Alzheimer’s Disease is the most common type of dementia caused by gradual death of neurons (nerve cells) in the brain. It was first described by Alois Alzheimer in 1907. The frequency increases with age, being 0.3 per cent between 60 and 69 yea rs, three per cent between 70 and 79 years and 11 per cent over 80 years of age. Alzheimer’s is becoming more common in India as the life expectancy increases.
The death of neurons seems to be mainly due to deposits of proteins called beta amyloid between the neurons and may also be due to tangles in the neuron. A lot of research into preventing deposition of beta amyloid and formation of tangles is underway. However, the approved drugs for treatment of Alzheimer’s act by modulating the levels of chemicals called neurotransmitters in the brain which help neurons to communicate with each other.
Take professional help
It is important that the diagnosis of Alzheimer’s be confirmed by consulting a physician, neurologist, psychiatrist or geriatrician. Alzheimer’s progresses gradually to a severe stage in around seven years and hence rapidly progressive dementia is likely to be due to another cause. About 10 per cent of cases of dementia have a reversible cause which is completely treatable. It is vital that these should not be missed.
The symptoms of Alzheimer’s are broadly divided into two types — cognitive and behavioural or psychiatric.
Treatment of cognitive symptoms
There are two types of drugs available for treatment of Alzheimer’s. The first group are cholinesterase inhibitors (AChI) and there are three drugs in this class — donepezil, rivastigmine and galantamine. They increase the brain levels of a neurotransmitter called acetyl choline. Unfortunately the effect is mild and these drugs are not useful in the earliest stage of the disease. They are approved for mild, moderate and severe disease. These drugs stabilise the progression of the disease for around twelve months in about half the patients using them. After that the disease starts to worsen again. The drugs are generally well tolerated, the only side effect being nausea, vomiting or diarrhoea in a few. Donepezil is the most widely used and is relatively cheap costing around Rs. 300 per month.
The other approved drug is called Memantine. It blocks a neurotransmitter called NMDA. It is approved for moderately severe Alzheimer’s and again has a modest effect. It can be used along with AchI, is well tolerated and costs around Rs. 600 per month.
Treatment of behavioural and psychiatric symptoms in dementia (BPSD)
All attempts should be made to treat these symptoms without drugs (see “Tips to caregivers”). No drugs are specifically approved by the US FDA for BPSD. However, if the patient is at risk to himself or to others because of violent or dangerous behaviour, he needs to be put on psychiatric medications. The most common medications used are risperidone, haloperidol and quetiapine.
Patients who are apathetic may be depressed and may require antidepressants. Drugs like haloperidol or quetiapine can also be used for intractable sleep disturbance or night time wandering.
Tips to caregivers
The patient should be informed of the diagnosis and counselling given. Financial issues like making a will, joint bank accounts and giving power of attorney should be discussed to avoid problems later on when the patient is unable to make decisions. End of life issues should ideally be discussed without upsetting the patient.
Patients can develop behavioural symptoms even at early stages of the disease. Patients need sympathy, as they are not being purposely difficult; rather these are symptoms of the disease.
Sudden agitation, confusion or aggression can be due to side effects of drugs, pain (e.g. stomach pain, full bladder) or physical discomfort.
Create a calm and comfortable environment.
Avoid arguing with the patient. If he says he has a plane to catch agree with him and gradually divert his attention.
Patients with Alzheimer’s often get confused and agitated with a change from their familiar surroundings. Hence it is not advisable to change their location frequently; avoid hospitalisation if possible.
Secure the house to prevent the patient from wandering away.
There is a tendency to get more agitated and confused in the evening — this is called sundowning.
Sleep disturbance is common and should be managed without medicines if possible.
The caregiver is under enormous stress and prone to burn out and hence needs a break from time to time. It would be ideal if family members can provide relief.
