Clearing Up Alzheimer’s

In this interview, Eric Tangalos, M.D., a primary care physician and geriatrician affiliated with the Alzheimer’s Disease Research Center at Mayo Clinic, Rochester, Minn., explains why older people with memory problems should have a thorough diagnostic workup. If fears are confirmed, information and planning can smooth the path for the ensuing years.

Is an autopsy of the brain the only way to diagnose Alzheimer’s disease?

Many people believe that you have to have the brain at autopsy before you can diagnose Alzheimer’s, but that’s not right. We do that for research, to confirm the diagnosis, but we can also identify the disease clinically with time and other tests.

A two- to four-hour battery of neuropsychological tests is a routine part of our Alzheimer’s research at Mayo Clinic. We compare skill levels of people who may have Alzheimer’s with those of people at the same age and education level. We know that an 85-year-old is not going to function as well as a 75-year-old. These tests show us exactly what people can and cannot do based on comparisons to standard tests of people with the same sex, education and age.

Could you describe these neuropsychological tests?

These are mental tests that look at different functions in the brain. Different parts of the brain do different things. Language can be affected, or problem solving. These tests break down the functions of the brain into more basic elements. Short-term memory is different from long-term memory. Performing calculations is different from remembering words. Drawing pictures is different from working through a maze.

Figuring out what a person can and cannot do not only helps establish the right diagnosis, but also helps determine what the individual is still capable of doing either at work or at home. From these studies and knowing what support they have at home, we can tell if the person can still function independently or if he or she is really on the edge and should be looking for a safer living environment.

Does everyone have to go through a battery of tests?

It is a good idea to have a full evaluation when contemplating the diagnosis. I tell people that there’s not a better investment in time or effort. There are lots of brief tests that can be done in the office, but they can only screen for disease and may miss a problem altogether. Longer cognitive tests are more thorough and provide information that has greater accuracy.

How can people recognize the early signs of Alzheimer’s?

In the earliest stage of the disease, a diagnosis can be really difficult. What you’re looking for is something that doesn’t fit with the individual’s former level of function. That’s why family members often notice the symptoms first. The disease is more than just memory — it can involve language, problem solving or even how we draw a clock.

It’s easy to misplace your car in the parking lot. That’s happened to all of us. But most of us eventually find our cars. People with Alzheimer’s lose the capacity to adjust and solve the problem of the lost car. In fact, they might jump to the conclusion that the car has been stolen.

Alzheimer’s is a progressive disease that first manifests itself with problems usually related to memory. Over time, people have more difficulty with tasks. By the end of the disease process, Alzheimer’s is pretty easy to recognize. Our goal is to find out from family as quickly as possible when something is truly amiss in order to do something about it.

What are the warning signs of Alzheimer’s disease?

The Alzheimer’s Association’s 10 warning signs are:

  1. Memory loss
  2. Difficulty performing familiar tasks
  3. Problems with language
  4. Disorientation to time and place
  5. Poor or decreased judgment
  6. Problems with abstract thinking
  7. Misplacing things
  8. Changes in mood or behavior
  9. Changes in personality
  10. Loss of initiative

At what point in the disease are most people getting diagnosed?

There are three broad stages of Alzheimer’s. The first stage is cognitive decline, the second stage is functional decline and the third stage is behavioral decline — which usually occurs during the last three years of the person’s life.

Most people come in during the second stage, when they are having trouble balancing a checkbook or are getting lost. It’s gotten to the point that something has to be done.

Why don’t people go to their doctor sooner?

There remains a tremendous anxiety regarding Alzheimer’s. They want to blame aging even when they can tell that other people their age aren’t having the same difficulties. People hide their symptoms, or spouses cover for them. There’s a fear of losing control. They don’t want to give up their driving privileges or go in a nursing home. But just because you have a memory problem doesn’t mean you can’t drive a car. We look for what you have retained as well as what you may have lost.

Do some doctors hesitate to make an Alzheimer’s diagnosis?

Many doctors still believe that an early diagnosis of Alzheimer’s would overwhelm both families and physicians. It takes a lot of time and effort to manage the disease, both from the person’s family and from his or her physician. That’s why the Alzheimer’s Association tries to provide resources in the community.

I like to use the Alzheimer’s word sooner rather than later. I don’t want my patients or families to hide from it. We believe in diagnostic disclosure because we think there is a lot that can be done for the problem and that the sooner it is recognized, the more we have available as treatment options.

Today, I think we’re talking about Alzheimer’s as openly as we were starting to talk about cancer 30 years ago and about depression 10 to 15 years ago. It’s a real disease, long before it prevents a person from functioning, and we need to do something about it.

Can magnetic resonance imaging (MRI) or computerized tomography (CT) scans help in diagnosing Alzheimer’s?

There’s no biological marker that shows someone has the disease. The brain typically changes with Alzheimer’s, and those changes can be pretty specific and show up on imaging tests. But that’s not enough to make a diagnosis. There’s a lot of overlap in what we consider normal and abnormal, so even if some areas change on CT or MRI, the person may still function quite well.

In our research, we use brain changes on MRI to help us confirm the possibility of Alzheimer’s. In most clinical settings, brain imaging should be used only to rule out such things as hemorrhages, brain tumors or strokes.

What other diseases should be ruled out?

We’d want to check the thyroid, to rule out problems there. And, in many cases, the symptoms of depression can be mistaken for Alzheimer’s — and vice versa. We also routinely look for vitamin B-12 deficiency and always try to make sure that the person is generally healthy and doesn’t have some other serious medical problem that would complicate our diagnosis. A lot of our older patients have other medical problems that just make things worse — like heart disease, diabetes, kidney disease, lung disease or any combination of these.

Do people need to be referred to a neurologist?

Most of the doctors treating Alzheimer’s are primary care physicians. I’ve asked neurologists for help with a diagnosis, especially with younger patients. But many people, particularly frail older adults, can’t get to any medical center with specialists. It’s just too hard for them to travel.

The problems facing people with Alzheimer’s are issues of society and economy, and these are best handled by a primary care physician, as long as there are resources in the community to help and the doctor has a true interest in understanding the disease and his or her patients with it.

What’s the benefit of an early diagnosis?

There are both drug and nondrug interventions, and everything works best in the earliest stages of disease.

How much do Alzheimer’s drugs help?

Drug therapy is only modestly effective. It’s not a magic bullet, but it can delay or slow the progress of the disease. It’s not like taking an antibiotic and seeing your fever go away, or taking a diuretic and losing 10 pounds. Alzheimer’s drugs help some people more than others, but in general, you end up better on the drugs than not on them. With this disease right now, “better” is just not getting worse.

If drugs don’t help much, why get diagnosed early?

An early diagnosis isn’t just about starting drug therapy. You can change your home environment and simplify the world around you. A lot can be done to make the environment easier for a person with Alzheimer’s. I’m a big fan of motion detectors. They’re inexpensive and can be very handy in the bathroom or on the back staircase. They do the thinking for you, and when attached to a light switch, they turn on a light even before it comes to mind to do it yourself.

You might choose to have a phone with big push buttons. You can put photos of whom you’re calling on the appropriate speed-dial buttons. You can also make small adjustments to improve communication. For example, it’s difficult for people with Alzheimer’s to concentrate on what is being said if there’s noise, like a TV, in the background. The solution is simple: Turn off the TV before you talk.

What else can be done?

People with Alzheimer’s do better when they have a routine. It allows them to refresh and reinforce their pattern of behavior every day. They get to relearn their habits over and over and this is good.

When you put them in strange surroundings, they don’t do well. That’s why they may have trouble when you bring them to your house for the holidays, or if they have to be hospitalized. A change in routine is not good for people with Alzheimer’s — there are just too many problems to try and solve.

The change in routine is one of the reasons why people with Alzheimer’s often have such a swift downturn after the death of a spouse. The spouse may have been helping to both think for and protect the person.

Are there other benefits of early diagnosis?

The earlier you’re diagnosed, the more capable you are of deciding how you want the rest of your life to be structured. Predictable routines will help you succeed instead of fail.

The sooner you move into a structured environment, the more protected you’ll be. The ideal setting is probably one that includes independent housing, assisted living and nursing services on the same campus. The same philosophy is at play throughout, so there’s less to learn with each move.

I tell people to move early or late, but not in the middle stages of their disease. Each move will result in a decline in the person’s retained abilities. In the early stages, the person can adjust to it better. And in the late stages, their function is already extremely impaired. The middle stage is where we can still try to keep the patient from really losing ground, and a move at this time causes the disease to deteriorate even further.

The problem is that most people don’t get diagnosed with Alzheimer’s until they reach the middle stage. If you move them during this middle stage, their function declines and it doesn’t come back.

Is there anything people can do to reduce their risk?

There’s a close link between Alzheimer’s and vascular disease. Baby boomers who are concerned about maintaining their brains should take care of their blood vessels as well. That means exercise, which helps keep your blood pressure and weight down. There’s also emerging evidence that exercising your brain with socialization and tasks might help.

What do you hope to see in the future?

I’d like to see people come in earlier for diagnosis. The real problem is that they’re coming too late. That’s easy to understand because Alzheimer’s is such a devastating disease. But we’d like patients and families to run toward a diagnosis, rather than away from it.

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