Is it really Alzheimer's? There are several differentials

Early diagnosis is critical, but so is heightened awareness of a range of conditions that trigger reversible dementia.

By Kathleen Phalen Tomaselli amednews correspondent — Posted March 6, 2006

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They are a generation of rebels and rock 'n' rollers ready to defy the restraints of old age. Still, bodies and minds change as decades pass, and the first of the nearly 77 million postwar babies are turning 60 this year at the rate of 8,000 a day.

In other words, the Gray Wave is upon us.

And some forecasts offer the dire estimate that more than 50% of them will have Alzheimer's disease by the time they are 85. "It's hard to make predictions about what 2030 will look like," says Barry Fabius, MD, an internist and medical director of geriatrics at Holy Redeemer Health System outside Philadelphia. "For the worst-case scenario, we can prepare for a huge population of demented individuals. ... It's rare that it would be that simple to explain. The population is very diverse. Some are very robust and healthy. On the other end of the spectrum, there are those with dementia and six or seven co-morbidities."

And symptoms and circumstances often make these situations complex.

The greatest challenge for doctors may well be rooted in preparation for and an understanding of the unique characteristics of seniors. Medications are metabolized differently, depression presents without sadness, and memory loss is often passed off as a normal part of aging -- the kinds of nuances aging specialists are trained to spot. But with only 6,000 geriatricians in the United States, the burden falls to primary care physicians who are not always equipped with the time or training to sort out aging's idiosyncrasies.

Reversible dementia and Alzheimer's are sometimes missed and underdiagnosed. "By the time I have a patient in my office, they've had symptoms of Alzheimer's for four or five years," says Sharon Brangman, MD, a board member of the American Geriatric Society and director of the Central New York Alzheimer's Disease Assistance Center in Syracuse, N.Y.

Nonetheless, growing older doesn't always mean that dementia and cognitive impairment are normal. It means that memory loss needs investigating, pills don't always work, and just because a patient says things are fine, they might not be. "The real challenge," Dr. Brangman says, "is to figure a way to help primary care doctors do what's becoming an increasingly hard and economically challenging job."

Mistaken identity

The cavalier phrase "I must be getting old" -- used as absolution for a host of physical or mental foibles such as losing keys, having trouble getting out of a chair or forgetting someone's birthday -- only fuels outmoded and negative attitudes about aging. "We have preconceived notions that affect our health," Dr. Brangman says. "Aging is not a disease. Yet so much is blamed on [it]."

Often, with dementia-like symptoms the following culprits can go untreated or be confused with Alzheimer's:

  • Medication problems: prescription, over the counter and herbal.
  • B12 deficiency or other poor nutrition issues.
  • Depression.
  • Infections such as urinary tract infection or pneumonia.
  • Normal pressure hydrocephalus.
  • Out-of-control diabetes.
  • Electrolyte imbalance.
  • Hyper- or hypothyroidism.
  • Hyper- or hypoglycemia.
  • Alcoholism.
  • Neurosyphilis.
  • Subdural hematoma.

Medication issues top this list because physiologically, the body's response changes with age. Many patients older than 60 have multiple chronic conditions, and taking six to eight pills a day is not uncommon. "There is no information on how these interact and react on an older body," Dr. Fabius says. "Medication problems can cause confusion or mimic dementia."

For instance, anticholinergic drugs, often used for colds and allergies, sleep disturbances, bladder control, hypertension and Parkinson's disease, can lead to symptoms (short-term memory loss, incoherent speech and an inability to concentrate) that are mistaken for Alzheimer's disease, French scientists say. According to a study in the Feb. 1 issue of the British Medical Journal, researchers found that 80% of elderly patients using anticholinergics for at least one year were diagnosed with mild cognitive impairment compared with 35% for those who did not take the drugs on a regular basis.

Depression also can look like Alzheimer's or mild cognitive impairment. Causing confusion, inability to concentrate, memory loss and even poor hygiene, it can be present without sadness. Often accompanied by a host of physical complaints such as aches and pains, sleep disturbances or poor appetite, it is difficult to spot, especially when the patient is not aware of the problem.

"Generally with a young person, there is a change in mood and they might be flat-faced, but older people may still laugh and smile," Dr. Brangman says. "When older people get depressed, people make the mistake of thinking, 'I would be depressed, too, if I just lost my wife.' There is a lot of rationalization, and we don't treat it."

Meanwhile, television broadcasts have portrayed normal pressure hydrocephalus as a frequently misdiagnosed condition often confused with Alzheimer's or Parkinson's. Gait disturbance, forgetfulness and urinary incontinence, early symptoms of NPH, sometimes can make it difficult for untrained physicians to tell the difference between the two.

But the feeling of feet glued to the floor, or difficulty walking, is the first symptom to appear in NPH. In Alzheimer's, verbal problems, memory loss and confusion tend to appear before gait problems. Similar to Alzheimer's, NPH progresses over time, and the longer symptoms have been present, the less likely it is that treatment will be successful. "NPH can be relieved with shunts, but it depends on the amount of damage," Dr. Fabius says. "It must be caught early on. The later stages are difficult to treat."

While general cognitive changes are still a subject of debate, some experts say they appear as we age. "There is slowing in the retrieval of information, but it should not impair functioning," says Donna Rasin-Waters, PhD, a clinical psychologist specializing in geropsychology for the American Psychological Assn.'s Society of Clinical Psychology. She uses the television show "Jeopardy" to illustrate. "Watch when they have the teens, they go through the board so fast," she says. "Then watch the older adults, they don't always get through all the items, there is a slowing, a delay in response time."

But there are also indications of when this scenario is normal and when it indicates a problem, says Marie Carrillo, PhD, director of medical and scientific affairs for the Alzheimer's Assn. in Chicago. "Glaring memory loss -- if you meet someone and 10 minutes later you say, 'I haven't seen you before,' like it never happened -- is not normal," Dr. Carrillo says. "If you have difficulty performing regular tasks, problems with sequential tasks not knowing what comes next or you put the keys in the refrigerator, that's not normal."

Diagnosis begins with a good history from several people, including family members and caregivers. Patients often have a hard time admitting problems, instead saying things like, "I'm fine. I don't know why everyone is making all this fuss."

Time challenges make history-taking difficult for primary care physicians. Some suggest charging staff with this task. "I respect family doctors' time and resources," Dr. Fabius says. "They could use the Mini-Mental Status Examination. It takes 10 minutes. I use it on all our patients, and it is very successful."

But Dr. Rasin-Waters warns of problems inherent in testing. Issues of cultural differences and literacy can affect results. "We have to understand that when we test, the tools are based on a white population. And minority test scores are often lower," she says, explaining that many older African-Americans grew up during segregation with educational disparities. "The differences disappear if you account for educational backgrounds. A patient might get misdiagnosed with mild cognitive impairment."

Verbal changes -- difficulty finding the right word -- are often the first signs of Alzheimer's slow progression. If the change or dementia is sudden, it's probably something else.

It's important to assess speech, motor memory, sensory recognition and complex behavior sequencing, says the American Academy of Family Physicians. Speech problems can be detected by asking a patient to name body parts or objects in the room. To test motor memory, ask a patient to pantomime using a tool such as a hammer or toothbrush. Sensory recognition is evaluated by asking a patient to close his or her eyes and then placing an object, such as a key or a coin, in the patient's hand. Ask him or her to identify it without looking. If the patient can't, there could be a problem.

Executive function is impaired as Alzheimer's progresses, so asking a patient to perform a series of simple tasks such as putting a piece of paper in his or her right hand, folding it in half and putting it on the floor would be difficult for someone who is cognitively impaired, as would spelling the word "world" backwards or naming items in a grocery store. "I had a patient who was having her family over for Thanksgiving but couldn't remember how to prepare the meal," Dr. Brangman says.

Early diagnosis increases the quality of life for patients. "The best we can do is slow the disease," Dr. Rasin-Waters says. "The earlier we detect it, the better prepared we are to handle the demands for care."

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Slowing dementia: The 30-minute plan

The key to slowing the progression of dementia is remaining active in three dimensions -- physical, social and cognitive, according to Barry Fabius, MD, the medical director of St. Joseph's Manor, part of the Holy Redeemer Health System in Meadowbrook, Pa. He suggests such activity daily. For example:

Physical: 30 minutes of exercise even if it means three 10-minute walks. A recently released longitudinal study of 1,740 participants, published in the Jan. 17 issue of the Annals of Internal Medicine by researchers at the Center for Health Studies in Seattle, found that regular exercise reduced dementia risk.

Societal: 30 minutes of social contact. Studies indicate that social isolation leads to cognitive impairment.

Cognitive: 30 minutes of cognitive challenges such as checkers, cards, drawing, sculpting, writing and knitting to keep minds active. Complex mental activity significantly reduces the risk of dementia, according to researchers at the University of South Wales in Sydney, Australia, who published findings in the January issue of Psychological Medicine. A previous study by scientists at the same institution showed that after five weeks of memory-based mental exercise, participants increased brain chemistry markers in the opposite direction to that seen in Alzheimer's.

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Aid in treating older patients

Caregivers often need care. Take Mary, 65, a retired librarian. This was supposed to be her time, but guilt and anxiety got in the way. "She found herself unable to enjoy her life, preoccupied and worried that her 96-year-old mother could have a health crisis at any moment," says Donna Rasin-Waters, PhD, a clinical psychologist specializing in geropsychology for the American Psychological Assn.'s Society of Clinical Psychology. "Mary had been caring for her mother for as long as she could remember."

According to the APA, 50% to 70% of all primary care medical visits by older patients are related to psychological factors such as anxiety, depression and stress. Psychological and psychiatric intervention has been shown to reduce symptoms, increase compliance and improve quality of life for older adults.

Geriatric psychiatrists, for instance, are specially trained in late-life mental illnesses and disorders, such as dementia, depression, anxiety and schizophrenia, and can aid primary care doctors in complex situations involving both mental illness and other medical conditions. Understanding family caregiver roles, the geriatric psychiatrist educates families and may refer for other appropriate services.

Meanwhile, using psychological and neuropsychological testing, geropsychologists help detect mild cognitive impairment and separate primary dementia from emotional factors that can create cognitive changes. For Mary, the resulting intervention focused on cognitive techniques to reduce feelings of guilt and anxiety; interpersonal intervention to increase her network of support; and suggestions to improve the time spent with her mother, included taking an oral history from her mother to pass on to grandchildren. "Within eight sessions, there was dramatic improvement," Dr. Rasin-Waters says.

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External links

AMA resources on dementia (link)

American Geriatrics Society (link)

Alzheimer's Assn. statement on President Bush's budget (link)

Mini-Mental Status Examination (link)

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