followed by the loss of other functions of thinking like word finding, the ability to do calculations and the ability to remember how to do procedural things like loading the dishwasher. Eventually, someone with Alzheimer’s encounters problems doing almost anything. It really affects daily life in a major way. It also affects many other members of the family, including spouses and children in particular.

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What’s the difference between dementia and Alzheimer's disease? 

Dr. Larry Lawhorne discusses the difference between dementia and Alzheimer’s disease. Click play to watch the video or read the transcript.

 

A very common cause of dementia is Alzheimer's disease, accounting for 40 to 60 percent of all cases of dementia. But there many causes of dementia, such as vascular dementia, Lewy body dementia, normal pressure hydrocephalus and frontotemporal dementia. The most common after Alzheimer's disease is vascular dementia. Vascular dementia occurs in a setting of high blood pressure, elevated cholesterol and other cardiovascular diseases. While Alzheimer's patients lose function slowly, people with vascular dementia lose their ability to remember and think in a step-wise progression.

Making a diagnosis can be complicated because now we think there is mixed dementia. Someone may be on his way to developing Alzheimer's disease but may also have enough vascular risk factors to have vascular dementia, too. Lewy body dementia is an interesting and distinctive disorder. People with Lewy body dementia often first experience visual hallucinations. They may also have some movement disorder. They may have a little bit of tremor. They may have problems walking. People with Lewy body dementia are also very sensitive to antipsychotic medicines, which tend to make them much more unsteady.

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What are the common early signs and symptoms of Alzheimer's disease?

Dr. Larry Lawhorne discusses the early signs and symptoms of Alzheimer’s disease. Click play to watch the video or read the transcript.

 

Remember that this can be very subtle, but there is almost always memory loss. It’s usually short-term memory that is affected, like forgetting what your wife just told you or forgetting what your husband just told you. There are also other symptoms that relate to cognition, such as some loss of language skills. Word finding is a very common problem that people have in early Alzheimer's disease. They just can’t remember the word for something. They might be able to describe it. They’ll say, “Well, you know, I need that thing that you hold in your hand and you write with.” “You need a pen?” “Yes, that’s right. I need a pen.

People may start to forget how to do procedural things like taking out the trash. A wife might say that she had to start reminding her husband it was trash day. Then, after a while, she would have to follow him around to remind him to empty all the trash bins into the garbage bag. And then finally, he’d just not remember how to do it correctly or in the right sequence.

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How do the symptoms of Alzheimer’s disease progress?

Dr. Larry Lawhorne discusses how the symptoms of Alzheimer’s disease progress. Click play to watch the video or read the transcript.

 

What some people refer to as executive function goes away. This is your ability to look at a situation, size up what you need to do and carry out the steps in a process to complete the task. Calculations go away. Somebody who was once an ace at managing checkbooks may say they lost interest in it, or don’t want to do it anymore or actually can’t do it. Then, what’s often most disturbing to family members are changes in personality and mood.

If you look back over the whole set of symptoms that can occur, you almost always have loss of memory and the loss of language skills, word finding, the ability to do procedural things that you've always done and changes in mood and personality. Those are the characteristic things that happen but they can be so subtle and gradual that family members may not recognize the changes right away because they are assisting or helping their loved one. Then, when the person can no longer remember or complete tasks, it seems like it happened all of a sudden, when actually, if you look back, it was a slow, progressive process.

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What’s the difference between the forgetfulness of old age and the memory loss of Alzheimer's and other dementias?

Dr. Larry Lawhorne discusses how the difference between the forgetfulness of old age and the memory loss of Alzheimer's and other dementias. Click play to watch the video or read the transcript

 

It comes down to whether the forgetfulness makes a difference in your daily life. Does it affect your day-to-day living? Almost all of us will forget where we put our car keys, but we're able to go back, trace where we’ve been and eventually find the car keys. 

 Or you have trouble remembering somebody’s name. You're sitting there thinking, “Well, that kid that sat behind me in high school who used to always flick my ear, what was his name? I can’t think of that.” Then, sometime later, it’ll come to you. It’s frustrating, but it doesn’t affect your ability to do the things you need to do day in and day out. It’s delayed memory loss. It’s not really totally lost.

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How do you talk to patients who are worried about their memory loss?

Dr. Larry Lawhorne discusses how doctors talk with patients who are worried about their memory loss. Click play to watch the video or read the transcript.

 

I spend a lot of time in my office talking to people about that. It is one of the most feared processes that people think about, but most of the time, we can do some simple testing of memory. Sometimes it might be hard to remember where you parked the car, but you know you can find the car.

If you can find the car, it’s okay. It’s not going to affect your life but we want to be able to talk about it to reassure you that you're okay. Most people who come in worried about memory loss often don’t have it. They often don’t have Alzheimer's disease, but they know people who do. They have people in the family who have it and they’re just worried about it.

    Is Alzheimer’s disease hereditary?

    Dr. Larry Lawhorne discusses the hereditary component of Alzheimer’s disease. Click play to watch the video or read the transcript.

     

    People often ask if they are at risk for Alzheimer’s if people in their family have the condition. The answer is complicated. There is a genetic component to Alzheimer's disease and across the globe, there are studies that show that certain chromosomal changes, certain changes in genetic makeup will increase the risk for Alzheimer's disease and some dementias. In the U.S. and especially in the Miami Valley, we don’t really have the strong familial patterns of inheritance for Alzheimer's disease. But if there is Alzheimer's disease in the family, you are at increased risk and you should talk with your doctor about how to prepare and plans to put in place.

    There is genetic testing that can be done, but it is not helpful in predicting if you will get Alzheimer’s, and there is no cure. If you're not going to get this until you're 70 or 80 years old, you can do a lot of living between now and then.

    If tests show that someone is genetically predisposed to Alzheimer’s, how can they reduce their risk?

    Dr. Larry Lawhorne discusses how people who are genetically predisposed to Alzheimer’s disease can reduce their risk. Click play to watch the video or read the transcript.

     

    If you do have a positive family history, you can work with your doctor to reduce other risk factors – like cardiovascular disease – that might contribute to the development of Alzheimer’s disease or the loss of brain cells. The more active you keep your brain, the more you can reduce your chances of getting Alzheimer's disease and other dementias. Activities that help are word games, crossword puzzles, number games, exercise and maintaining strong social relationships.

    Are there preventive steps everyone can follow to ward off Alzheimer’s?

    Dr. Larry Lawhorne discusses preventive steps everyone can follow to ward off Alzheimer’s. Click play to watch the video or read the transcript.

     

    You should get plenty of exercise. You should have good nutrition, and use alcohol only in moderation. You should not smoke. You should control your blood pressure and your cholesterol.

    We know that people with a social network stay healthy longer. Even if they get sick or injured, they seem to recover more quickly if they have a strong support system.

    And we know that keeping the mind active makes a difference. A study that followed a group of nuns for many years found that the more the women read, the more sophisticated their writing became. These women also had a lower chance of getting Alzheimer's disease than people who did not read as much and who didn't write with complex sentences.

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    How is Alzheimer's disease diagnosed?

    Dr. Larry Lawhorne discusses how Alzheimer’s disease is diagnosed. Click play to watch the video or read the transcript.

     

    A person’s medical history and the family history can reveal clues about their loss of function. We ask detailed questions like:

    • “If he’s not interested in doing the checkbook anymore, is he not interested or do you think he’s having more problems doing the math? 
    • “If you're having to remind him that Thursday’s trash day and it’s Wednesday night, is it just because he’s being cantankerous or is it because he doesn’t remember it’s Wednesday night?” 

    Once we think someone has a memory problem or a thinking problem, then we do some specific testing to get information about a person’s ability to remember and think. We use the Montreal Cognitive Assessment test or the Mini-Mental State exam. One example is when we ask about similarities. I may ask, “How are a train and a bicycle alike?” People with early dementia can describe each thing, but they won’t be able to say they are both means of transportation or a way to get from point A to point B. 

    We also perform a thorough physical exam to see if the person has any deficits in strength or coordination or any signs of a past stroke. This can reveal cases of vascular dementia.

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    What tests are used to help make an Alzheimer’s diagnosis?

    Dr. Larry Lawhorne discusses the tests used to diagnose Alzheimer’s. Click play to watch the video or read the transcript.

     

    We do routine blood work to check thyroid, liver and kidney function and to look for any nutritional or chemical deficiencies, as well as Alzheimer’s biomarkers.

    Imaging tests such as a CT scan, MRI or PET scan may also be performed, depending on the patient’s symptoms, but usually are not done right away. We ask if the person recently had a fall and went to the emergency room. If they did, a CT scan would be on file and we can check that. Other imaging tests are most often used.

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    What about psychological testing?

    Dr. Larry Lawhorne discusses how psychological testing is used to diagnose Alzheimer’s. Click play to watch the video or read the transcript.

     

    One of the most important tests we can do is formal neuropsychological testing, which takes a few hours. This testing gives an idea of someone’s basic intellect, their memory and other thinking functions. It also tells you more about mood, depression and anxiety.

    Neuropsychological testing reveals a person’s strengths. Do they remember something better if they hear it or if they see it? Or do they need to both hear it and see it? 

    As a person gets older, they may experience benign forgetfulness and a little bit of depression, especially if they are losing loved ones and friends. All of this combined can look like Alzheimer's disease. Drilling down to the root of the issue may reveal that it’s not dementia but depression or loneliness or boredom or fearfulness. You don’t want to miss Alzheimer's disease or dementia, but you also don’t want to characterize somebody as having it if they have something else that’s treatable.

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    How do you measure a person’s change in cognitive abilities?

    Dr. Larry Lawhorne discusses how testing can measure a change in someone’s cognitive abilities. Click play to watch the video or read the transcript.

     

    One of the important things about Alzheimer's disease and other dementias is to know what the person’s function was before they had the symptoms that send them to the doctor. When we think about dementia, we should think of it as an acquired cognitive disorder. People who have attention deficit or dyslexia, it’s very important to know that. It’s very important to know that baseline. That’s where neuropsychological testing can help determine which functions or lack of function is new and how much existed before. It is extremely important to know a person’s function before family and others started worrying about memory and other thinking problems.

      Why is it important to diagnose Alzheimer's early?

      Dr. Larry Lawhorne discusses the importance of an early Alzheimer’s disease diagnosis. Click play to watch the video or read the transcript.

       

      An early diagnosis leaves time for planning. When a person’s judgment and insight is still good, we can ask them lots of questions about what they want or do not want as the disease progresses. This is extremely important to families.

      The patient and the person they choose to make decisions for them when they no longer can, should sit down with their doctor and discuss what they want as it relates to the use of a feeding tube, being on a ventilator, breaking a hip, being in the hospital or being in hospice. It takes such a burden off the family to know what people want at the end of life.

      Lots of other good things can also be addressed, too. Here is a script for how to do it: Dad says, “Son, when you think I can’t drive anymore, just tell me and take my keys away. When you think I can’t manage my finances anymore, just tell me and I’ll sign a paper that says you can do it. If a doctor or somebody else says that I can’t handle it anymore, then you take over.” 

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      What do family members need to remember when a relative gets an early Alzheimer’s diagnosis?

      Dr. Larry Lawhorne discusses what family members should remember when a relative gets an early Alzheimer’s diagnosis. Click play to watch the video or read the transcript.

       

      People with early Alzheimer's disease are still of value. They can still do things. Sometimes, as soon as the diagnosis is made, everybody around them thinks, “Well, you know, they can’t do it anymore.” That’s not true. They’re not wrong about everything. They remember some things better than their family members might remember them. 

      A few years ago I attended a town hall meeting where only people with early Alzheimer's disease could talk. Nobody else was allowed to speak. It was so informative. A man who was a plumber said, “You know, I can still do my job. I can still do it well.” He said, “I’m having a terrible time driving and remembering where I am, but when I get to the job, I’m as good a plumber as I ever was and it’s not my fault that I got this disease. So just get me to the job and I can still work.”

        What are the treatment options for Alzheimer’s disease?

        Dr. Larry Lawhorne discusses treatment options for Alzheimer’s. Click play to watch the video or read the transcript.

         

        The treatment options for Alzheimer's disease are in some ways limited. There is one class of drugs called cholinesterase inhibitors that have been available for some time. People with Alzheimer’s lose a neurotransmitter called acetylcholine. An enzyme called cholinesterase breaks down acetylcholine. The medicines prevent the cholinesterase from breaking down the acetylcholine in the brain. Early in Alzheimer's disease, when enough brain cells are making that chemical, the medicine works. Later in the disease, when fewer brain cells are making acetylcholine, the medicine may not make much difference.

        The other class of drugs protects damaged brain cells from further injury from glutamate, which is a normal chemical in the brain. The generic name is memantine. For some reason, glutamate attacks the brain cells injured by Alzheimer's disease and makes them die faster. Memantine protects the brain cells for a little bit longer. 

        Neither of these medicines provides a cure. Most studies show they may slow down the progression of the disease. It’s important to talk with your physician about the particular type of dementia a loved one has in terms of how you approach the treatment.

          Will new treatments for Alzheimer’s disease be available in the future?

          Dr. Larry Lawhorne discusses new treatment for Alzheimer’s that may be available in the future. Click play to watch the video or read the transcript.

           

          Almost all of the research being done on treatment right now focuses on amyloid. Amyloid is a glob of cell debris that starts to gum things up in the brain, making it hard for nerve cells to communicate with each other. We know from the early days of Alzheimer's disease that these amyloid plaques, as they’re called, are very prominent in people with Alzheimer's disease. The idea is that if you can make the plaques go away, then a person would do better.

          When you get right down to it, what we want to do is keep those plaques from forming in the first place. We’ve got to figure out what causes those plaques to form. 

          Some experts say the cholinesterase inhibitors don’t work well because we give them way too late. Studies now underway are looking at people with very positive family histories for Alzheimer’s and doing sophisticated blood and spinal fluid tests and PET scans to see how much risk they have for Alzheimer’s and then starting those medications long before they get symptoms of memory loss. It will be interesting to see about that.

            Can patients take part in clinical trials for Alzheimer’s disease? 

            Dr. Larry Lawhorne discusses how patients can take part in clinical trials. Click play to watch the video or read the transcript.

             

            There are a lot of studies going on now. If you go to the Alzheimer’s Association website, you can see a list of clinical trials. You can enter your profile there and they will match you with trials that you might qualify for. There are a lot of opportunities with clinical trials for people who are early in the disease or younger in age.

            Different clinical trials have different criteria for entry. Clinical trials that are very interested in the hereditary aspects of Alzheimer's disease may want to do chromosomal studies and gene studies as part of the qualifications, but it’s going to vary from trial to trial. 

              Is there a difference in life expectancy for patients who take medicine for the condition and those who don’t?

              Dr. Larry Lawhorne discusses life expectancy for Alzheimer’s patients who take medication and those who don’t. Click play to watch the video or read the transcript.

               

              Probably not, but it’s hard to say. People live a long time with Alzheimer’s disease. It could be from the medicine or it could be that we’re diagnosing it earlier. It depends on how fast the disease progresses. The medication doesn’t slow down the disease process, but it does seem to extend the length of time a person can live at home, before needing nursing home care.

              Life expectancy probably depends more on the burden of amyloid in the brain and other medical or neuropsychiatric conditions the person might have. It can also depend on the amount of available social support. 

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              If Alzheimer’s affects the ability to function, communicate and reason, how does one die from the disease?

              Dr. Larry Lawhorne discusses how someone can die from Alzheimer’s disease. Click play to watch the video or read the transcript.

               

              What usually happens in people with Alzheimer's disease — if they don’t have a heart attack or die from an injury — is that they lose the ability to swallow.

              If you cannot swallow, you are in danger of becoming undernourished and can die of malnutrition. Problems with swallowing can also cause pneumonia, especially if food gets into the lungs. Alzheimer’s patients often get repeated cases of pneumonia and are more susceptible to infections that can spread through the bloodstream, such as a severe urinary tract infection.

              People often ask why someone with Alzheimer’s can’t be fed with a feeding tube once they lose the ability to swallow. We can improve someone’s nutritional values with tube feeding, but we can’t change their cognition or the progression of the disease. We can’t change that the patient is becoming bedbound, no longer communicates with family and that their quality of life may not be what they want.

              This is why it’s important to have the discussion about end of life when a person still is able to express their wishes. 

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              How do doctors help patients and families manage the daily progression of Alzheimer’s disease?

              Dr. Larry Lawhorne discusses how doctors help patients and families manage the daily progression of Alzheimer’s disease. Click play to watch the video or read the transcript.

               

              We are a group of geriatricians. People might also see family physicians or internists. What we offer is that we make the journey with you. Caregivers want to call us up and talk about a problem or how they handled a situation. A few years ago, a wife called and said, “My husband doesn’t think I’m his wife anymore and he wants me to leave. This is what I did. Tell me what you think.” She said, “I went in the other room. I changed clothes. I brought our wedding album in and I said, ‘You know, it’s wonderful being married to you. I was just looking at our wedding album.’”

              I told her I would have done exactly the same thing. The point of the story is that we learn so much from patients and caregivers – even people who don’t participate in clinical trials teach us a lot. The Alzheimer's Association provides lots of support groups and the more caregivers can share with each other, the more they can learn. It really is the journey that is important.

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              What resources do you recommend for someone newly diagnosed with Alzheimer’s disease?

              Dr. Larry Lawhorne discusses helpful resources for someone newly diagnosed with Alzheimer’s disease. Click play to watch the video or read the transcript.

               

              Once you tell a patient and their family about an Alzheimer’s diagnosis, they don’t hear much. I tell people the diagnosis means they will have continuing problems with memory and thinking and I give them some pamphlets and the website for the Alzheimer's Association. Then we make an appointment for the next week to talk more about everything.

              The Alzheimer's Association website is very useful for families in terms of preparing for the next few months and the next few years. The book, The 36-Hour Day, by Nancy Mace and Peter Rabins is also very helpful. Mace is a PhD nurse and Rabins is a psychiatrist who’s worked with dementia at Johns Hopkins for decades. The book shares strategies to manage different kinds of Alzheimer’s behaviors. 

              A diagnosis starts what is really a constant conversation about preparation. As we’ve talked about, it’s a journey that’s going to go on for a long time. 

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              Source: Larry Lawhorne, MD, Wright State Physicians; National Institute on Aging, Alzheimer’s Association

              Content Updated: February 20, 2018

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