Questions & Answers

Currently, there is no cure for Alzheimer's disease (AD). However, there are medications that can help control its symptoms. In addition, treatments are also available to help manage agitation, depression, or psychotic symptoms (hallucinations or delusions), which may occur as the disease progresses. Consult a physician before taking any medications.

FDA-Approved Drugs

There are five Food and Drug Administration (FDA)-approved drugs that can control symptoms and slow the progression of AD. Four, called cholinesterase inhibitors, Cognex® (tacrine), Aricept® (donepezil), Exelon® (rivastigmine), and Razadyne® (galantamine), slow the metabolic breakdown of acetylcholine, an important brain chemical involved in nerve cell communication. These drugs make more of this chemical available for communication between cells. This slows the progression of cognitive impairment and can be effective for some patients with AD. These four medications are all approved for the treatment of mild to moderate symptoms of Alzheimer’s disease. In 2006, the FDA approved Aricept for the management of severe AD symptoms. The fifth medication, Namenda® (memantine), is approved for the treatment of moderate to severe AD. Namenda appears to protect the brain's nerve cells against excess amounts of glutamate, a messenger chemical released in large amounts by AD-damaged brain cells.

The effectiveness of these drugs varies from person to person, and some drugs may be better tolerated than others by certain individuals. Side effects include nausea, dizziness, headache and fatigue. All medications are taken orally. However, in 2007, the FDA approved the ExelonPatch (rivastigmine transdermal system) to deliver this drug through the skin. Cognex, though effective, has more adverse side effects and although still available, is now rarely prescribed.

Medications to Control Depression, Anxiety and Psychotic Symptoms

For patients in the middle stages of AD, there are also medications to control depression, anxiety and psychotic behavior, including paranoid thoughts, delusions and hallucinations. These individuals can also exhibit aggression, hyperactivity and combativeness. Medications for these symptoms are considered when non-medication alternatives have failed and/or these symptoms put the AD patient or others in danger.

Potential Treatments for AD

Many potential AD treatments are being investigated in laboratories and tested in human clinical trials. Scientists continue basic research on therapies that could potentially clear the protein plaques in the brain. The safety and efficacy of possible treatments are being tested on humans, including drugs that could remove plaques, immunotherapy with beta amyloid antibodies, non-steroidal anti-inflammatory drugs (NSAIDs) and statins (drugs used to lower cholesterol). The protective effects of estrogen, antioxidants (Vitamins A, C and E), ginkgo biloba and omega 3 fatty acids (found mainly in fish such as tuna and salmon) are also being tested in trials. To date, no consistent results have emerged from various studies, but further research and future results from rigorous trials should help clarify the benefit of these and other treatments.

Immunotherapy

In 1999, studies revealed that injection of beta amyloid itself, called active immunization, caused laboratory mice to produce antibodies against the protein and reduced its accumulation. Spurred on by the potential of immunotherapy, some pharmaceutical companies started human clinical trials in 2001. However, in 2002, the trials were halted when about six percent of participants developed a potentially serious side effect, acute encephalitis (inflammation in the brain). Autopsies of several participants who died of other causes revealed that a large amount of beta amyloid had been cleared from their brains, their brain volume was lower, and lower levels of tau, another protein related to AD, were found in their spinal fluid. Further, for the living trial participants who developed antibodies, there was evidence of better memory, attention and concentration. More recently, some pharmaceutical companies have begun further human trials using passive immunotherapy, in which antibodies to a protein rather than the protein itself are given to the recipient.

NSAIDs (non-steroidal anti-inflammatory drugs)

Studies suggest that brain inflammation may play a role in damage due to AD, and that nonsteroidal anti-inflammatory drugs (NSAIDs) could potentially slow its progression. However, human clinical trials have not shown the benefit of these medications. In one trial of people with AD, naproxen (Aleve®) and rofecoxib (Vioxx®) did not delay the advance of the disease. Another clinical trial examining whether celecoxib (Celebrex®) and naproxen could prevent AD in at risk, older healthy people was stopped because data indicated an apparent increase in cardiovascular and cerebrovascular events among participants taking naproxen. Researchers continue to explore the role of other anti-inflammatory drugs in the treatment or prevention of AD.

Statins

Several clinical trials are underway to test whether statins, cholesterol-lowering drugs, may help slow progression of AD.

Estrogen

Research suggests that estrogen taken to manage the symptoms of menopause may also protect the brain. Therefore, scientists have been interested in whether estrogen could reduce the risk or slow the advance of AD. However, clinical trials of those already diagnosed with AD, showed that estrogen had no impact on its progression. Other studies indicate that women who begin using estrogen after age 60 to 65 are at increased risk of developing dementia, as well as heart attack and stroke. Estrogen is now only recommended for short term use to treat menopausal symptoms. Recent research has helped clarify the neuroprotective role of estrogen taken by younger women before menopause. According to a study published in August 2007, scientists from the Mayo Clinic found that women who had one or both ovaries removed prior to menopause had an increased long-term risk of dementia or cognitive impairment. However, those who underwent ovary removal, but also had estrogen treatment until at least age 50 did not experience this higher risk. These findings suggest that if taken before menopause, the neuroprotective benefits of estrogen may outweigh the risks of side effects, such as heart problems, stroke and cognitive impairment. Women of any age should consult with a physician about the individual risks and benefits of undergoing or considering hormone replacement therapy.

Antioxidants

Vitamin E may offer some protection against cell damage caused by free radicals. However, research has produced conflicting results and further rigorous scientific study will be needed to clarify the role of this antioxidant. Ongoing clinical trials are investigating whether vitamins E and C can slow the progression of AD. Another clinical trial is examining whether Vitamin E and/or selenium can prevent AD or cognitive decline. In April of 2005, the New England Journal of Medicine published results of a study that compared the use of vitamin E, Aricept (donepezil - an Alzheimer's disease treatment) and a placebo in delaying progression from mild cognitive impairment (MCI) to Alzheimer’s disease. People with MCI experience memory problems, but are able to function independently; however, MCI is often a transitional stage that leads to the serious cognitive decline of Alzheimer's disease. The study found that over the course of three years, none of the treatments affected the advance of the disease.

Ginkgo biloba

Ginkgo biloba, an extract from the leaves of the ginkgo tree, is said to have antioxidant and anti-inflammatory properties. It may also increase blood flow in the brain. However, the results of a large multicenter clinical trial led by the University of Pittsburgh School of Medicine, and published in the Journal of the American Medical Association in November of 2008, found that Ginkgo biloba does not reduce the risk of developing Alzheimer’s disease or dementia in either healthy older individuals or in those with mild cognitive impairment. A similar clinical trial is underway in Europe.

Omega-3 fatty acids

Omega-3 fatty acids are found mainly in “oily” fish such as salmon and albacore tuna, but are also present in certain nuts and oils. Scientists believe they may have a protective effect on the brain. Clinical trials are underway to test whether these fatty acids can slow the both cognitive and functional decline in those with mild to moderate AD.

Before taking any medications, over-the-counter drugs, supplements or herbs, visit a physician for a full medical evaluation. The American Health Assistance Foundation does not endorse any medications, vitamins or herbs. A qualified physician should make an informed decision based on each person's medical history and current prescriptions.

Unfamiliar surroundings—such as a move to a new home—can sometimes increase an Alzheimer's patient's confusion and anxiety, which can lead to escapist behavior such as you have experienced with your father. It can be very difficult to speak openly with a beloved family member who is suffering from the disease. However, in order for your father to begin to accept his new environment, he needs to be told the truth. Some patients may become angry about being told they have been placed in a nursing home. Others sometimes become depressed because they feel rejected and alone. So by all means continue to visit your father as often as possible, as he will need your support and reassurance that he has not been "abandoned." Your father will require continual calm assurance that the facility is now his new home, that he will be well-cared, and that he is safe and loved. Because of the nature of Alzheimer's, you may have to repeat this many times. If your father becomes angry over the news, it is not a good idea to argue with him as this may cause him to become more agitated or distressed. Instead try redirecting his attention to a new subject or activity. If your father becomes depressed, talk to his physician about the possibility of prescribing antidepressants.

You can also try labeling various personal belongings with his name (such as "Joe's room", "Joe's chair", "Joe's hairbrush", etc.) as visual reminders of his surroundings. It may seem trivial to you, but it can help to relieve a patient's anxiety when they are in "unfamiliar" surroundings. With patience and a good daily routine, he should eventually begin to feel more secure and "at home."

Your father is obviously already aware that he has problems with his short-term memory—hence the reason that he writes notes for himself—but he probably denies that a problem exists. There could be any number of things contributing to his memory issues and it may be premature to think he has dementia. For example, stress, depression, vitamin B12 deficiency, interactions between medications (or side effects from a new drug), hypothyroidism (low thyroid hormone levels), and viral infections can all cause memory problems, confusion, and mood swings. Many of these conditions are treatable, but without a thorough doctor's examination it is not possible to diagnose your father or potentially treat his problem.

Talk to your father and tell him that you are concerned about what is going on with him. First try reasoning with your father and ask him to please visit his physician. He may be afraid to learn the truth about what is causing his memory problems, and therefore does not want to see a doctor. He may need your reassurance that whatever the diagnosis, you and your mother will be there for him. But whether you bribe him, trick him, cajole him, force him, nag him, or guilt him into going, you must somehow get your father to visit a doctor. One trick that sometimes works is to make an appointment for him but say the appointment is for your mother. Then she could ask him to take her to the appointment because she is apprehensive of seeing the doctor alone. You should warn the doctor's office ahead of time what you are planning, telling them that your father may be resistant to seeing a doctor. Once at the office, the doctor can conveniently examine your father too.

The 10 milligram dose of Namenda twice daily (20 mg/day total) is the normal recommended dosage, so you do not have to worry that your mother is being prescribed too high a dose. Just remember that with Alzheimer's disease, most patients will have "good" days and "bad" days. Unfortunately, the good days tend to become less common as the disease progresses. Sometimes caregivers will notice that their loved one's condition suddenly worsens and will mistakenly attribute the symptoms to a new medication (or an existing medication's new dose). Namenda is generally well-tolerated with an overall low incidence rate of adverse effects. Therefore, it could be pure chance that her decline has coincided with the new prescribed dosage.

However, it never hurts to inform your mother's physician about her latest symptoms. Her new behaviors may just be a part of Alzheimer's, or the doctor may determine that they are indicative of another condition. For example, a shuffling gait could indicate a condition called Normal Pressure Hydrocephalus or NPH. NPH has symptoms very similar to Alzheimer's disease (such as progressive mental deterioration leading to dementia, difficulty with walking, and even incontinence), which is why NPH is oftentimes misdiagnosed for Alzheimer's. If nothing else, your mother's doctor can reassess her medications and make any necessary adjustments.

Accusations of thievery are fairly common in Alzheimer's patients. Because their short-term memory is impaired, patients often forget where they have placed items and believe that an item has been stolen when it cannot be found. Calmly reassure your mother that none of her money has been taken. She may be anxious or agitated about something completely unrelated to the money, and her behavior is a result of her anxiety. She may, for example, not be adjusted to her new environment. Or she may feel anxious about being "alone" in a care facility or being a burden to you. She needs your reassurance that both she and her possessions are safe, that she is not a burden, and that both you and the center will take good care of her in the future. If she becomes insistent, do not argue with her about the money as this will only cause her to become more agitated. Instead, you can try to address the emotion behind her accusations and redirect her attention. For example, the next time she reports being robbed, say something such as: "You're concerned about losing your money, aren't you? We all are. You do not have worry about money because you will always be taken care of by us. I know your life has not been easy and that you've worked hard for what you have. Can you tell me about what it was like when you were first starting out in the world?" Sometimes an empathetic approach will help to reduce her anxiety by shifting her attention to a more calming subject.

Mild forgetfulness and memory delays often occur as part of the normal aging process. Older individuals simply need more time to learn a new fact or to remember an old one. We all have occasional difficulty remembering a word, someone's name, or where they placed their car keys. Memory loss—particularly of short-term memory—will increase with age and it is all quite normal. A 50 year old will simply not be able to remember things as quickly or well as a person half their age.

Despite this discouraging news, there is evidence to suggest that exercising your mind as well as your body can help to reduce memory loss. As an added benefit, healthy diet and exercise can also help to reduce your risk of developing Alzheimer's disease. You should strive for diet that is low in saturated and trans fats and high in antioxidants. Foods considered antioxidant-rich include blackberries, blueberries, spinach, strawberries, red bell peppers, walnuts, artichoke hearts, green tea, dark chocolate, red wine and tomatoes, among many others. You can mentally exercise your brain by doing puzzles, word games, learning a new language or technology—anything really that challenges your mind and really makes you think. But don't forget about your body. Physical exercise for your body is just as important because it can help to lower blood pressure, reduce your body weight (or maintain a healthy weight), and decrease stress levels. Reducing stress will not only act to aid your short-term memory, but can also improve your overall emotional well-being, which is good for your long-term cognitive health. Finally, be sure to get enough sleep. Most adults need at least 7-8 consecutive hours of sleep each night in order for their memory functioning to be at its best.

Donepezil is an acetylcholinesterase inhibitor that can help to improve cognition in Alzheimer's disease patients. As such, it has been explored as a possible therapy for other disorders that affect memory and/or attention. For example, the effectiveness of donepezil has been investigated for the treatment of mild cognitive impairment (MCI), schizophrenia, vascular dementia, Parkinson's disease with dementia (PDD), dementia with Lewy bodies (DLB), autism, Down syndrome, attention deficit hyperactivity disorder (ADHD), Tourette's syndrome, traumatic brain injury, and the cognitive symptoms associated with multiple sclerosis. Donepezil has been found to be most effective in cases of MCI, vascular dementia, PDD, DLB, and multiple sclerosis. However, donepezil is currently only FDA-approved for the treatment of mild- to moderate-Alzheimer's disease.

The gene, called Apolipoprotein E (ApoE), appears to be a risk factor for the late-onset form of Alzheimer's disease. There are three forms (also known as alleles) of this gene: ApoE2, ApoE3 and ApoE4. Roughly one in four Americans has the ApoE4 gene and one in twenty has ApoE2. While inheritance of ApoE4 increases the risk of developing the late-onset form of Alzheimer's disease, inheritance of ApoE2 substantially protects against the disease.

There is a genetic test that determines which ApoE alleles you are carrying, but it is expensive. You can ask your primary care physician to recommend a genetic counselor and testing facility in your area. However, be aware that even if you were to find out you have the ApoE4 gene, it would only mean that you have a slightly higher risk of developing Alzheimer's disease than the general population. Having the ApoE4 gene does not mean that a person will definitely get Alzheimer's disease. Remember that about a quarter of the population has this gene—the majority of these people never go on to develop Alzheimer's disease. A genetic counselor can explain your specific results in greater detail. In the meantime, keep up the good work with your exercising and try to limit your intake of foods high in trans- or saturated-fats and cholesterol.