Alzheimer's disease: The basics.

In 1906 Alois Alzheimer, a neurologist practicing in Munich Germany, reported on a 51 year old woman who became unexpectedly demented and died of her disease within three years. In this single case report, he noted that under light microscope there were two peculiar finding - plaques and neurofibrillary tangles. For sixty years Alzheimer's disease was felt to be a rare disorder, limited to people before the age of sixty. For dementia cases the diagnostic label was "senile dementia", which was felt to be a vascular disorder. Doctors often told families that their loved one had hardening of the arteries.

About 1970, questions began to arise about the relationship between Alzheimer's disease (rare) and Senile Dementia.

I recall attending a lecture at Washington University School of Medicine (St. Louis) when Dr. Robert Butler from the National Institute of Aging showed the convincing evidence that Senile Dementia was the same as Alzheimer's disease. I remember the sense of amazement but understood that the two illnesses followed roughly the same course, and looked the same under the microscope.

Symptoms of Alzheimer's include:

1.Memory loss affecting job skills or other activities
2.Difficulty performing familiar tasks (apraxia)
3.Problems with language (aphasia)
4.Disorientation regarding time or place
5.Impaired judgment
6.Problems with abstract thinking, math, and balancing checkbooks (acalculia)
7.Misplacing objects
8.Changes in mood or behavior
9.Changes in personality
10.Loss of initiative
11. Memory recruitment (asking loved ones answers to simple questions such as what day is it today?).
12. Altered taste and smell (dysguesia and dysosmia)

The illness is progressive, typically resulting in death within 8 -10 years of first symptoms. As the Alzheimer's progresses wandering or getting lost in familiar places occurs. Agitation with violent behavior or hours of disruptive verbalization (Help! Help!) can manifest in about 20-30% of cases. Clinical (and treatable) depression can occur at any point in the course of the illness, but most frequently manifests in the two years before diagnosis is made.

As the illness enters its final stages, the patient becomes fully disabled. All activities of daily living must be done by others. This includes eating, toilet, and personal hygiene. In the nursing home, the patients require assisted feeding. Diapers are required at all times and care must be taken to prevent decubitus skin ulcers. Dental care and hair care is done for the patient. Often patients forget how to walk at this time, and are confined to bed and wheel chairs. Osteoporosis from inactivity and lack of sun exposure, leaves these patients subject to falls with hip fractures. Verbal skills are often reduced to sounds or near words.

Death occurs when the immune system breaks down. The patients frequently die of pneumonia, flu, or bladder infections that spread into the blood stream.

Often I recommend to families that flu shots and antibiotics be withheld in the final year of life. I have witnessed too many instances where the family requests the infections be repeatedly treated. The patient's debility continues to deteriorate leading to a bed ridden state, and the next infection recurs within a month or so. After the third or fourth cycle of infection, the patient is growing a bacteria which is highly resistant to antibiotics. This makes this non-verbal bedridden patient an infections disease threat to their neighbors in the nursing home.