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Description of the disease

AD is named after Dr. Alois Alzheimer, a German doctor. In 1906, Dr. Alzheimer describedchanges in the brain tissue of a woman who had died of an unusual mental illness. He foundabnormal clumps (now called amyloid plaques) and tangled bundles of fibers (now calledneurofibrillary tangles)."General Information." National Institute on Aging . N.p., n.d. Web. 25 Nov. 2010..

Recent research in India and Africa suggests that the risk of Alzheimers disease waspossibly higher for urban as compared to rural areas. This has raised several important issues forresearch: What is the deciding factor? Is it increased life expectancy? Is it lifestyle? Is it diet?[]

It is generally believed that men and women are equally at risk of Alzheimers disease.However, in developed countries, it is commonly observed that more women than men patientsare to be found in old age homes and special care facilities. This is a reflection of the higherlongevity of women as compared to men, and since this is a disease which strikes older people,there are more women patients than men. There is no evidence that women are at an increasedrisk of the disease than men, when the age factor is correlated in existing data. Also, women arebetter able to care for male patients than men are able to care for female patients. Thus, a womanwith Alzheimers disease has a higher chance of being put into an institution because of herhusbands inability to take care of her. However, a man with Alzheimers disease has a higherchance of his wife taking care of him at home. Thus, a greater number of women patients arefound in institutions. []

Some research studies have suggested that those with higher education are at a lower risk for Alzheimers disease than those with less education. Although this has been repeatedly

demonstrated in several projects, the reason for this association is unknown. []From the available evidence, it would appear that the number of cases of Alzheimersdisease in Asia, and particularly in India and Africa, is lower than that reported from studies indeveloped countries. This raises a major question - why?"ALZHEIMER'S DISEASE : Some facts and figures." WHO SEAR, Regional Health Situation, and World AIDSDay, Health Report . N.p., n.d. Web. 25 Nov. 2010..

As many as 5 million Americans suffer from Alzheimers disease. While younger people mayget Alzheimers disease, it is much less common. The disease usually begins after age 60, andrisk goes up with age. About 5 percent of men and women ages 65 to 74 have Alzheimers

disease, and nearly half of those age 85 and older may have the disease. It is important to note,however, that Alzheimers disease is not a normal part of aging."CDC::Aging - Healthy Brain Initiative: Alzheimer's Disease." Centers for Disease Control and Prevention . N.p.,n.d. Web. 25 Nov. 2010. .

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Causes of the disease

Another characteristic of Alzheimer's disease is that brain cells produce reduced amounts of chemicals, known as neurotransmitters, that are required for communication between nerves.These chemicals include acetylcholine, serotonin, and norepinephrine."Causes and Risk Factors of Alzheimers Disease ." WebMD - Better information. Better health. . N.p., n.d. Web. 25Nov. 2010. .

In all brain regions, one might predict higher NFT counts to be associated with lower[neuropsychological] test scores and a longer disease duration. However, the correlations withtest scores were statistically significant in the expected direction only for NFTs in the nBM.NFT: neurofibrillary tanglenBM: nucleus basalis of Meynert.Samuel, William A., Victor W. Henderson, and Carol A. Miller. "Severity of Dementia in Alzheimer Disease andNeurofibrillary Tangles in Multiple Brain Regions." Alzheimer Disease & Associated Disorders 5.1 (1991): 1-11.Print.

The brains of people with AD have an abundance of two abnormal structuresamyloidplaques and neurofibrillary tanglesthat are made of misfolded proteins (see "ProteinMisfolding" for more information). This is especially true in certain regions of the brain that areimportant in memory.

The third main feature of AD is the loss of connections between cells. This leads todiminished cell function and cell death."The Hallmarks of AD." National Institute on Aging . N.p., n.d. Web. 25 Nov. 2010.

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Symptoms of the disease

Alzheimers disease is a progressive, degenerative brain disorder, clinically defined by agradual decline in both memory and impairment of at least one other area of higher intellectualfunction. Such impairments may include aphasia, apraxia, agnosia, or disturbances in executivefunctioning.Grossberg, George T., and Sanjeev M. Kamat. Alzheimer's: the latest assessment and treatment strategies . Sudbury,Mass.: Jones and Bartlett Publishers, 2011. Print.

MildMemory lossConfusion about the location of familiar places (getting lost begins to occur)Taking longer than before to accomplish normal daily tasksTrouble handling money and paying billsPoor judgment leading to bad decisionsLoss of spontaneity and sense of initiativeMood and personality changes, increased anxiety and/or aggressionModerateIncreasing memory loss and confusionShortened attention spanInappropriate outbursts of angerProblems recognizing friends and family membersDifficulty with language and problems with reading, writing, and working with numbers

Difficulty organizing thoughts and thinking logicallyInability to learn new things or to cope with new or unexpected situationsRestlessness, agitation, anxiety, tearfulness, wanderingespecially in the late afternoon or at nightRepetitive statements or movement, occasional muscle twitchesHallucinations, delusions, suspiciousness or paranoia, irritabilityLoss of impulse control (shown through undressing at inappropriate times or places or vulgar language)An inability to carry out activities that involve multiple steps in sequence, such as dressing, making a pot of coffee,or setting the tableSevereWeight lossSeizuresSkin infectionsDifficulty swallowingGroaning, moaning, or gruntingIncreased sleepingLack of bladder and bowel control

"The Changing Brain in AD." National Institute on Aging . N.p., n.d. Web. 25 Nov. 2010..

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EarlyShort-term memory loss is the most common early symptom of Alzheimers disease. Do you have troubleremembering recent conversations or events?Difficulty performing familiar tasks. Are you stumped by everyday activities, like brushing your teeth, washingyour hair, or making a telephone call?Disorientation. Do you get lost in your own neighborhood? Do you find yourself putting household items in placesthey dont belong, like placing a book in the refrigerator?Increasing problems with planning and managing. Have activities like balancing your checkbook, paying bills,or preparing a shopping list become more difficult?

Trouble with language. Are you unable to recall words for everyday things? For example, does car become thatthing I drive or chair that thing I sit on?Rapid, unpredictable mood swings. Do you suddenly shift from happy to sad or from calm to angry with noapparent reason?Lack of motivation. Have activities you have always loved lost their appeal? Do you see less of your friends &family? Are you spending more time staring at the television?Changes in sleep. Do you sleep more than usual? Do you sleep during the day rather than at night?

MiddleDifficulty completing everyday tasks, such as getting dressed, going to bathroom, or preparing mealsHallucinationsStrong feelings of paranoia and angerWandering

LateInability to communicate with or recognize other peopleInability to walk Difficulty swallowingInability to smile

"Alzheimers Disease Symptoms." WebMD - Better information. Better health. . N.p., n.d. Web. 25 Nov. 2010..

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Tests and treatments

Four medications, tested in clinical trials, have been approved by the FDA for use in treatingAD symptoms. Donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne)are prescribed to treat mild to moderate AD symptoms. Donepezil was recently approved to treatsevere AD as well. These drugs, known as cholinesterase inhibitors, act by stopping or slowingthe action of acetylcholinesterase, an enzyme that breaks down acetylcholine. They help to

maintain higher levels of acetylcholine in the brain. In some people, the drugs maintain abilitiesto carry out activities of daily living. They also may maintain some thinking, memory, orspeaking skills, and can help with certain behavioral symptoms. However, they will not stop orreverse the underlying progression of AD and appear to help people only for months to a fewyears. The newest approved AD medication is memantine (Namenda), which is prescribed totreat moderate to severe AD symptoms. This drug appears to work by regulating levels of glutamate, another neurotransmitter involved in memory function. Like the cholinesteraseinhibitors, memantine will not stop or reverse AD."The Search for New Treatments." National Institute on Aging . N.p., n.d. Web. 25 Nov. 2010..

Step 1: In evaluating a patient, the physician will need to check if there is a substantialdeterioration in the intellectual function of the aged person relative to his/her previousstatus, who otherwise seems to be in good physical condition. In medical terms, it is necessary toseek evidence of dementia.

Doctors will administer neuropsychological tests to check various components of intellectual function. Examples of such tests are the Fuld Object Memory Test in which patientsare shown 10 objects and then asked to memorize this list of objects and repeat it to theexaminer. An average healthy adult should be easily able to recall 7-8 objects. However, patientsof Alzheimers disease can recall only one or two objects. Another neuropsychological test is theBoston Naming Test in which subjects are shown various objects and asked to name them. Mosthealthy people can easily name these objects, while patients with Alzheimers disease have

trouble naming even such simple objects as a comb or a pen. Similarly, there areneuropsychological tests for speech, calculation, problem-solving and judgement. Based on theresults of these tests, loss of intellectual functions can be documented.

Step 2: The doctor needs to ensure that the loss of intellectual functioning is severeenough to disable the person in activities of daily living. Patients of Alzheimers disease areextremely disabled in function. When loss of intellectual function is so severe that it leads todisabilities, conditions for Step 2 in the diagnosis of Alzheimers disease are met.

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Step 3: In the diagnosis of Alzheimers disease, it is important to exclude other causes of loss of intellectual function. For this purpose, doctors will take a detailed history of the patientsillness from their relatives, then conduct a comprehensive medical, neurological andneuropsychological examination. Blood tests and X-ray tests, such as CT scan and MRI scan,will help to exclude conditions such as thyroid disease, brain tumour or stroke. In Alzheimers

disease, CT and MRI scans show a shrinking of the brain. This is medically referred to as"cortical atrophy"."ALZHEIMER'S DISEASE : Diagnosis of Alzheimer's disease." WHO SEAR, Regional Health Situation, and World AIDS Day, Health Report . N.p., n.d. Web. 25 Nov. 2010..

The combination of drugs with different mechanisms of action may be more effectivethan individual medications alone. Choline precursors have been combined with ChEIs withoutobservable benefit. Most practicing clinicians would not combine two ChEIs since their actionsare not additive. The combination of ChEIs with vitamin E or Ginkgo biloba does not appear toworsen adverse effects; however, there is no efficacy evidence for this practice. Selegiline has

been combined with ChEIs in small pilot studies suggesting an additive effect, but this remainsto be replicated.

The most notably beneficial strategy of combined mechanisms is that of memantinecombined with the commonly used ChEI donepezil. In a large, placebo-controlled clinical trial,memantine significantly improved cognitive, global, and functional outcomes in patients withmoderate to severe AD maintained on stable doses of donepezil compared with the ChEItreatment alone. Since these findings will likely have a significant impact on clinical practice, itwill be helpful to know the effects of memantine in combination with other ChEIs in moderate tosevere AD, as well as in earlier stages of the disease.Tariot, Pierre N., and Howard J. Federoff. "Current Treatment for Alzheimer Disease and FutureProspects." Alzheimer Disease & Associated Disorders 17.4 (2003): S105-S113. Print.

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