Neurologists the world over will focus their attention on a mysterious illness that still defies proper explanation – namely, Alzheimer’s Disease (AD). Considered one of the commonest neurological diseases with devastating physical and mental impacts on the patient, early diagnosis and medications can however control and improve their quality of life, says an eminent Neurologist. Consultant Neurologist Sri Jayewardenepura General Hospital and Postgraduate Training Centre, Dr Harsha Gunasekara discusses A.D impacts on people affected by it and the burden on caregivers working round the clock.
Excerpts:
Q: World Alzheimer’s Day will be observed tomorrow, September 21. Although common in Sri Lanka, most people don’t still fully understand about this condition. What is Alzheimer’s disease?
A. Alzheimer’s Disease (AD) is a progressive and irreversible disease that impairs memory and other important brain functions.
At first, persons with AD may experience mild confusion and difficulty in remembering, but eventually they may undergo complete memory loss and dramatic personality changes. AD is the commonest of all types of dementia.
Q: Is AD the same as Dementia?
A. Dementia is a group of symptoms characterised by a decline in intellectual functioning, severe enough to interfere with a person’s normal daily activities and social relationships. There are different types of dementia and AD is the most common type of dementia in older people.
Q: What are the organs affected due to Dementia and AD?
A. As in all types of dementia, Alzheimer’s primarily affects the brain and secondly the neural control of some other organs such as the bladder or bowel. AD is a neurodegenerative disease, which means there is progressive and irreversible damage and death of brain cells (neurones) that are involved in memory and thinking that happens over a course of time. The total brain size shrinks with Alzheimer’s - the brain will gradually have fewer cells and connections (synapses).
Q:What are the trigger factors that cause it?
A. Scientists do not yet fully understand what exactly triggers the pathological process in AD. However, the complex series of pathological events that take place in the brain has been well established by research. Five percent of patients with AD have familial Alzheimer’s disease, which is an early onset of the disease that appears to be inherited. In familial Alzheimer’s disease, several members of the same generation in a family are often affected. Ninety-five percent of patients have sporadic AD and their family members are not at increased risk of developing AD.
Q:Is alcohol and smoking contributory causes for AD?
A. Alcohol abuse can cause other types of dementia but studies have not established a direct link. However, smoking has shown to increase the risk of developing AD at a later age.
Q: Pre-existing Non Communicable Diseases (NCD) such as diabetes, hypertension psychiatric ailments, depression- do they also contribute to AD?
A. NCDs such as diabetes and hypertension are key risk factors for the development of vascular dementia, which is the second most common type of dementia.
There is growing evidence that these NCDs increase the risk of AD as well and in some patients both AD and vascular dementia can co-exist.
Q: Psychiatric diseases?
A. Psychiatric diseases like depression can cause dementia-like states and symptoms of depression, behavioural, mood and personality changes are well recognised in AD.
Q: Of the risk factors you stated, which is the most common and significant?
A. All the risk factors mentioned are equally important as they are closely linked and cannot be singled out as more important or less important. In addition, lifestyle factors which contribute to these NCDs such as unhealthy dietary patterns, lack of physical exercise, obesity, stress and lack of relaxation activities all play a role in the risk of AD.
These risk factors collectively affect a person’s ‘brain health’. Controlling these can prevent not only AD, but also other serious NCDs such as cancer, heart diseases and stroke.
Q:Early symptoms to look for?
A. Memory loss is one of the first or more recognisable signs of dementia. Other early signs include; asking the same questions repeatedly, forgetting common words when speaking, mixing up words — e.g. saying “bed” instead of “table.”
Some patients will show features such as, taking longer to complete familiar tasks, as following a recipe, misplacing items in inappropriate places, e.g. keeping a wallet in a kitchen drawer, getting lost while walking or driving in a familiar area and changes in mood or behaviour for no apparent reason.
Some early symptoms of AD are difficult in remembering things, particularly new information, such as an appointment you have made.
While people who are aging normally may forget things such as birthdays, they will typically remember them later; that is ‘you remember that you forgot’.
However, with Alzheimer’s disease, that doesn’t happen. You forget something and then you don’t get that information back; it doesn’t seem familiar to you even if someone reminds you. A number of conditions — not only Alzheimer’s disease — can cause memory loss in older adults. Getting prompt diagnosis and appropriate care is important.
Normal age-related memory loss doesn’t prevent you from living a full, productive life. There’s a difference, however, between normal changes in memory and memory loss associated with Alzheimer’s disease.
Q: What age group is most at risk of developing AD? Why?
A. Increasing age is the greatest known risk factor (non-modifiable unlike the ones mentioned above) for Alzheimer’s. Alzheimer’s is not a part of normal aging, but your risk increases greatly after you reach age 65.
The rate of dementia doubles every decade after age 60. People with rare genetic changes linked to early-onset of Alzheimer’s begin experiencing symptoms as early as their 30s.
Q: Gender wise, are men or women more prone to getting AD? Why?
A. Women seem to be more likely than men to develop AD. This in part could be because they live longer.
In addition, the rate of neurodegeneration seems faster in women and the risk of carrying certain genes which increase the risk of AD are more common in women.
Q:How is AD diagnosed? What is the usual procedure followed? Scans?
A. There is no single test or scan to establish the diagnosis. Brain scans may show supportive features but these may be non-specific for AD. Diagnosis of AD is established by evaluation of symptoms and signs, running tests to assess memory impairment and other thinking skills, judge functional abilities, and identify behavioural changes.Tests will also be performed to look for other common causes of dementia, particularly, the reversible ones.
Q:Treatment- how do you treat AD?
A. Based on current medical knowledge, there is no cure for AD. However, some medications may help delay the progression of symptoms associated with AD.
Also, some medicines may help control behavioural symptoms, such as sleeplessness, agitation, wandering, anxiety, and depression.
Depression and anxiety may commonly co-exist and will need referral for counselling/ interventions such as cognitive behaviour therapy, relaxation therapy and multi-sensory stimulation.
Treating these behavioural symptoms often makes people with Alzheimer’s more comfortable and their care easier.
However, these medications only help delaying the progression of symptoms associated with AD and have to be started early in the course of the disease based on recommendation of specialist doctors treating the disease.
Q: Are these treatments available in state hospitals?
A. Most of the medications recommended for treatment are available in Sri Lanka.
Q: As Sri Lanka has a fast aging population, can we expect to see more cases of AD in the future?
A. Yes, definitely due to the aging population we expect to see more patients with AD in the future. Improved awareness of the disease among the public through awareness programs and health education has also contributed to increased turnover of patients seeking medical attention for memory loss.
Q: How long does it take for the disease to progress to its more advanced stages?
A. Symptoms progress at different rates and in different patterns. The appearance and progression of symptoms vary from one person to another. On an average, from the onset of symptoms, people with AD can live from eight years (the average) up to 20 years.
Q: If the person is healthy and follows healthy lifestyles is there a way to delay its progression?
A. Yes, as mentioned before, adopting a lifestyle promoting brain health will reduce the risk of AD. Control of risk factors will also help in slowing down its progression.
Q: Gaps – what do you consider as the most pressing gaps that need to be filled in the detection, diagnosing and treatment of AD patients in the country?
A. Patients with AD should be managed by a multidisciplinary team including Neurologists, Psychiatrists, Neuropsychologists, Specialist Nurses, Occupational Therapists, social workers and care givers.
From a diagnostic and monitoring point of view, lack of Neuropsychologists in the country is a major problem in managing patients with AD. The patients’ family members or relatives are the main care givers in Sri Lanka.
This is an advantage from the patient’s point of view but can cause a major burden on family members.
Q: Residential care in hospitals or nursing homes? How practical are they?
A. Residential care is indicated in advanced stages of the disease with features such as severe impairment of activities of daily living, difficulty in swallowing, frequent infections, incontinence, continued weight loss despite artificial feeding or other concurrent illness. In Sri Lanka, these services are limited even in the private sector and available in nursing homes rather than in hospitals. Providing such services are beyond the scope of professional organisations.
Q: Your message to readers on how to minimise risks of Dementia and AD, and the outcome like Stroke ?
A. Dementia and Stroke account for over two-thirds of patients with neurological disability which could be collectively prevented by adopting a lifestyle that promotes brain health.
A healthy diet with more vegetables and fruit and less salt, sugar and saturated fats, regular physical activity, avoidance of smoking and excessive alcohol intake, control of stress and treatment of high blood pressure and diabetes are the key factors for a healthy lifestyle. Even with the presence of mild symptoms of memory impairment, medical attention should be obtained early so that treatment could be initiated without delay after appropriate investigations.