Mild Alzheimer’s Disease

As Alzheimer’s disease progresses, people experience greater memory loss and other cognitive difficulties. Problems can include wandering and getting lost, trouble handling money and paying bills, repeating questions, taking longer to complete normal daily tasks, and personality and behavior changes. People are often diagnosed in this stage.

Moderate Alzheimer’s Disease

In this stage, damage occurs in areas of the brain that control language, reasoning, sensory processing, and conscious thought. Memory loss and confusion grow worse, and people begin to have problems recognizing family and friends. They may be unable to learn new things, carry out multistep tasks such as getting dressed, or cope with new situations. In addition, people at this stage may have hallucinations and may behave impulsively.

Severe Alzheimer’s Disease

Ultimately, plaques and tangles spread throughout the brain, and brain tissue shrinks significantly. People with severe Alzheimer’s cannot communicate and are completely dependent on others for their care. Near the end, the person may be in bed most or all of the time as the body shuts down.

Alzheimer’s: Causes and Basic facts

What Causes Alzheimer’s

Scientists don’t yet fully understand what causes Alzheimer’s disease in most people. In people with early-onset Alzheimer’s, a genetic mutation is usually the cause. Late-onset Alzheimer’s arises from a complex series of brain changes that occur over decades. The causes probably include a combination of genetic, environmental, and lifestyle factors. The importance of any one of these factors in increasing or decreasing the risk of developing Alzheimer’s may differ from person to person.

The Basics of Alzheimer’s

Scientists are conducting studies to learn more about plaques, tangles, and other biological features of Alzheimer’s disease. Advances in brain imaging techniques allow researchers to see the development and spread of abnormal amyloid and tau proteins in the living brain, as well as changes in brain structure and function. Scientists are also exploring the very earliest steps in the disease process by studying changes in the brain and body fluids that can be detected years before Alzheimer’s symptoms appear. Findings from these studies will help in understanding the causes of Alzheimer’s and make diagnosis easier.

One of the great mysteries of Alzheimer’s disease is why it largely strikes older adults. Research on normal brain aging is shedding light on this question. For example, scientists are learning how age-related changes in the brain may harm neurons and contribute to Alzheimer’s damage. These age-related changes include atrophy (shrinking) of certain parts of the brain, inflammation, production of unstable molecules called free radicals, and mitochondrial dysfunction (a breakdown of energy production within a cell).

Genetics

Most people with Alzheimer’s have the late-onset form of the disease, in which symptoms become apparent in their mid-60s. The apolipoprotein E (APOE) gene is involved in late-onset Alzheimer’s. This gene has several forms. One of them, APOE ε4, increases a person’s risk of developing the disease and is also associated with an earlier age of disease onset. However, carrying the APOE ε4 form of the gene does not mean that a person will definitely develop Alzheimer’s disease, and some people with no APOE ε4 may also develop the disease.

Also, scientists have identified a number of regions of interest in the genome (an organism’s complete set of DNA) that may increase a person’s risk for late-onset Alzheimer’s to varying degrees.

Early-onset Alzheimer’s occurs in people age 30 to 60 and represents less than 5 percent of all people with Alzheimer’s. Most cases are caused by an inherited change in one of three genes, resulting in a type known as early-onset familial Alzheimer’s disease, or FAD. For others, the disease appears to develop without any specific, known cause, much as it does for people with late-onset disease.

Most people with Down syndrome develop Alzheimer’s. This may be because people with Down syndrome have an extra copy of chromosome 21, which contains the gene that generates harmful amyloid.

Health, Environmental, and Lifestyle Factors

Research suggests that a host of factors beyond genetics may play a role in the development and course of Alzheimer’s disease. There is a great deal of interest, for example, in the relationship between cognitive decline and vascular conditions such as heart disease, stroke, and high blood pressure, as well as metabolic conditions such as diabetes and obesity. Ongoing research will help us understand whether and how reducing risk factors for these conditions may also reduce the risk of Alzheimer’s.

A nutritious diet, physical activity, social engagement, and mentally stimulating pursuits have all been associated with helping people stay healthy as they age. These factors might also help risk of cognitive decline and Alzheimer’s disease. Clinical trials are testing some of these possibilities.

Leslie Kernisan, MD MPH

Recently, while I was at a family celebration, several people mentioned memory concerns to me.

Some were older adults concerned about the memory of their spouses. Some were adult children concerned about the memory of their parents. And a few were older adults who have noticed  some slowing down of their own memory.

“But you know, nothing much that can be done at my age,” remarked one man in his eighties.

Wrong. In fact, there is a lot that can and should be done, if you notice memory or thinking changes in yourself or in another older adult. And you should do it because it ends up making a difference for brain health and quality of life.

First among them: identify medications that make brain function worse.

I cannot tell you how often I find that seniors are taking over-the-counter or prescription medications that dampen their brain function. Sometimes it’s truly necessary but often it’s not.

What especially troubles me is that most of these older adults — and their families — have no idea that many have been linked to developing dementia, or to worsening of dementia symptoms. So it’s worth spotting them whether you are concerned about mild cognitive impairment or caring for someone with full-blown Alzheimers.

Every older adult and family should know how to optimize brain function. Avoiding problem medications — or at least using them judiciously and in the lowest doses necessary — is key to this.

And don’t give anyone a pass when they say “Oh, I’ve always taken this drug.” Younger and healthier brains experience less dysfunction from these drugs. That’s because a younger brain has more processing power and is more resilient. So drugs that aren’t such problems earlier in life often have more impact later in life. Just because you took a drug in your youth or middle years doesn’t mean it’s harmless to continue once you are older.

Below, I share the most commonly used drugs that you should look out for if you are worried about memory problems.

The Four Most Commonly Used Types of Medications That Dampen Brain Function

1. Benzodiazepines. This class of medication is often prescribed to help people sleep, or to help with anxiety. They do work well for this purpose, but they are habit-forming and have been associated with developing dementia.

• Commonly prescribed benzodiazepines include lorazepam, diazepam, temazepam, alprazolam (brand names Ativan, Valium, Restoril, and Xanax, respectively)
• For more on the risks of benzodiazepines, plus a handout clinically proven to help seniors reduce their use of these drugs, see “How You Can Help Someone Stop Ativan.”
• Note that it can be dangerous to stop benzodiazepines suddenly. These drugs should always be tapered, under medical supervision.
• Alternatives to consider:
  • For insomnia, there is no easy and fast alternative. Just about all sedatives — many are listed in this post — dampen brain function. Many people can learn to sleep without drugs, but it usually takes a comprehensive effort over weeks or even months. This may involve cognitive-behavioral therapy, as well as increased exercise and other lifestyle changes. You can learn more about comprehensive insomnia treatment by getting the Insomnia Workbook (often available at the library!) or something similar.
  • For anxiety, there is also no easy replacement. However, there are some drug options that affect brain function less, such as SSRIs (e.g. sertraline and citalopram, brand names Zoloft and Celexa). Cognitive behavioral therapy and mindfulness therapy also helps, if sustained.
  • Even if it’s not possible to entirely stop a benzodiazepine, tapering to a lower dose will likely help brain function in the short-term.
• Other risks in seniors:
  • Benzodiazepines increase fall risk.
  • These drugs sometimes are abused, especially in people with a history of substance abuse.
• Other things to keep in mind:
  • If a person does develop dementia, it becomes much harder to stop these drugs. That’s because everyone has to endure some increased anxiety, agitation, and/or insomnia while the senior adjusts to tapering these drugs, and the more cognitively impaired the senior is, the harder it is on everyone. So it’s much better to find non-benzo ways to deal with anxiety and insomnia sooner, rather than later. (Don’t kick that can down the road!)

2. Non-benzodiazepine prescription sedatives.

By far the most commonly used are the “z-drugs” which include zolpidem, zaleplon, and eszopiclone (brand names Ambien, Sonata, and Lunesta, respectively). These have beenshown in clinical studies to impair thinking — and balance! — in the short-term.

• Some studies have linked these drugs to dementia. However we also know that developing dementia is associated with sleep problems, so the cause-effect relationship remains a little murky.
• For alternatives, see the section about insomnia above.
• Occasionally, geriatricians will try trazodone (25-50mg) as a sleep aid. It is thought to be less risky than the z-drugs or benzodiazepines. Of course, it seems to have less of a strong effect on insomnia as well.
• Other risks in seniors:
  • These drugs worsen balance and increase fall risk.

3. Anticholinergics. This group covers most over-the-counter sleeping aids, as well as a variety of other prescription drugs. These medications have the chemical property of blocking the neurotransmitter acetylcholine. This means they have the opposite effect of an Alzheimer’s drug like donepezil (brand name Aricept), which is a cholinesterase inhibitor, meaning it inhibits the enzyme that breaks down acetylcholine. A 2015 studyfound that greater use of these drugs was linked to a higher chance of developing Alzheimer’s.

Drugs vary in how strong their anticholinergic activity is. Focus your energies on spotting the ones that have “high” anticholinergic activity. For a good list that classifies drugs as high or low anticholinergic activity, see here.

I reviewed the most commonly used of these drugs in my NextAvenue article, “7 Common Drugs That Are Toxic for Your Brain.” Briefly, drugs of this type to look out for include:

• Sedating antihistamines, such as diphenhydramine (brand name Benadryl).
• The “PM” versions of over-the-counter analgesics (e.g. Nyquil, Tylenol PM); the “PM” ingredient is usually a sedating antihistamine.
• Medications for overactive bladder, such as the bladder relaxants oxybutynin and tolterodine (brand names Ditropan and Detrol, respectively).
  • Note that medications that relax the urethra, such as tamsulosin or terazosin (Flomax and Hytrin, respectively) are NOT anticholinergic. So they’re not risky in the same way, although they can cause orthostatic hypotension and other problems in older adults. Medications that shrink the prostate, such as finasteride (Proscar) aren’t anticholinergic either.
• Medications for vertigo, motion sickness, or nausea, such as meclizine, scopolamine, or promethazine (brand names Antivert, Scopace, and Phenergan).
• Medications for itching, such as hydroxyzine and diphenhydramine (brand names Vistaril and Benadryl).
• Muscle relaxants, such as cyclobenzaprine (brand name Flexaril).
• “Tricyclic” antidepressants, which are an older type of antidepressant which is now mainly prescribed for nerve pain, and includes amitryptiline and nortriptyline (brand names Elavil and Pamelor).

For help spotting other anticholinergics, ask a pharmacist or the doctor, or review the list.

Alternatives to these drugs really depend on what they are being prescribed for. Often non-drug alternatives are available, but they may not be offered unless you ask. For example, an oral medication for itching can be replaced by a topical cream. Or the right kind of stretching can help with tight muscles.

Aside from affecting thinking, these drugs can potentially worsen balance. They also are known to cause dry mouth, dry eyes, and can worsen constipation. (Acetylcholine helps the gut keep things moving.)

4. Antipsychotics and mood-stabilizers. In older adults, these are usually prescribed to manage difficult behaviors related to Alzheimer’s and other dementias. (In a minority of seniors, they are prescribed for serious mental illness such as schizophrenia. Mood-stabilizing drugs are also used to treat seizures.) For dementia behaviors, these drugs are often inappropriately prescribed, as in this recent NYT story. All antipsychotics and mood-stabilizers are sedating and dampen brain function. In older people with dementia, they’ve also been linked to a higher chance of dying.

• Commonly prescribed antipsychotics are mainly “second-generation” and include risperidone, quetiapine, olanzapine, and aripiprazole (Risperdal, Seroquel, Zyprexa, and Abilify, respectively).
• The first-generation antipsychotic haloperidol (Haldol) is still sometimes used.
• Valproate (brand name Depakote) is a commonly used mood-stabilizer.
• Alternatives to consider:
  • Alternatives to these drugs should always be explored. Generally you need to start by properly assessing what’s causing the agitation, and trying to manage that. A number of behavioral approaches can also help with difficult behaviors. For more, see this nice NPR story from March 2015.
  • For medication alternatives, there is some scientific evidence suggesting that the SSRI citalopram may help, that cholinesterase inhibitors such as donepezil may help, and that the dementia drug memantine may help. These are usually well-tolerated so it’s often reasonable to give them a try.
• If an antipsychotics or mood-stabilizer is used, it should be as a last resort and at the lowest effective dose. This means starting with a teeny dose. However, many non-geriatrician clinicians start at much higher doses than I would.
• Other risks in seniors:
  • Antipsychotics have been associated with falls. There is also increased risk of death, as above.
• Caveat regarding discontinuing antipsychotics in people with dementia: Research has found that there is a fair risk of “relapse” (meaning agitation or psychotic symptoms getting worse) after  antipsychotics are discontinued. A 2015 study of nursing home residents with dementia concluded that antipsychotic discontinuation is most likely to succeed if it’s combined with adding more social interventions and also exercise.

A Fifth Type of Medication That Affects Brain Function

Opiate pain medications. Unlike the other drugs mentioned above, opiates (other than tramadol) are not on the Beer’s list of medications that older adults should avoid. That said, they do seem to dampen thinking abilities a bit, even in long-term users. (With time and regular use, people develop tolerance so they are less drowsy, but seems there can still be an effect on thinking.) As far as I know, opiates are not thought to accelerate long-term cognitive decline.

• Commonly prescribed opiates include hydrocodone, oxycodone, morphine, codeine, methadone, hydromorphone, and fentanyl. (Brand names depend on the formulation and on whether the drug is mixed with acetaminophen.)
• Tramadol (brand name Ultram) is a weaker opiate with weaker prescribing controls.
  • Many geriatricians consider it more problematic than the classic Schedule II opiates listed above, as it interacts with a lot of medications and still affects brain function. It’s a “dirty drug,” as one of my friends likes to say.
• Alternatives depend on what type of pain is present. Generally, if people are taking opiates then they have pain that needs to be treated. However, a thoughtful holistic approach to pain often enables a person to get by with less medication, which can improve thinking abilities.
• For people who have moderate or severe dementia, it’s important to know that untreated pain can worsen their thinking. So sometimes a low dose of opiate medication does end up improving their thinking.
• Other risks in seniors:
  • There is some risk of developing a problematic addiction, although that’s uncommon unless there’s a prior history of substance abuse. In my experience, having someone else — usually younger — steal or use the drugs is a more likely problem.

Where to Learn About Other Drugs That Affect Brain Function

Many other drugs that affect brain function, but they are either not used as often as the ones above, or seem to affect a minority of older adults.

Notably, there has been a lot of concern in the media about statins, but ameta-analysis published in 2015 could not confirm an association between statin use and cognitive impairment. This doesn’t mean that statins aren’t overprescribed or riskier than we used to think, and it’s also quite possible that a minority of people do have their thinking affected by statins. But if you are trying to eliminate medications that dampen brain function, I would recommend you focus on the ones I listed above first.

For a comprehensive list of medications identified as risky by the experts at the American Geriatrics Society, be sure to review the 2012 Beer’s Criteria.

What to Do if You or Your Relative Is On These Medications

So what should you do if you discover that your older relative — or you yourself — are taking some of these medications?

If it’s an over-the-counter anticholinergic, you can just stop it. Allergies can be treated with non-sedating antihistamines like loratadine (brand name Claritin), or you can ask the doctor about a nasal steroid spray. “PM” painkillers can be replaced by the non-PM version, and remember that the safest OTC analgesic for older adults is acetaminophen (Tylenol).

If you are taking an over-the-counter sleep aid, it contains a sedating antihistamine and those are strongly anticholinergic. You can just stop an OTC sleep aid, but in the short term, insomnia often gets worse. So you’ll need to address the insomnia with non-drug techniques. You can also bring it up with the doctor — it’s important to rule out pain and serious medical problems as a cause of insomnia — but be careful: many of them will prescribe a sleeping pill, because they haven’t trained in geriatrics and they under-estimate the risks of these drugs.

If one or more of the medications above has been prescribed, don’t stop without first consulting with a health professional. You’ll want to make an appointment soon, to review the reasons that the medication was prescribed, alternative options for treating the problem, and then work out a plan to reduce or eliminate the drug.

To prepare for the appointment, try going through the five steps I describe in this article: “How to Review Medications for Safety & Appropriateness.”

I also recommend reviewing HealthinAging.org’s guide, “What to Ask Your Health Provider if a Medication You Take is Listed in the Beers Criteria.”

Remember, when it comes to maintaining independence and quality of life, nothing is more important than optimizing brain function.

We can’t turn back the clock and not all brain changes are reversible. But by spotting problem medications and reducing them whenever possible, we can help older adults think their best.

Leslie Kernisan, MD MPH

If you have concerns about an aging parent’s memory, you’ve probably wondered if they have Alzheimer’s disease or another dementia. After all, you already know it’s fairly common for older people to start slipping mentally, and the Alzheimer’s Association estimates that the lifetime risk for a woman in her 60s is one in six.

What to do about your concerns and worries? Whether you search online or ask friends, most advice boils down to this: Tell the doctor.

This advice isn’t wrong. But, it’s incomplete.

Yes, you should tell the doctor you’re worried. (If you’re worried about upsetting your parent, send the doctor your concerns in writing. No HIPAA authorization is needed for you to share your concerns with a parent’s health professional.)

But if you, your parent and the doctor truly want to get to the bottom of things, you can take a simple approach that is incredibly effective. Start taking notes on the eight behaviors known to correspond with Alzheimer’s.

By doing so, you’ll be gathering the kind of detailed information that doctors (like myself) need in order to confirm thinking problems and detect the likely disease.

8 Alzheimer’s Behaviors to Track

For each of the behaviors we’ll discuss, try to jot down the following:

• Whether there’s been a decline or change compared to the way your parent used to be
• Whether this seems to be due to memory and thinking, versus physical limitations such as pain, shortness of breath or physical disabilities
• When you – or another person – first noticed problems, and what you observed
• What kinds of problems you see your parent having now

Note: If you don’t notice a problem in any of the following eight areas, be specific in documenting this. (E.g., “No such problem noted.”) That way, you and your family will know you didn’t just forget to consider that behavior.

The Eight Behaviors

1. Poor Judgment

Have you noticed any behaviors or situations that seem to indicate bad decisions? Any unusual or excessive spending? Or perhaps a poor understanding of safety concerns that everyone else is worried about? Write down anything you or another person close to your parents has reported or observed.

2. Reduced Interest in Leisure Activities

Have you noticed that your parent no longer seems as interested or involved in his hobbies? Did your mother read voraciously but now hardly makes progress on her novel? Has your dad given up his bridge games? Any change in hobbies or leisure activities should be noted, especially if such a change doesn’t seem to be related to a problem with physical health.

3. Repeating Oneself

Any repeating of stories? Any asking the same questions repeatedly? Has your parent been declaring the same thing (“I really love those roses you gave me.”) over and over again? If so, jot that down.

4. Difficulty Learning to Use Something New

Any difficulty learning to use a new gadget, such as a smartphone? Any trouble with a new appliance? Make note of what your parent has difficulty adapting to and how he tried to manage.

5. Forgetting the Year or Month

Any difficulty keeping track of the current year or month? If it happens more than once, make a note of that especially.

6. Difficulty Managing Money and Finances

Have you noticed any problems managing bills, expenses or taxes? You might have to ask your parents about this if you aren’t usually involved in their finances.

7. Problems with Appointments and Commitments

Has your parent missed any appointments or forgotten about a get-together that you’d planned? Everyone forgets something occasionally, but if this has happened repeatedly, be sure to document when it started and how bad it’s gotten.

8. Daily Struggles with Memory or Thinking

It’s normal for older adults to have a lapse here and there. But if your parent seems to experience a memory or thinking problem every day, make a note of this. It’s a good idea to add specific examples describing what you – or another person – observed.

Why Tracking These Behaviors Can Help Detect Alzheimer’s Disease

The eight behaviors above correspond to the brain ability’s to manage memory, judgment, learning or complex tasks.

To diagnose Alzheimer’s or another dementia, your parent’s doctors must document that your parent has been having persistent difficulties in two or more areas related to brain function. (This is necessary but not sufficient for diagnosis – the doctors must also rule out other causes for thinking problems.)

Now, doctors can assess the different aspects of brain function through certain office-based thinking tests. However, research has found that asking family members about the behaviors above can be just as effective when it comes to spotting probable dementia, including Alzheimer’s disease.

In fact, a questionnaire covering the eight behaviors above has been extensively tested by dementia experts. It’s called the AD8 Informant Interview.

Getting this type of observational information from family members helps doctors determine whether the behavior is a persisting, and maybe even worsening, problem. This matters because a single office-based test only provides a snapshot of how your parent’s brain is doing on that day.

Last but not least, geriatricians such as myself love getting these kinds of behavioral observations from families. Why? Well, it’s practical information related to people’s daily lives. By knowing more about what kinds of problems an older person has been experiencing, we can make useful recommendations right away to help families with safety, independence and even family conflicts.

How to Help Your Family Get the Right Care

Doctors who are knowledgeable about dementia will ask a family about problems related to the eight behaviors above.

Unfortunately, many primary care doctors aren’t experienced in evaluating dementia. I’ve had worried families tell me that other doctors waved off their concerns or told them this is just what happens when people age.

Such things happen partly because families are often a bit vague when they voice concerns. This means the doctor has to do more work in investigating the concern and in documenting specific problems that can help diagnose Alzheimer’s. Some doctors will do this work, but since office visits are often rushed, many of them won’t get around to it.

Unless that is, you bring detailed information to help the doctors take further action. The more specifics you can share regarding what you’ve observed, the more likely you’ll get the help your parent and your family need.

Plus, whether or not Alzheimer’s caused these behaviors, they often cause anxiety and frustration within families. So it’s important to bring them up to a doctor so that you can get help understanding the cause and learn what to do next.

Don’t go on for too long with the worrying and the wondering. Take notes so that you can then take better action.

Drinking and Driving

Adults of all ages who drink and drive are at higher risk of traffic accidents and related problems than those who do not drink. Drinking slows reaction times and coordination and interferes with eye movement and information processing. People who drink even a moderate amount can have traffic accidents, possibly resulting in injury or death to themselves and others. Even without alcohol, the risk of crashes goes up starting at age 55. Also, older drivers tend to be more seriously hurt in crashes than younger drivers. Alcohol adds to these age-related risks.

In all states, it is against the law for people to drive if their blood alcohol concentration (BAC) is above .08. Blood alcohol concentration measures the percentage of ethanol—the chemical name for alcohol—in a person’s blood. The higher the BAC, the more impaired a person is. The amount of alcohol consumed, gender, weight, and body fat all affect a person’s BAC. A BAC below the legal limit can still impair driving skills. Some people are impaired even when they don’t think they are. If you plan to drive, don’t drink. If you drink, let someone else who has not been drinking do the driving.

Drinking and Relationships

Alcohol misuse and abuse can strain relationships with family members, friends, and others. At the extreme, heavy drinking can contribute to domestic violence and child abuse or neglect. Alcohol use is often involved when people become violent as well as when they are violently attacked. If you feel that alcohol is endangering you or someone else, call 911 or get other help right away.

Signs of Problem Drinking

It’s not always obvious that someone drinks too much. For older adults, clues to a possible alcohol use disorder include memory loss, depression, anxiety, poor appetite, unexplained bruises, falls, sleeping problems, and inattention to cleanliness or appearance. Answering “yes” to at least one of the following questions is also a sign of a possible drinking problem.

• Have you ever felt you should cut down on your drinking?
• Have people annoyed you by criticizing your drinking?
• Have you ever felt bad or guilty about your drinking?
• Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

If you answered “yes” to any of these questions, talk with your health care provider. Also seek help if you feel you are having drinking-related problems with your health, relationships, or work.

Reasons Older Adults May Drink

Older adults drink for different reasons than do younger adults. Some have been drinking for many years and are physically dependent on alcohol. Others start drinking later in life because of health problems, boredom after retirement, or loneliness after the death of a spouse or close friend. This is called “late-onset drinking.” Feeling tense or depressed can also trigger drinking.

People Can Be Treated Successfully

Most people with alcohol problems can be treated successfully. People with an alcohol use disorder and those who misuse alcohol and cannot stay within healthy drinking limits should stop drinking altogether. Others can cut back until their drinking is under control. Changing drinking habits isn’t easy. Often it takes more than one try to succeed. But people don’t have to “go it alone.” There are plenty of sources of help.

(Watch the video to learn more about getting help for alcohol use disorder (AUD). To enlarge the video, click the brackets in the lower right-hand corner. To reduce the video, press the Escape (Esc) button on your keyboard.)

Treatment for Alcohol Problems

A doctor can help decide the best treatment for people with alcohol problems. Many people need more than one kind of treatment. Medicines can help people with an alcohol use disorder quit drinking. Meeting with a therapist or substance-abuse counselor or with a support group may also help. Support from family and friends is important, too. A doctor can help a person decide on the best treatment. Making a change sooner rather than later makes treatment more likely to succeed.

Older people with alcohol problems respond to treatment as well as younger people. Some studies suggest that older adults do better when they are treated with other people the same age instead of mixed in with younger adults. Some communities have treatment programs and support groups specifically for older adults.

As people age, sometimes any sign of forgetfulness or mild confusion is immediately classified or referred to as Alzheimer’s disease. In fact, Alzheimer’s disease is one part of a much larger spectrum of cognitive impairment called dementia.

Dementia:  Is the loss of cognitive functioning—thinking, remembering, and reasoning—and behavioral abilities to such an extent that it interferes with a person’s daily life and activities. Dementia ranges in severity from the mildest stage, when it is just beginning to affect a person’s functioning, to the most severe stage, when the person must depend completely on others for basic activities of daily living.

Alzheimer’s disease: Alzheimer’s is the most common cause of dementia among older adults.

Is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks. In most people with Alzheimer’s, symptoms first appear in their mid-60s. Estimates vary, but experts suggest that more than 5 million Americans may have Alzheimer’s.

Alzheimer’s disease is currently ranked as the sixth leading cause of death in the United States, but recent indicate that the disorder may rank third, just behind heart disease and cancer, as a cause of death for older people.

The causes of dementia: Causes can vary, depending on the types of brain changes that may be taking place. Other dementias include Lewy body dementia, frontotemporal disorders, and vascular dementia. It is common for people to have mixed dementia—a combination of two or more disorders, at least one of which is dementia. For example, some people have both Alzheimer’s disease and vascular dementia.

Alzheimer’s disease is named after Dr. Alois Alzheimer. In 1906, Dr. Alzheimer noticed changes in the brain tissue of a woman who had died of an unusual mental illness. Her symptoms included memory loss, language problems, and unpredictable behavior. After she died, he examined her brain and found many abnormal clumps (now called amyloid plaques) and tangled bundles of fibers (now called neurofibrillary, or tau, tangles).

These plaques and tangles in the brain are still considered some of the main features of Alzheimer’s disease. Another feature is the loss of connections between nerve cells (neurons) in the brain. Neurons transmit messages between different parts of the brain, and from the brain to muscles and organs in the body.

Scientists continue to unravel the complex brain changes involved in the onset and progression of Alzheimer’s disease. It seems likely that damage to the brain starts a decade or more before memory and other cognitive problems appear. During this preclinical stage of Alzheimer’s disease, people seem to be symptom-free, but toxic changes are taking place in the brain. Abnormal deposits of proteins form amyloid plaques and tau tangles throughout the brain, and once-healthy neurons stop functioning, lose connections with other neurons, and die.

The damage initially appears to take place in the hippocampus, the part of the brain essential in forming memories. As more neurons die, additional parts of the brain are affected, and they begin to shrink. By the final stage of Alzheimer’s, damage is widespread, and brain tissue has shrunk significantly

Signs and Symptoms

Memory problems are typically one of the first signs of cognitive impairment related to Alzheimer’s disease. Some people with memory problems have a condition called mild cognitive impairment(MCI). In MCI, people have more memory problems than normal for their age, but their symptoms do not interfere with their everyday lives. Movement difficulties and problems with the sense of smell have also been linked to MCI. Older people with MCI are at greater risk for developing Alzheimer’s, but not all of them do. Some may even go back to normal cognition.

The first symptoms of Alzheimer’s vary from person to person. For many, decline in non-memory aspects of cognition, such as word-finding, vision/spatial issues, and impaired reasoning or judgment, may signal the very early stages of Alzheimer’s disease. Researchers are studying biomarkers (biological signs of disease found in brain images, cerebrospinal fluid, and blood) to see if they can detect early changes in the brains of people with MCI and in cognitively normal people who may be at greater risk for Alzheimer’s. Studies indicate that such early detection may be possible, but more research is needed before these techniques can be relied upon to diagnose Alzheimer’s disease in everyday medical practice.

Publication Date: March 2014

Doctors use several methods and tools to help determine whether a person who is having memory problems has “possible Alzheimer’s dementia” (dementia may be due to another cause) or “probable Alzheimer’s dementia” (no other cause for dementia can be found).

To diagnose Alzheimer’s, doctors may:

• Ask the person and a family member or friend questions about overall health, past medical problems, ability to carry out daily activities, and changes in behavior and personality
• Conduct tests of memory, problem solving, attention, counting, and language
• Carry out standard medical tests, such as blood and urine tests, to identify other possible causes of the problem
• Perform brain scans, such as computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET), to rule out other possible causes for symptoms.

These tests may be repeated to give doctors information about how the person’s memory and other cognitive functions are changing over time.

Alzheimer’s disease can be definitely diagnosed only after death, by linking clinical measures with an examination of brain tissue in an autopsy.

People with memory and thinking concerns should talk to their doctor to find out whether their symptoms are due to Alzheimer’s or another cause, such as stroke, tumor, Parkinson’s disease, sleep disturbances, side effects of medication, an infection, or a non-Alzheimer’s dementia. Some of these conditions may be treatable and possibly reversible.

If the diagnosis is Alzheimer’s, beginning treatment early in the disease process may help preserve daily functioning for some time, even though the underlying disease process cannot be stopped or reversed. An early diagnosis also helps families plan for the future. They can take care of financial and legal matters, address potential safety issues, learn about living arrangements, and develop support networks.

In addition, an early diagnosis gives people greater opportunities to participate in clinical trials that are testing possible new treatments for Alzheimer’s disease or other research studies.

Treatment of Alzheimer’s Disease

Alzheimer’s disease is complex, and it is unlikely that any one drug or other intervention can successfully treat it. Current approaches focus on helping people maintain mental function, manage behavioral symptoms, and slow or delay the symptoms of disease. Researchers hope to develop therapies targeting specific genetic, molecular, and cellular mechanisms so that the actual underlying cause of the disease can be stopped or prevented.

Maintaining Mental Function

Several medications are approved by the U.S. Food and Drug Administration to treat symptoms of Alzheimer’s. Donepezil (Aricept^®), rivastigmine (Exelon^®), and galantamine (Razadyne^®) are used to treat mild to moderate Alzheimer’s (donepezil can be used for severe Alzheimer’s as well). Memantine (Namenda^®) is used to treat moderate to severe Alzheimer’s. These drugs work by regulating neurotransmitters, the chemicals that transmit messages between neurons. They may help maintain thinking, memory, and communication skills, and help with certain behavioral problems. However, these drugs don’t change the underlying disease process. They are effective for some but not all people, and may help only for a limited time.

Managing Behavior

Common behavioral symptoms of Alzheimer’s include sleeplessness, wandering, agitation, anxiety, and aggression. Scientists are learning why these symptoms occur and are studying new treatments—drug and non-drug—to manage them. Research has shown that treating behavioral symptoms can make people with Alzheimer’s more comfortable and makes things easier for caregivers.

Looking for New Treatments

Alzheimer’s disease research has developed to a point where scientists can look beyond treating symptoms to think about addressing underlying disease processes. In ongoing clinical trials, scientists are developing and testing several possible interventions, including immunization therapy, drug therapies, cognitive training, physical activity, and treatments used for cardiovascular and diabetes.

People doing aerobic activities move large muscles in a rhythmic manner for a sustained period. Brisk walking, jogging, biking, dancing, and swimming are all examples of aerobic activities. This type of activity is also called endurance activity.

Aerobic activity makes a person’s heart beat more rapidly to meet the demands of the body’s movement.

Over time, regular aerobic activity makes the heart and cardiovascular system stronger and fitter.

The intensity of these activities can be either relatively moderate or relatively vigorous, depending on an older adult’s level of fitness.

How intense?

Older adults can meet the national guidelines by doing relatively moderate-intensity activity, relatively vigorous–intensity activity, or a combination of both. Time spent in light activity (such as light housework) and sedentary activities (such as watching TV) do not count.

The relative intensity of aerobic activity is related to a person’s level of cardio respiratory fitness.

• Moderate-intensity activity requires a medium level of effort. On a scale of 0 to 10, where sitting is 0 and the greatest effort possible is 10, moderate-intensity activity is a 5 or 6 and produces noticeable increases in breathing rate and heart rate.
• Vigorous-intensity activity is a 7 or 8 on this scale and produces large increases in a person’s breathing and heart rate.

A general rule of thumb is that 2 minutes of moderate–intensity activity count the same as 1 minute of vigorous-intensity activity. For example, 30 minutes of moderate-intensity activity a week is roughly same as 15 minutes of vigorous-intensity activity.

Muscle-Strengthening Activities

At least 2 days a week, older adults should do muscle–strengthening activities that involve all the major muscle groups. These are the muscles of the legs, hips, chest, back, abdomen, shoulders, and arms.

Muscle-strengthening activities make muscles do more work than they are accustomed to during activities of daily life.

Examples of muscle-strengthening activities include lifting weights, working with resistance bands, doing calisthenics using body weight for resistance (such as push-ups, pull-ups, and sit-ups), climbing stairs, carrying heavy loads, and heavy gardening.

Muscle-strengthening activities count if they involve a moderate to high level of intensity, or effort, and work the major muscle groups of the body. Whatever the reason for doing it, any muscle-strengthening activity counts toward meeting the national guidelines. For example, muscle-strengthening activity done as part of a therapy or rehabilitation program can count.

No specific amount of time is recommended for muscle strengthening, but muscle-strengthening exercises should be performed to the point at which it would be difficult to do another repetition without help. When resistance training is used to enhance muscle strength, one set of 8 to 12 repetitions of each exercise is effective, although two or three sets may be more effective. Development of muscle strength and endurance is progressive over time. This means that gradual increases in the amount of weight or the days per week of exercise will result in stronger muscles.

Balance Activities for Older Adults at Risk of Falls

Older adults are at increased risk of falls if they have had falls in the recent past or have trouble walking. In older adults at increased risk of falls, strong evidence shows that regular physical activity is safe and reduces the risk of falls.

Reduction in falls is seen for participants in programs that include balance and moderate-intensity muscle-strengthening activities for 90 minutes (1 hour and 30 minutes) a week plus moderate-intensity walking for about 1 hour a week. Preferably, older adults at risk of falls should do balance training 3 or more days a week and do standardized exercises from a program demonstrated to reduce falls.

Examples of these exercises include backward walking, sideways walking, heel walking, toe walking, and standing from a sitting position. The exercises can increase in difficulty by progressing from holding onto a stable support (like furniture) while doing the exercises to doing them without support. It’s not known whether different combinations of type, amount, or frequency of activity can reduce falls to a greater degree. Tai chi exercises also may help prevent falls.

Many factors influence decisions to be active, such as personal goals, current physical activity habits, and health and safety considerations. Adults as well as older adults older adults should consult a health-care provider before becoming physically active. A health-care provider can help people attain and maintain regular physical activity by providing advice on appropriate types of activities and ways to progress at a safe and steady pace that is appropriate for the individual.

Adults with chronic conditions should talk with their health-care provider to determine whether their conditions limit their ability to do regular physical activity in any way. Such a conversation should also help people learn about appropriate types and amounts of physical activity.

Examples of Aerobic Activity and Muscle Strengthening Activity

What Is Advance Care Planning?

Advance care planning involves learning about the types of decisions that might need to be made, considering those decisions ahead of time, and then letting others know about your preferences, often by putting them into an advance directive. An advance directive is a legal document that goes into effect only if you are incapacitated and unable to speak for yourself. This could be the result of disease or severe injury—no matter how old you are. It helps others know what type of medical care you want. It also allows you to express your values and desires related to end-of-life care. You might think of an advance directive as a living document—one that you can adjust as your situation changes because of new information or a change in your health.

Decisions That Could Come Up Near Death

Sometimes when doctors believe a cure is no longer possible and you are dying, decisions must be made about the use of emergency treatments to keep you alive. Doctors can use several artificial or mechanical ways to try to do this. Decisions that might come up at this time relate to:

• CPR (cardiopulmonary resuscitation)
• ventilator use
• artificial nutrition (tube feeding) or artificial hydration (intravenous fluids)
• comfort care

CPR. CPR (cardiopulmonary resuscitation) might restore your heartbeat if your heart stops or is in a life-threatening abnormal rhythm. The heart of a young, otherwise healthy person might resume beating normally after CPR. An otherwise healthy older person, whose heart is beating erratically or not beating at all, might also be helped by CPR. CPR is less likely to work for an older person who is ill, can’t be successfully treated, and is already close to death. It involves repeatedly pushing on the chest with force, while putting air into the lungs. This force has to be quite strong, and sometimes ribs are broken or a lung collapses. Electric shocks known as defibrillation and medicines might also be used as part of the process.

Ventilator use. Ventilators are machines that help you breathe. A tube connected to the ventilator is put through the throat into the trachea (windpipe) so the machine can force air into the lungs. Putting the tube down the throat is called intubation. Because the tube is uncomfortable, medicines are used to keep you sedated (unconscious) while on a ventilator. If you can’t breathe on your own after a few days, a doctor may perform a tracheotomy or “trach” (rhymes with “make”). During this bedside surgery, the tube is inserted directly into the trachea through a hole in the neck. For long-term help with breathing, a trach is more comfortable, and sedation is not needed. People using such a breathing tube aren’t able to speak without special help because exhaled air goes out of the trach rather than past their vocal cords.

Artificial nutrition or artificial hydration. A feeding tube and/or intravenous (IV) liquids are sometimes used to provide nutrition when a person is not able to eat or drink. These measures can be helpful if you are recovering from an illness. However, if you are near death, these could actually make you more uncomfortable. For example, IV liquids, which are given through a plastic tube put into a vein, can increase the burden on failing kidneys. Or if the body is shutting down near death, it is not able to digest food properly, even when provided through a feeding tube. At first, the feeding tube is threaded through the nose down to the stomach. In time, if tube feeding is still needed, the tube is surgically inserted into the stomach.

Comfort care. Comfort care is anything that can be done to soothe you and relieve suffering while staying in line with your wishes. Comfort care includes managing shortness of breath; offering ice chips for dry mouth; limiting medical testing; providing spiritual and emotional counseling; and giving medication for pain, anxiety, nausea, or constipation. Often this is done through hospice, which may be offered in the home, in a hospice facility, in a skilled nursing facility, or in a hospital. With hospice, a team of healthcare providers works together to provide the best possible quality of life in a patient’s final days, weeks, or months. After death, the hospice team continues to offer support to the family. Learn more about providing comfort at the end of life.

Getting Started

Start by thinking about what kind of treatment you do or do not want in a medical emergency. It might help to talk with your doctor about how your present health conditions might influence your health in the future. For example, what decisions would you or your family face if your high blood pressure leads to a stroke?

If you don’t have any medical issues now, your family medical history might be a clue to thinking about the future. Talk to your doctor about decisions that might come up if you develop health problems similar to those of other family members.

In considering treatment decisions, your personal values are key. Is your main desire to have the most days of life, or to have the most life in your days? What if an illness leaves you paralyzed or in a permanent coma and you need to be on a ventilator? Would you want that?

What makes life meaningful to you? You might want doctors to try CPR if your heart stops or to try using a ventilator for a short time if you’ve had trouble breathing, if that means that, in the future, you could be well enough to spend time with your family. Even if the emergency leaves you simply able to spend your days listening to books on tape or gazing out the window watching the birds and squirrels compete for seeds in the bird feeder, you might be content with that.

But, there are many other scenarios. Here are a few. What would you decide?

• If a stroke leaves you paralyzed and then your heart stops, would you want CPR? What if you were also mentally impaired by a stroke—does your decision change?
• What if you develop dementia, don’t recognize family and friends, and, in time, cannot feed yourself? Would you want a feeding tube used to give you nutrition?
• What if you are permanently unconscious and then develop pneumonia? Would you want antibiotics and a ventilator used?

For some people, staying alive as long as medically possible is the most important thing. An advance directive can help make sure that happens.

Your decisions about how to handle any of these situations could be different at age 40 than at age 85. Or they could be different if you have an incurable condition as opposed to being generally healthy. An advance directive allows you to provide instructions for these types of situations and then to change the instructions as you get older or if your viewpoint changes.

Making Your Wishes Known

There are two elements in an advance directive—a living will and a durable power of attorney for health care. There are also other documents that can supplement your advance directive or stand alone. You can choose which documents to create, depending on how you want decisions to be made. These documents include:

• living will
• durable power of attorney for health care
• other documents discussing DNR (do not resuscitate) orders, organ and tissue donation, dialysis, and blood transfusions

Living will. A living will is a written document that helps you tell doctors how you want to be treated if you are dying or permanently unconscious and cannot make decisions about emergency treatment. In a living will, you can say which of the procedures described above you would want, which ones you wouldn’t want, and under which conditions each of your choices applies.

Durable power of attorney for health care. A durable power of attorney for health care is a legal document naming a healthcare proxy, someone to make medical decisions for you at times when you might not be able to do so. Your proxy, also known as a surrogate or agent, should be familiar with your values and wishes. This means that he or she will be able to decide as you would when treatment decisions need to be made. A proxy can be chosen in addition to or instead of a living will. Having a healthcare proxy helps you plan for situations that cannot be foreseen, like a serious auto accident.

A durable power of attorney for health care enables you to be more specific about your medical treatment than a living will.

Some people are reluctant to put specific health decisions in writing. For them, naming a healthcare agent might be a good approach, especially if there is someone they feel comfortable talking with about their values and preferences.

Other advance care planning documents. You might also want to prepare separate documents to express your wishes about a single medical issue or something not already covered in your advance directive. A living will usually covers only the specific life-sustaining treatments discussed earlier. You might want to give your healthcare proxy specific instructions about other issues, such as blood transfusion or kidney dialysis. This is especially important if your doctor suggests that, given your health condition, such treatments might be needed in the future.

Two medical issues that might arise at the end of life are DNR orders and organ and tissue donation.

A DNR (do not resuscitate) order tells medical staff in a hospital or nursing facility that you do not want them to try to return your heart to a normal rhythm if it stops or is beating unevenly. Even though a living will might say CPR is not wanted, it is helpful to have a DNR order as part of your medical file if you go to a hospital. Posting a DNR next to your bed might avoid confusion in an emergency situation. Without a DNR order, medical staff will make every effort to restore the normal rhythm of your heart. Anon-hospital DNR will alert emergency medical personnel to your wishes regarding CPR and other measures to restore your heartbeat if you are not in the hospital. A similar document that is less familiar is called a DNI (do not intubate) order. A DNI tells medical staff in a hospital or nursing facility that you do not want to be put on a breathing machine.

Organ and tissue donation allows organs or body parts from a generally healthy person who has died to be transplanted into people who need them. Commonly, the heart, lungs, pancreas, kidneys, corneas, liver, and skin are donated. There is no age limit for organ and tissue donation. You can carry a donation card in your wallet. Some states allow you to add this decision to your driver’s license. Some people also include organ donation in their advance care planning documents. At the time of death, family may be asked about organ donation. If those close to you, especially your proxy, know how you feel about organ donation, they will be ready to respond.

Making It Official

Once you have talked with your doctor and have an idea of the types of decisions that could come up in the future and whom you would like as a proxy, if you want one at all, the next step is to fill out the legal forms detailing your wishes. A lawyer can help but is not required. If you decide to use a lawyer, don’t depend on him or her to help you understand different medical treatments. That’s why you should start the planning process by talking with your doctor.

Many states have their own advance directive forms. Your local Area Agency on Aging can help you locate the right forms. You can find your area agency phone number by calling the Eldercare Locator toll-free at 1-800-677-1116 or going online at www.eldercare.gov.

Some states want your advance directive to be witnessed; some want your signature notarized. A notary is a person licensed by the state to witness signatures. You might find a notary at your bank, post office, or local library, or call your insurance agent. Some notaries charge a fee.

Some people spend a lot of time in more than one state—for example, visiting children and grandchildren. If that’s your situation also, you might consider preparing an advance directive using forms for each state—and keep a copy in each place, too.

After You Set Up Your Advance Directive

There are key people who should be told that you have an advance directive. Give copies to your healthcare proxy and alternate proxy. Give your doctor a copy for your medical records. Tell key family members and friends where you keep a copy. If you have to go to the hospital, give staff there a copy to include in your records. Because you might change your advance directive in the future, it’s a good idea to keep track of who receives a copy.

Review your advance care planning decisions from time to time—for example, every 10 years, if not more often. You might want to revise your preferences for care if your situation or your health changes. Or, you might want to make adjustments if you receive a serious diagnosis; if you get married, separated, or divorced; if your spouse dies; or if something happens to your proxy or alternate. If your preferences change, you will want to make sure your doctor, proxy, and family know about them.

Still Not Sure?

What happens if you have no advance directive or have made no plans and you become unable to speak for yourself? In such cases, the state where you live will assign someone to make medical decisions on your behalf. This will probably be your spouse, your parents if they are available, or your children if they are adults. If you have no family members, the state will choose someone to represent your best interests.

Always remember, an advance directive is only used if you are in danger of dying and need certain emergency or special measures to keep you alive but are not able to make those decisions on your own. An advance directive allows you to continue to make your wishes about medical treatment known.

Looking Toward the Future

Nobody can predict the future. You may never face a medical situation where you are unable to speak for yourself and make your wishes known. But having an advance directive may give you and those close to you some peace of mind.