CENTRAL  SOUTH  DAKOTA  MEDICAL NEWS
THE CLINICAL VIEW
By: Phillip E. Hoffsten, M.D.
11/23/2000

 Update on Alzheimer's Disease

About one year ago, a series of articles about dementia was published in these columns. I described the situation for four different people who had developed dementia. Dementia is the generic term to describe the individual whose mind is no longer able to function to control the activities of daily living. A person with dementia has memory problems to the point where they do not recall to turn off the water or turn off the stove or where their keys are. Personal hygiene is usually impaired. Normal activities are not done and the function of the person in the home becomes disrupted so that meals are not prepared and the house is not cared for. Frequently, the person becomes very frustrated as things do not work and anger, even with abuse and physical violence, can become a problem. Dementia is by far the most common reason for a person to be admitted to our nursing home facilities.

Dementias can be caused by many different conditions. It is a facet of the late stages of Parkinson's disease, the sometimes result of strokes, the end result of chronic alcoholism, but by far the most common cause of dementia is a disease called Alzheimer's disease. Note that Alzheimer's disease may be one cause of dementia but not all individuals with dementia have Alzheimer's disease.

Alzheimer's disease was first described by Dr. Alzheimer in 1906 in Germany. He described the case of a woman 51 years of age who began to lose her memory and ability to communicate. Her personality changed, she became jealous and paranoid and had auditory hallucinations. She became agitated and would scream at others in her home for hours at a time.  Eventually, she became more withdrawn, eventually bedridden in a fetal position incontinent of urine and stool and died 4-1/2 years after the onset of her condition. Dr. Alzheimer examined her brain in the postmortum. He described "neuritic plaques and neurofibulary tangles". These terms have little meaning to somebody who is not schooled in pathology but basically they represent abnormal proteins that accumulate in the brain tissue of individuals who have Alzheimer's disease. These abnormalities appear to be relatively specific allowing the pathologist to make the diagnosis of "Alzheimer's disease". Initially, it was felt by Dr. Alzheimer that his observation applied to very young people who developed dementia. However, in the 1960s, it became clear that Alzheimer's disease became more prevalent with age. We now know that about 1 % of the population at age 70 has this condition and by age 85 about 8% of the population has this condition. It is thus a condition that is progressive and much more prevalent with age.  In spite of extensive research on this topic in the past 10 years, there is still no clear identifiable cause. Genetic factors seem to play a permissive part but even individuals who seem to have the genes for development of Alzheimer's disease do not always develop it. Whatever environmental factors are involved are unknown.

While the cause of the disease is unknown, it is now recognized that the chemical messengers that the brain uses are decreased in the brains of people with this condition. Medical researchers have developed two medications that seem to be of some help in maintaining these chemical messengers and restoring function in people with Alzheimer's disease. The medicines do not seem to reverse the basic disease process but they do seem to allow the person to function at a higher level for a longer period of time. If started early in the course of the illness, these medications can contribute a substantial amount of time that a person can remain at home with near normal function.

The first of these drugs was called Aricept and was released several years ago. If begun at an early time before function is too badly deteriorated, this medication could add six months to a one year to the length of time that an individual with Alzheimer's disease might be able to function in their own home. If one considers the expense and savings that occurs from additional time at home and also the joy of remaining in their own home this is a very substantial gift. The side effects of Aricept usually decrease with time. They include nausea and low blood pressure. Simply reducing the dose of medication for a brief period of time and then working it back up more slowly often gets around the side effect profile.

More recently a new drug called Exelon was released. It works on the same principle as Aricept but seems perhaps to have fewer side effects. Slight nausea, occasional vomiting and decreased appetite can occur with individuals taking Exelon but titrating the dose up slowly usually can get around these side effects.

The use of these medications requires the diagnosis of Alzheimer's disease based on clinical judgment. Then, the person's function can be measured with a test called the mini mental status test. By taking this test several days in a row, one can get an idea of how well the person with Alzheimer's disease is functioning. Then the medication can be started and the test repeated on a weekly basis. The mini mental status exam can be done by family members at home and the score is measured to see if function is getting better. If the medication seems to be a help over the first several months, its continued use is probably a warranted step. As mentioned, it can lead to additional months or even years of time at home with relatively normal function rather than having to be in a nursing facility.

There is perhaps no disease more difficult to face and deal with by either the patient or the family members. It is very frightening to think that a person's mental function is being lost. With understanding and with the help of your local caregivers a more favorable outcome for this condition can be achieved. The caregivers at your local clinic are aware of the various considerations and can provide a great deal of support for families and patients that have Alzheimer's disease. Someday, we may have a cure or prevention for this. Unfortunately, at this time, we only have a way to slow the process.