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Alzheimer'
s disease, a disorder of pivotal
importance to older adults, strikes
8 to 15 percent of people over the
age of 65 (Ritchie & Kildea,
1995). Alzheimer' s disease is one
of the most feared mental disorders
because of its gradual, yet relentless,
attack on memory. Memory loss, however,
is not the only impairment. Symptoms
extend to other cognitive deficits
in language, object recognition,
and executive functioning. 3 Behavioral
symptoms such as psychosis, agitation,
depression, and wandering are common
and impose tremendous strain on
caregivers. Diagnosis is challenging
because of the lack of biological
markers, insidious onset, and need
to exclude other causes of dementia.
This section covers assessment and
diagnosis, behavioral symptoms,
course, prevalence and incidence,
cost, etiology, and treatment. It
features Alzheimer' s disease because
it is the most prevalent form of
dementia. However, many of the issues
raised also pertain to other forms
of dementia, such as multiinfarct
dementia, dementia of Parkinson's
disease, dementia of Huntington's
disease, dementia of Pick's disease,
frontal lobe dementia, and others.
Assessment
and Diagnosis of Alzheimer' s Disease
Mild
Cognitive Impairment
Declines
in cognitive functioning have been
identified both as part of the normal
process of aging and as an indicator
of Alzheimer' s disease. DSM-IV
first designated this as age-related
cognitive decline and, more recently,
as mild cognitive impairment (MCI).
MCI characterizes those individuals
who have a memory problem but do
not meet the generally accepted
criteria for Alzheimer' s diseaseMCI
is important because it is known
that a certain percentage of patients
will convert to Alzheimer' s disease
over a period of time (probably
in the range of 15 to 20 percent
per year). Thus, if such individuals
could be identified reliably, treatments
could be given that would delay
or prevent the progression to diagnosed
Alzheimer' s disease.
The diagnosis of Alzheimer' s disease
depends on the identification of
the characteristic clinical features
and on the exclusion of other common
causes of dementia. There are currently
no biological markers for Alzheimer'
s disease except for pathological
verification by biopsy or at autopsy
(or through rare autosomal dominant
mutations). With the reliance on
clinical criteria and the need for
exclusion of other causes of dementia,
the current approach to Alzheimer'
s disease diagnosis is time- and
labor-intensive, costly, and largely
dependent on the expertise of the
examiner.
The diagnosis of Alzheimer' s disease
not only requires the presence of
memory impairment but also another
cognitive deficit, such as language
disturbance or disturbance in executive
functioning. The diagnosis also
calls for impairments in social
and occupational functioning that
represent a significant functional
decline (DSM-IV). The other causes
of dementia that must be ruled out
include cerebrovascular disease,
Parkinson's disease, Huntington's
disease, subdural hematoma, normal-pressure
hydrocephalus, brain tumor, systemic
conditions (e.g., hypothyroidism,
vitamin B12 or folic acid deficiency,
niacin deficiency, hypercalcemia,
neurosyphilis, HIV infection), and
substance-induced conditions.
The diagnosis of dementia can be
complicated by the possibility of
other disorders that coexist with,
or share features of, Alzheimer'
s disease. For example, delirium
is a common condition in older patients
and can be confused with dementia
in its acute stages. Other types
of dementia, such as vascular dementia,
share cognitive and behavioral symptoms
with Alzheimer' s disease, and thus
may be difficult to distinguish
from Alzheimer' s disease. The cognitive
symptoms of early Alzheimer' s disease
and those associated with normal
age-related decline also may be
similar. Finally, cognitive deficits
are prominent in both late-life
depression and schizophrenia. While
the severity of deficits is less
in these disorders than that in
later stages of dementia, distinctions
may be difficult if the dementia
is early in its course.
Diagnosis of Alzheimer' s disease
would be greatly improved by the
discovery of a biological marker
that correlates strongly with neuropathological
signs of Alzheimer' s disease, reflects
the severity of pathological changes
in Alzheimer' s disease, and precedes
the appearance of clinical symptomatology.
Behavioral Symptoms
1.
Alzheimer' s disease is associated
with a range of symptoms evident
in cognition and other behaviors;
these include, most notably, psychosis,
depression, agitation, and wandering.
Other behavioral symptoms of Alzheimer'
s disease include insomnia; incontinence;
catastrophic verbal, emotional,
or physical outbursts; sexual disorders;
and weight loss.
2.
Behavioral symptoms, however, are
not required for diagnosis.
3.
Alzheimer' s disease, especially
behavioral symptoms, appears to
place patients at risk for abuse
by caregiver. Behavioral symptoms
occur at some point during the disease
with high frequencies: 30 to 50
percent of individuals with Alzheimer'
s disease experience delusions,
10 to 25 percent have hallucinations,
and 40 to 50 percent have symptoms
of depression.
4.
Patients with psychotic disorders
have greater cognitive impairment,
more rapidly progressive dementia,
and greater frontal and temporal
dysfunction on functional brain
imaging (Jeste et al., 1992; Sultzer
et al., 1995). Patients with psychotic
illness also exhibit more agitation,
depression, wandering, anger, personality
change, family or marital problems,
and lack of self-care (Rockwell
et al., 1994).
Course
1. Patients with Alzheimer' s disease
experience a gradual decline in
functioning throughout the course
of their illness. Typically, a loss
of 4 points per year on the Mini
Mental Status Exam is detected,
but there is a great deal of heterogeneity
in the rate of decline.
2.
Memory dysfunction is not only the
most prominent deficit in dementia
but also is the most likely presenting
symptom. Deficits in language and
executive functioning, while common
in the disorder, tend to manifest
later in its course (Locascio et
al., 1995).
3.
Depression is prevalent in the early
stages of dementia and appears to
recede with functional decline.
Although this may reflect decreasing
awareness of depression by the patient,
it also could reflect inadequate
detection of depression by health
professionals. Behavioral symptoms,
such as agitation, seem to be more
prevalent in the later stages of
Alzheimer' s disease; however, psychosis
has been observed in patients with
varying levels of severity. The
duration of illness, from onset
of symptoms to death, averages 8
to 10 years (DSM-IV).
Pharmacological Treatment
of Alzheimer' s Disease
Pharmacological treatment of Alzheimer'
s disease is a promising new focus
for interventions. A delay in onset
of Alzheimer' s disease for 5 years
might reduce the prevalence of Alzheimer'
s disease by as much as one-half
(Breitner, 1991). In other words,
to influence the prevalence of Alzheimer'
s disease, it may be necessary only
to delay the onset of the disease
to the point where mortality from
other sources supersedes the incidence
of Alzheimer' s disease. Thus, a
central goal in Alzheimer' s disease
treatment research is the identification
of agents that prevent the occurrence,
defer the onset, slow the progression,
or improve the symptoms of Alzheimer'
s disease. Progress has been made
in this research arena, with several
agents showing beneficial effects
in Alzheimer' s disease.
Treatment of
Behavioral Symptoms
The behavioral symptoms of Alzheimer'
s disease have received less therapeutic
attention than cognitive symptoms.
Few double-blind, placebo-controlled
studies of medications for behavioral
symptoms of Alzheimer' s disease
have been performed. For the most
part, behavioral symptoms have been
treated with medications developed
for primary psychiatric symptoms.
The emergence of new antipsychotic
and antidepressant medications requires
that these agents be studied specifically
for Alzheimer' s disease. The observation
that cholinergic agents used to
enhance cognition in Alzheimer'
s disease may have beneficial behavioral
effects also needs further exploration.
Several challenges are encountered
with the pharmacological treatment
of Alzheimer' s disease. First,
because of the cognitive deficits
that are the hallmark of dementia,
caregiver assistance is crucial
for compliance with pharmacotherapy
regimens. Second, although the current
pharmacotherapies are likely to
be most useful if administered early
in the course of the disorder, early
detection of Alzheimer' s disease
is encumbered by the lack of a verified
biological or biobehavioral marker.
Third, little is currently known
about the optimal duration of treatment
with pharmacotherapies.
Psychosocial
Treatment of Alzheimer' s Disease
Patients and Caregivers
Psychosocial interventions are extremely
important in Alzheimer' s disease.
Although there has been some research
on preserving cognition, most research
has focused on treating patients
behavioral symptoms and relieving
caregiver burden. Support for caregivers
is crucial because caregivers of
older patients are at risk for depression,
anxiety, and somatic problems. Psychosocial
interventions targeted either at
patients or family caregivers can
improve outcomes for patients and
caregivers alike.
Psychosocial techniques developed
for use in patients with cognitive
impairment may be helpful in Alzheimer'
s disease. Strengthening ways to
deal with cognitive losses may reduce
functional limitations for patients
with the early stages of Alzheimer'
s disease, before multiple brain
systems become compromised. For
example, training in the use of
memory aids, such as mnemonics,
computerized recall devices, or
copious use of notetaking, may assist
patients with mild dementia. While
initial research on the use of cognitive
rehabilitation in dementia is promising,
further studies are needed.
We are having regular meetings
of care givers group.
SELF-HELP-GROUP
These
groups can be a source of information
and support and can provide an opportunity
for people to talk about their feelings.
Health professionals, doctors and
nurses, counselors or psychotherapists
in a hospital run some groups. More
commonly, people with cancer run
groups. They often offer different
techniques to teach coping strategies
together with relaxation or visualization,
as well as practical information
and emotional support.
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