Table of Contents
- Is It Alzheimer’s? Making the Diagnosis
- Selecting the Best Doctor to Treat Alzheimer’s Disease
- What You Must Do if You Have Memory Problems
- Is This the Right Physician for You?
- Specialists Who May Treat Alzheimer’s Disease
- Choosing a Doctor – Age, Sex, Credentials and Coverage
- Before Your Doctor’s Appointment – Write Down Concerns and Seek Answers
- Review Your Medications and Supplements with Your Doctor
- Case Study – Does Anyone Really Know Elizabeth?
- Alzheimer’s Making the Diagnosis: What Doctors Must Do
- Tip of the Tongue Inability is Common
- What We Know about Age and Alzheimer’s Disease
- Mandatory Lab Tests for Alzheimer’s
- Additional Laboratory Testing for Dementia
- Lumbar Puncture
- Electroencephalography (EEG)
- Polysomnography (Sleep Study)
- Structural Scans: CT and MRI
- Functional Scans: PET and F-MRI
- When Should a Specialist be Called?
- Treatable Dementia Versus Diseases That Contribute to Alzheimer’s
- Is it Alzheimer’s or Not?
- Attributable Causes of Alzheimer’s
- Case Study – Sophia’s Weight Loss Surgery and Dementia
- Alzheimer’s and the Worried Well
- Women and Alzheimer’s Disease
- The Schulman Study Gives Insight
- Is Your Brain Really Healthy?
Is It Alzheimer’s? Making the Diagnosis
Last summer, George, a 72-year-old former CEO, came to see me accompanied by his wife and two daughters. In his own limited way, he let me know that he was there only because his family “tricked” him into coming. He inferred that his wife and daughters were convinced that he could no longer take care of himself and now they could take his money. Twice during his rambling dissertation, George stumbled to find the right word for “tricked.” First saying, “kicked,” then, “licked,” he then exclaimed, “You know . . . fooled.” After many more attempts, the correct word, “tricked,” finally was spoken.
In an effort to calm the man down, I touched George on the shoulder and asked him if he knew my name. “Sure, you’re a white coat, a medicine man. Your name is . . . ” he repeated five times. To put an end this frustration, I said, “My name is Dr. Fortanasce.” He retorted, “No that’s not it!”
The family reported that they had taken George to their primary-care doctor five times in the past year. At the first visit, George refused to let anyone go with him to the doctor’s appointment. His wife called the doctor to explain her concerns, but the doctor merely said, “Oh, it’s nothing. We all get older. George is just feeling his age.”
The second time (after several of his personal checks bounced), George was accompanied by his wife. This time the doctor did an EKG, a chest x-ray, and a complete blood count. All tests were negative. The doctor advised George to get a financial adviser.
By the third visit to his primary-care doctor, George had become withdrawn and had little interest in playing golf or in other activities. His wife said, “I know it’s his age, but he is so irritable now.”
So, the good doctor started George on an antidepressant to lift his mood and said he’d see him again in two months. Each subsequent visit seemed shorter than the one before and consisted of taking George’s vital signs and listening to his heart and lungs.
Weeks later, George’s wife called the doctor and told him her husband had worsened. He was throwing temper tantrums and accusing her of not putting things where they belong. “He’s confused and claims that I’m cheating on him with this man in the corner of our bedroom,” she whispered on the phone so George would not hear.
This time, the primary-care doctor prescribed Thorazine, an antipsychotic medication, and told her that George may need to see a psychiatrist if he continued this behavior.
Soon after that, George began to feel faint when getting up from a chair. Then, one day while his wife was combing his hair, she noticed a painful, red lump on his crown. George didn’t remember falling. Again, she called the primary-care doctor, but he was out of town, and the covering physician said, “I don’t know George’s history. You might go to the ER, if you’re that concerned.”
By this time, they called me without a referral from their primary-care physician-simply because one of their daughters had gotten my name from her own doctor, and she insisted that her parents see a neurologist.
A thorough neurological exam revealed severe short-term memory loss with good long-term memory. As an example, George could name every player on the 1928 New York Yankee baseball team, yet he didn’t know the current date or year. I also found some paranoia such as his believing “this is not really my wife but an imposter.”
This paranoia, called Capgras Syndrome, is a common occurrence with Alzheimer’s where the person no longer believes the husband or wife is their spouse. Hearing George say this aloud caused his wife to break down crying right there in the examination room. (And this is a frequent and heartbreaking occurrence with Alzheimer’s patients and their spouses.)
The neurological exam also showed severe vibratory loss of both lower extremities, which is a common sign of B-12 deficiency and common in elderly adults. Correcting this problem is usually as easy as boosting vitamin B-12 supplementation. George also showed a right Babinski reflex, a sign of a left hemisphere injury, which was indicated through his impaired balance.
Perhaps the most stunning finding was George’s blood pressure, which was 140/80 lying down but only 90/50 standing up-a reading that’s dangerously low for an elderly person. That day, I performed lab and imaging exams. George’s lab test confirmed what I thought–a critically low vitamin B-12 level of 180. His MRI scan showed a small, but definite, subdural hemorrhage a blood clot on the brain.
Once I got George in treatment which included brain surgery for the subdural, he improved greatly. His daughter called to report on his improved mental status, but added, “He’s still not the same dad I’ve always known.”
Could George have avoided some of these problems if his family had seen a neurologist early on when he first displayed symptoms? Allow me to show you why finding the right physician and obtaining proper diagnostic tests are so important early on when symptoms of Alzheimer’s first begin. Having the right treatment early could save you or your loved ones from a misdiagnosis, incorrect treatment, and unnecessary family stress.
That said, you could use these criteria as a plan for selecting a physician for a loved one-a parent or even your spouse-who may have signs of Alzheimer’s.
Selecting the Best Doctor to Treat Alzheimer’s Disease
Most physicians can do the initial work-up of a patient suspected to have a memory problem. Most physicians can come to a preliminary diagnosis. That said, however, Alzheimer’s is the great masquerader and certainly not an easy diagnosis to make in the initial stages (like Mild Cognitive Impairment). Only certain physicians can make this diagnosis accurately.
What You Must Do if You Have Memory Problems
If you suspect that you have memory problems, it’s important to ask someone close to you-your spouse, a child, or a colleague-to accompany you to the doctor’s visit and be there with you during the exam. When you make the initial appointment, it’s imperative that you explain the problem and ask for an extended visit. Helping your doctor understand that this entails a memory problem will enable him or her to select the proper tests and focus the exam.
An early diagnosis is important and often mind saving for the following reasons:
- It allows for timely intervention for treatable dementia. Some problems associated with treatable dementia include vascular problems (vascular dementia), vitamin B-12 deficiency, incorrect medications or combinations of medications, drug or alcohol problems, or other untreated medical problems.
- It allows for intervention that might reverse the development of the dementia. Sometimes simply changing a medication, changing the strength of a medication, or adding vitamin B-12 supplementation can correct problems associated with early dementia.
- It allows for the patient and family to prepare for the future. If the problem is, in fact, Alzheimer’s disease, there are medications available to help with the early symptoms. These treatments might improve the patient’s quality of life in the early stages and also allow time for the family to adjust to what may lie ahead with Alzheimer’s disease
- It is essential in the recognition of MCI that has a high conversion to Alzheimer’s at a rate of up to 18% per year. The Anti-Alzheimer’s Prescription is of particular importance to this group
Is This the Right Physician for You?
When you’re considering a physician to make an accurate diagnosis of Alzheimer’s, it is important to select someone who is trained and experienced in treating brain diseases. Not all physicians are equal in their knowledge of a particular disease.
Be aware that problems often occur when there is more than one doctor administering treatment. For instance, you might have a primary-care physician, an allergist for problems with asthma, a cardiologist for hypertension, and even a rheumatologist for problems with osteoarthritis. Unless effective communication takes place between all the physicians, you are putting your health in danger. As an example, your primary-care physician may prescribe an antihistamine to help control a runny nose. Yet when you develop an upper respiratory infection, your allergist may write a prescription for the antibiotic erythromycin. Sometimes a combination of medications such as this is potentially dangerous and can cause irregular heart rhythms and other serious problems. While both doctors are working at making you well, it is important to have one doctor who knows all about you-your various health conditions, the signs and symptoms, the tests you’ve had, the diagnosis, the treatment plan, and all medications and natural dietary supplements you take. It must be emphasized that a knowledgeable patient is one who reports all the details about his or her life–including changes in medications–to each doctor.
Specialists Who May Treat Alzheimer’s Disease
Primary-care physician: This doctor is a general practitioner, a family practice doctor or pediatrician, or internist who has completed three years of training after medical school graduation.
Geriatrician: Geriatricians are doctors who specialize in care for people 65 and older. These doctors are typically board certified in internal medicine and have additional training in areas pertaining to elder care.
Psychiatrist: Psychiatrists are medical doctors who specialize in the evaluation, diagnosis and treatment of mental disorders. Psychiatrists can prescribe medications, and, in addition, psychiatrists may treat people through counseling.
Neurologist: Neurologists are doctors who specialize in diseases of the brain and nervous system. These doctors are best suited to diagnose and treat Alzheimer’s. They have extensive knowledge of all nervous system disorders and often have good training in recognizing psychological problems. They are considered the best to diagnose and treat Alzheimer’s Disease.
Neuropsychologist: A neuropsychologist works with a neurologist in performing psychological testing that might identify cognitive problems.
Choosing a Doctor – Age, Sex, Credentials and Coverage
In choosing a healthcare professional, some people ask friends for recommendations, check the physician’s credentials, or call the local hospital for referrals. In this age of managed care, you will need to check the list of doctors who will accept your insurance provider. Nevertheless, none of these methods is “foolproof” in finding a qualified professional with whom you can feel comfortable to share innermost feelings and concerns about memory problems.
Perhaps one of the most important steps to take when selecting a physician to diagnose and treat a memory problem is to know yourself – including your personal likes and dislikes. As you go through the process of choosing a physician, consider the following twenty questions. Some of these questions will pertain to your initial selection of a physician. Others are to consider after you’ve seen this physician several times-just to help you make sure this is the right doctor for you.
- Would you feel more comfortable with a man or woman?
- Should the physician be older than you, the same age, or younger?
- Do you have a preference as to educational background?
- Is the doctor board certified? This means that the doctor passed a standard exam given by the governing board in her specialty.
- Where did the doctor go to medical school? Your local medical society can provide this information.
- Is the doctor involved in any academic pursuits, such as teaching, writing or research? This doctor may be more up-to-date in the latest developments in the field.
- Where does the doctor have hospital privileges and where are these hospitals located? Some doctors may not admit patients to certain hospitals, and this is an important consideration for older adults with other health problems.
- Does the doctor accept your particular type of health insurance, or is the doctor a member of the medical panel associated with your HMO?
- Is the doctor’s staff friendly and reassuring? Do they smile and make you feel valued? Chances are the staff reflects the personality of the physician.
- What are the doctor’s office hours? Are these hours convenient for you or someone who is transporting you?
- During the initial visit, does the doctor go over a thorough review of your history, including medications, past surgery, personal lifestyle habits, and family history of Alzheimer’s disease?
- Does the doctor greet you looking at you-like you are a person of value?
- How much time does the doctor spend on follow up visits? Does the doctor allow you time to tell your story?
- Does the doctor examine you with a mental status exam if memory is the problem?
- Does the doctor order tests readily, or does he or she tend to minimize your concerns?
- Is the doctor ready to give you a prescription without explaining more about the side effects?
- Does the doctor return your phone calls?
- Does the doctor make you feel that your health comes above all else? Alternatively, do you fear your health care plan dictates the quality of care you receive?
- If you need hospitalization, will this doctor still treat you? Or will you be delegated to a “specialist hospital doctor” who knows nothing about you as a person? You must ask the doctor this question!
- Does the doctor use specialists to assist with your situation, if you request one? Sometimes health plans discourage physicians from referring to other specialists. Or the physician may have bad rapport with other specialists. Both are warning signs to find a new physician or get a new health plan.
On a side note, because of managed care, finding the right person to diagnose and treat Alzheimer’s disease properly and cost-effectively is not always easy. For those with a health maintenance organization (HMO), a “gatekeeper” or primary care physician must make the referral to the neurologist. Carefully read the policy manual to understand the specific rules, and then select a physician whom you can trust to know your personal and family medical history and take responsibility for your healthcare.
Before Your Doctor’s Appointment – Write Down Concerns and Seek Answers
Before your appointment with the neurologist, write down a list of concerns you may have about memory loss and Alzheimer’s disease and specific symptoms you might have. It is also helpful to get an in-depth family history before meeting with your doctor. So often, a family history of Alzheimer’s is crucial in making an accurate diagnosis and prescribing effective treatment.
On a side note, I mentioned “brain freeze,” which invariably occurs when you “fear the worst” and your adrenaline and cortisol levels peak and overwhelm the receptors. That’s why it’s important to always be prepared before you sit in front of the diagnostician and report on symptoms. Before your visit, consider and record the following:
- Your mental and physical health concerns
- Symptoms you’ve noticed such as forgetfulness or memory glitches
- Symptoms others have noticed about you (family members, colleagues)
- Unusual behaviors you’ve exhibited
- Your health history including conditions such as hypertension, type 2 diabetes, cardiovascular disease and other problem that may increase the risk of Alzheimer’s
- Your family history of Alzheimer’s disease
- Medications you are taking now and in the past, including prescribed and over-the-counter; unusual side effects of medications you are taking or have taken
- Natural dietary supplements you are taking
- Your lifestyle habits (exercise, diet, smoking, alcohol consumption, drugs such as marijuana, cocaine, amphetamines, tranquilizers)
- Your sleep habits
- Causes of stress in your life (marriage, work, social)
- Questions you have about Alzheimer’s disease
Review Your Medications and Supplements with Your Doctor
When it is time to see the doctor, bring your medications and any nutritional supplements you may be taking on your first visit. Your doctor will let you know which ones are safe to keep taking, depending on an analysis of the drugs or supplements and your new diagnosis and medications.
So if you wonder how you can be sure your doctor will take you seriously about memory loss or fear of Alzheimer’s, remember that the squeaky wheel often gets the grease. If you know what to ask, you will get what you need! Be organized before your visit and open and honest with your doctor at the visit, and you will find answers. Something else, always ask questions. If your doctor seems “annoyed” at your questions, that’s a red flag and you should look for another doctor!
Case Study – Does Anyone Really Know Elizabeth?
Elizabeth, 79, came to see me with her youngest daughter, Kimberly, who had just flown in from New York City. Kimberly had not seen her stepmother in several years and could not give an adequate history to me, and Elizabeth was too busy twisting and turning and mumbling to know why she was sitting in my office.
It was obvious that Kimberly was bothered by having to take her stepmother to the doctor. She continuously received calls from clients on her cell phone, even during the brief appointment. Finally, when she finished a lengthy phone conversation, she spoke. “Ok. I think we’re here because she’s not getting good sleep and my dad is worried. In addition, she’s a bit forgetful. Then, again, Elizabeth’s never had much of a memory to speak of.”
How do you begin to make a diagnosis without pertinent facts about the patient? So, I began by asking some key questions:
Was Elizabeth on any medications?
What dietary supplements did she take?
Who was Elizabeth’s primary-care doctor?
Did she have other health problems, such as cardiovascular disease, type 2 diabetes, or hypertension?
Was there anything in particular about which Elizabeth had been confused recently?
Why didn’t her husband accompany her, so I could have more patient history?
Had Elizabeth wandered off or forgotten where she had parked her car?
My list of questions about this petite elderly woman continued.
After thinking about all these questions, Kimberly finally spoke. “Gee! When I think about all your questions it makes me wonder if I have a memory problem. I often forget where I park my car in the city, and last week I missed a hair appointment.”
Sadly, no one really knew Elizabeth-because her family was not in tune with Elizabeth’s mental problems, her diagnosis and effective treatment were delayed.
Alzheimer’s Making the Diagnosis: What Doctors Must Do
All doctors must be thorough in making an accurate diagnosis of Alzheimer’s disease. Here are the some pertinent steps that I follow with every new patient:
- Take the patient’s medical and family history. In cases of Alzheimer’s, a person who knows the patient well and has recent knowledge of their mental state must accompany the person. Sudden deterioration versus a slow progressive change is important for the physician to know in order to decide what tests to order and what treatment to give. Tests that should be done are the MMSE (Mind Mental Status Exam), and the clock drawing tests.
- Record vital signs. The doctor will take the body temperature, pulse or heart rate, blood pressure, and respiratory rate to assess the most basic body functions.
- Check vibratory function in the feet. With this test, the doctor uses a tuning fork to check the patient’s vibratory reflex on the knee and big toe. Vibratory sensation is part of a system of pressure sensation in our feet that tells us if our weight is on our toes or heels. It’s the information needed for our gyroscope located in the brain stem. Without this information, the gyroscope cannot keep us upright. For example, when the lights are out and we cannot use our vision for balance, it’s this sensation that helps us keep our balance. It’s the major reason why older people fall at night or when they’re on uneven surfaces.
- Test for the presence of Babinski’s reflex by scratching the bottom of the feet. Babinski’s reflex is one of the infantile reflexes that are normal in children under 2 years old, but the reflex disappears as the child ages and the nervous system becomes more developed. In those over age 2, the presence of a Babinski’s reflex indicates damage to the nerve paths connecting the spinal cord and the brain (the corticospinal tract).
- Test for the Snout Reflex, the Glabella Tap, and the Palmar Mental Reflex. These Alzheimer’s tests elicit reflexes normally seen in newborn infants that help them root, suck for feeding, protect their eyes, or bring food to their mouths. The “grasp” reflex, another test, reappears usually in severe Alzheimer’s. The grasp reflex is often misinterpreted as a sign of violence or stubbornness, as the Alzheimer’s patient will grab onto your hand or arm and not let go until they are distracted with another object to cling to.
Tip of the Tongue Inability is Common
There’s a loss in recall or what I refer to as “tip of the tongue inability.” As an example, a patient in this stage might talk around something because he cannot remember the person’s name, saying, “You know, it’s the guy who shares space with me,” rather than, “My colleague, Dr. Smith.”
To make the premonitory recognition of Alzheimer’s, doctors consider a number of signs including lack of initiative, lack of interest, difficulty managing one’s checkbook, an abandonment of pleasurable pursuits (such as golf, tennis, gardening, cooking), and finally seeking solitude to hide one’s deficits.
What We Know about Age and Alzheimer’s Disease
Of all the risk factors, age is a strong determinant of Alzheimer’s. While the incidence of Alzheimer’s is about 1 percent in those aged 60 to 65, it skyrockets to 33 percent in adults 75 to 80. Then, at 85, the incidence of Alzheimer’s boosts to 50 percent. Women are more likely to develop Alzheimer’s disease than men, even when accounting for age differentials. In study after study, researchers confirm that Alzheimer’s increases exponentially with age, until age 85 when it begins to level off. The reason why this occurs may be that those elderly adults who are genetically predisposed to Alzheimer’s already have the disease. Or, it might be that those elderly adults who are not genetically predisposed have lived an “anti-Alzheimer’s” lifestyle, or they may have the APOL e2 gene, which is potentially protective against Alzheimer’s.
Let me explain. We know that the apolipoprotein-E2 (APOL e2) gene is associated with resistance to Alzheimer’s disease, while the APOL e4 allele is associated with an increased risk for Alzheimer’s disease. There is a test that can show if you have the APOL e4 gene. Along like many physicians, I encourage patients to get this test. If they do have the APOL e4 gene that shows an increased risk of early Alzheimer’s, they can control their risk by adopting the 4-steps in the Anti-Alzheimer’s Prescription, changing necessary dietary and lifestyle habits to delay getting this horrific disease. Not all of my colleagues agree with this tactic, they say there is nothing we can do. I believe this attitude can be a self-fulfilling prophecy.
Mandatory Lab Tests for Alzheimer’s
If you have a possible memory problem, the doctor must order specific laboratory tests in order to make an accurate diagnosis and then treat the problem. Trust your doctor to decide which set of tests is best in your case to ensure no other medical problems are present. This can help you avoid extra testing that may add little to your diagnosis and only increase the number of tests and expense. If you fear one specific diagnosis, such as brain cancer, be sure you tell your doctor. If you still do not feel comfortable with the diagnosis, talk to your doctor and then have more testing. Or, it’s always your right to get a second opinion until you have peace of mind that the problem has been diagnosed correctly. Then – and only then – can proper treatment and healing begin.
Complete Blood Count (CBC). Your doctor may get a sample of blood for a complete blood count and chemical profile. These results will help assess your general health and eliminate any other disease as a possible cause of the memory loss problem. This test measures the amount of red and white blood cells and shows how your vital organs such as the kidney and liver are functioning.
C-reactive Protein. C-reactive protein is a marker of inflammation in the body. Levels of C-reactive protein are elevated during infections, and people with heart disease and those who are obese have elevated levels. The development of future heart disease is often predicted by elevated levels of C-reactive protein. As I’ve explained, we now associate pro-inflammatory markers in the body, including C-reactive protein, with Alzheimer’s disease.
Homocysteine. Homocysteine is a product derived from the metabolism of methionine, an essential amino acid predominant in animal protein. Studies show that, at high levels, homocysteine damages artery walls, which can cause cholesterol to build up and block the vessels. High levels of serum homocysteine is also correlated with cognitive dysfunction. Taking supplements of B vitamins (folate, B-6, and B-12) may lower elevated homocysteine levels. Eating foods high in folic acid, vitamin B-6 and B-12 may also help lower homocysteine.
Vitamin B-12. B-12 (cadalmadim) is a catalyst for normal red blood cell production and neural function. This lab is best done with a fasting blood test. Deficiencies are usually due to an inherited factor and sometimes common in blonde haired blue-eyed people. A vitamin B-12 deficiency can cause neuropathy in a severe treatable dementia, which is usually seen after age 40.
Folic acid. Folic acid is the co-enzyme for purine synthesis required for nucleo protein synthesis and blood production. A deficiency in folic acid can cause a problem similar to B-12 deficiency.
TSH or Thyroid panel. A thyroid panel will show the level of thyroid hormones. A level below the normal range may cause depression. Thyroid is also decreased with stress, pollutants as pesticides, and people who have a history of “yo-yo” dieting. Drugs such as lithium also decrease thyroid production. Other deficiencies such as iodine, tyrosine, selenium, manganese can also negative affect thyroid production. Symptoms are fatigue, low body temperature with an increased sensitivity to cold, weight gain, constipation, depression, and treatable dementia. Patients with underactive thyroids may need primarily to take thyroid hormone medication. The thyroid is often compared to the idle of a car’s engine. If the car’s idle is too low, the car sputters. If your thyroid hormone is too low, your brain function sputters. Symptoms of thyroid problems may include fatigue, low body temperature with an increased sensitivity to cold, weight gain, constipation, depression, and treatable dementia.
Complete metabolic panel. This battery of blood chemical tests includes liver enzymes, electrolytes, and kidney function (blood urea nitrogen or BUN, serum creatinine) and is done to understand disease states and the function of organs.
Additional Laboratory Testing for Dementia
Additional lab tests are only necessary if there is clinical suspicion for specific types of dementia. These tests should include calcium, phosphorus, zinc, magnesium, copper and ceruloplasmin cortisol, human immunodeficiency virus (HIV), antiphospholipid antibodies, and antineuronal antibodies. While these tests mean nothing to the patient, they are important to a physician who knows how to diagnose dementia.
A lumbar puncture or cerebral spinal fluid (CSF) collection is a test to look at the fluid that surrounds the brain and spinal cord. Cerebral spinal fluid acts like a cushion, protecting the brain and spine from injury. While this procedure is usually not needed, in those patients under 65 years old, it is advisable. This procedure may be important if the younger patient has a history suggestive of hydrocephalous, infections, vasculitis, or cancer. The fluid is examined for cells, protein, glucose in addition for infections and inflammation as syphilis, HIV. Tests for markers of Alzheimer’s Disease as tau and amyloid- Beta peptide are becoming standard tests.
The EEG uses an apparatus for recording electrical activity from the brain. It uses special electrodes or probes placed on the scalp attached by wires to an amplifier that can convert the electrical signals to wavelike written forms on papers or as images on a computer screen. The EEG can help the doctor determine memory loss associated with an alteration in consciousness (such as seizures).
Polysomnography (Sleep Study)
If you snore or suffer with daytime fatigue, you may need a polysomnography (sleep study), which is done in a special laboratory. This sleep study includes a recording of electroencephalography (EEG), electrooculogram (EOG), and electromyogram (EMG) in order to assess the actual quality of your sleep. These tests provide important data that defines the time it takes you to fall asleep, the duration of your sleep, and the time you spend in the different stages of sleep. Brief arousals, full awakenings, and movements are recorded to determine the severity of the fragmentation of sleep, which might account for daytime sleepiness and other symptoms.
All of the tracings from the EEG, EOG, and EMG, and the respiratory monitors are carefully reviewed, literally second by second, by a trained technologist and a specialized physician. These tracings will help your doctor determine the quality and quantity of sleep, the continuity of airflow at the nose and mouth, and the movements of the abdomen and chest wall. The number of minutes of sleep is counted and the percentage of time spent in each stage is calculated. These specialists count every arousal, awakening, and movement, along with every apnea and hypopnea. The amount of time spent at various oxygen levels is also determined.
Structural Scans: CT and MRI
To determine the cause of memory problems, computerized tomography (CT) or CAT scans or magnetic resonance imaging (MRI) of the brain is mandatory. By giving a more detailed image of the brain, these scans may be able to confirm memory loss and be predictive of who might develop Alzheimer’s. The MRI scan currently offers the most sensitive non-invasive way of imaging the brain. The structural MRI can assess the shrinkage of the brain, especially in the hippocampus. Certain centers can now quantitate hippocampal atropy or loss, this has been correlated with mental status changes to predict those who with a high probability to develop AD. As mentioned we call this MCI or Mild Cognitive Impairment.
Functional Scans: PET and F-MRI
Both the Positron Emission Tomography (PET) and Functional Magnetic Resonance Imaging (FMRI) are sometimes used to assist with a diagnosis. The PET scan shows reduced brain cell activity in certain regions of the brain, which may be consistent with the diagnosis of Alzheimer’s disease. The FMRI is an MRI scan that tests the metabolism of the brain and shows which neurons are “on” and which ones are “off. The F-MRI is critically important for a greater understanding of brain physiology, especially that dealing with accentuating the brain’s reserve.
When Should a Specialist be Called?
If the memory loss is associated with walking difficulties or any localized weakness, loss of vision, sudden speech loss or loss of consciousness or sudden hallucination, illusions or severe confusion, your doctor may want to consult with another specialist on your case. Also, if there’s no clear explanation from lab tests or the EEG, then I recommend an immediate specialist evaluation. If the memory loss is progressive over an extended period of more than three months or remains steady for three months, a specialist’s consultation is warranted. Most importantly, if your physician does not do the minimum history, physical examination, laboratory and imaging tests, you must seek another opinion.
Treatable Dementia Versus Diseases That Contribute to Alzheimer’s
Treatable diseases are those caused by factors other than degenerative amyloid plaque and tangles or those due to genetic factors. For example, remember George? I diagnosed him with a vitamin B-12 deficiency. Vitamin B-12 is essential for neuronal vitality and life. If not for a lack of vitamin B-12 in his diet, he probably would not have had the memory loss. But vitamin B-12 deficiency is more common among elderly adults, and it’s a problem that must be considered (and then treated) when making a diagnosis.
Giving George vitamin B-12 supplementation intramuscular through the skin, which bypasses the gastrointestinal tract, restored normal function to those cells that had not already died. By not diagnosing a vitamin B-12 deficiency in time, irreparable damage can occur. Along with the vitamin B-12 deficiency, George also had a recently occurring massive brain hemorrhage, which worsened because of the intense swelling and pressure. Removing the subdural hemorrhage, giving vitamin B-12 supplementation, and alleviating George’s severe hypotension (low blood pressure) by changing his medications ended his signs of memory loss or dementia. Strokes can also cause vascular dementia. But vascular dementia is not the same as the dementia caused by Alzheimer’s disease.
Is it Alzheimer’s or Not?
Some of the signs and symptoms of an illness such as major depressive disorder or bipolar disorder may mimic Alzheimer’s, particularly the symptoms of depression, confusion, insomnia, paranoia and hallucinations. Sometimes physicians get confused while trying to differentiate the diagnosis. However, the patient with Alzheimer’s disease also has other more noticeable symptoms including difficulty performing familiar tasks, problems with abstract thinking such as balancing a checkbook, impaired memory and forgetfulness, an inability to follow simple commands, and problems with language and communication, and poor hygiene, among others.
Wanda became concerned about her mother, Rose, age 72, whom I had treated for major depressive disorder for almost two decades. Wanda called me one evening and said she’d been at her mother’s home about an hour away and noticed some dramatic changes in her habits, finding “a carton of eggs and package of lunchmeat” in her mom’s warm kitchen cabinet. She checked other rooms and found a once-frozen pizza stored neatly on the shelf in the laundry room, next to the detergent. Wanda said that her mother had been forgetful lately and had even forgotten her name several times when she called to check up on her. “Several times when she went to the hairdresser or to meet girlfriends for lunch, she forgot how to get home and a police officer had driven her home,” Wanda said, “and when I’d suggest that she talk to her doctor, she’d become angry at me.”
I urged Wanda to be more assertive and bring her mother to see me for testing. Within days, Rose, who had suffered with major depression for 20 years, was diagnosed with the early stages of Alzheimer’s disease.
Currently, there is no definitive diagnostic test for Alzheimer’s disease but a probable diagnosis is obtainable. But Alzheimer’s disease is not the same as major depressive disorder, which can happen at any age. Feelings of depression can often coexist with a physical illness.
For instance, Frank, age 70, came to see me with symptoms of low mood and forgetfulness. In doing the physical examination, I routinely ordered a Prostate-Specific Antigen (PSA) test, which measures the level of PSA in the blood. PSA is a biological marker or tumor marker and can help detect disease. When Frank’s PSA test came in moderately elevated, I referred him to an urologist at UCLA, who later diagnosed Frank with prostate cancer. Within a week, he underwent surgery, which was successful in treating the cancer. When he came back to my office two months later, his depression and forgetfulness had resolved.
Many times patients with underlying diseases such as prostate or pancreatic cancer present with depression as the main symptom. Patients with chronic obstructive pulmonary disease (COPD), including emphysema and chronic bronchitis, may have depression and difficulty sleeping. That is why it is imperative to see a medical doctor immediately for a complete evaluation, if you or a family member has signs and symptoms of depression, moodiness, forgetfulness, or other similar problem. The mood change may be a red flag alert to another serious health problem.
Attributable Causes of Alzheimer’s
I firmly believe that certain risk factors increase the chances of getting Alzheimer’s Disease-whether obesity, hypertension, abnormal lipids, type 2 diabetes, chronic stress, sleep disorders, or environmental factors. These factors either cause Alzheimer’s, or they can cause Alzheimer’s to progress much faster than it normally should in those who are genetically predisposed.
For instance, some people are genetically programmed to get vascular disease. They can eat a good diet, exercise, and do all the right things, but by age 50, like everyone else in the family before them, they get occlusion of an artery. Others who are not genetically predisposed can also suffer an MI (myocardial infarction or heart attack) by age 50 solely by eating a diet high in trans fats, saturate fats, and sodium, along with living a sedentary lifestyle. The same is true for Alzheimer’s disease. It is a manmade, lifestyle disease-and we can only blame ourselves. However, sometimes in a radical attempt to solve a problem, we create another more complex problem. Take my patient, Sophia as a clear-cut example.
Case Study – Sophia’s Weight Loss Surgery and Dementia
Sophia, a once-successful trial attorney, came to see me. At 59, her legal career was failing, and she had been asked by three senior partners to take a leave of absence. They told Sophia that she was making far too many mistakes and forgetting important assignments and appointments. But what really concerned her partners, causing them to take drastic action, was when Sophia fell asleep in court during an important trial. When the judge had asked Sophia, “Do you want to ask any questions to the witness?” her response was nonexistent, as she was sound asleep.
Like many women, Sophia came alone to my office and openly said she was having some memory problems. I noted that Sophia had a history of obesity and hypertension, but at the time I saw her, she was only mildly overweight.
The correct diagnosis was not made until I asked the nurse to assist her in undressing for the exam. When I returned to the room and started listening to her heart and observing her body, I saw a longitudinal, relatively recent, surgical scar across her abdomen. I determined immediately that Sophia had recent gastric bypass surgery, which she confirmed. We’re just learning more about gastric bypass surgery and how it’s becoming widely known to cause vitamins B-6, B-12, E, iron, and other deficiencies that can lead to dementia, imbalance, and neuropathy.
Sophia had another problem that was never diagnosed until my office visit with her. She had obstructive sleep apnea (OSA). Sleep apnea is increasingly common in obese men over age 50, and in women after age 60. The problem with sleep apnea is that it can lead to brain deterioration in the hippocampus, the learning and memory center of the brain, among other serious health problems, even stroke.
Sophia’s recent memory loss and her difficulty walking compounded other risk factors leading to signs of early dementia and general nervous system breakdown.
Sophia told me that she saw her primary-care doctor and a cardiologist every three months. Somehow, both of these physicians had missed these symptoms and, thus, Sophia’s personal life and career suffered greatly. If recognized early, the treatment is simple. In Sophia’s case, it was as simple as supplements of vitamins B-6 and B-12 and iron tablets, along with a breathing device called the CPAP to wear at night. The nasal-CPAP has a mask, which is strapped on your nose connected to a swivel and flexible hose to a special pump, which quietly provides air under pressure to your nose. The CPAP maintains a positive pressure inside your airway while you breathe. It acts as a support to prevent further narrowing or collapse of your airway, and it actually increases the size of the airway behind the palate and at the back of your tongue. Problem is, so many older adults like Sophia are not diagnosed in a timely manner and are just another new statistic as the more than 650,000 Americans under age 65 with Alzheimer’s or other dementia grows.
Alzheimer’s and the Worried Well
No chapter on the diagnosis of Alzheimer’s can be complete without discussing the “worried well.” The first hint that a physician is dealing with a “worried well” patient is when they make a statement similar to the following: “Doctor, I have serious memory loss and let me give you the exact details.”
First, if you have memory loss, you don’t remember the “exact details”! Many of the “worried well” patients come alone or their spouse sits patiently as they elaborate at length-and in detail-about their illness.
As an example, Alice, 74, came to see me about her serious memory problems. Active in several volunteer organizations, Alice maintained a lovely home and even worked part-time at her daughter’s clothing boutique in Los Angeles. Alice said, “Dr. Fortanasce, my memory problem started exactly two months and five days ago. I remember the moment as if it were yesterday. A police officer stopped me for speeding when I was coming home from work. When he approached my car, I blanked out. I couldn’t remember where I put my driver’s license or insurance card. The police officer was a dark-haired, muscular gentleman, and he assured me that everything was fine.”
Alice continued, “Since that time, my memory has failed me several times. For instance, sometimes I can’t remember my children’s names. I call “Janice” “Joan” and “Joan” “Janice.” I know I’m losing my mind.”
Alice needed an immediate evaluation, and I was happy to give her a clean bill of health! Another woman, Meredith, age 45, gave a similar history of periodic memory loss to me. But Meredith also had a focal neurological symptom: peripheral vision loss. I ordered an MRI, which showed a pituitary tumor. After treatment for the pituitary tumor, Meredith’s memory problem ended.
Though I do not expect you to read about all the myriad Alzheimer’s mimics, I do hope I’ve impressed upon you the complexity of the human brain and the absolute need for a competent consultation.
Women and Alzheimer’s Disease
If you’re a woman you may wonder if your feelings of memory loss or forgetfulness could be related to Alzheimer’s disease. Perhaps your husband has noticed that you were forgetful and you attributed it to not getting enough sleep or menopause. I have found that many women hesitate in asking their doctors about symptoms of Alzheimer’s, thinking the doctor will not take them seriously.
This is a growing concern of women-and physicians-that doctors take them and their symptoms seriously. Some experts believe that women are simply less aggressive than men are in demanding treatment; others believe that many healthcare providers regard women as hysterics and feel they over-utilize the healthcare system more frequently than men.
While this over-utilization of healthcare services may have positive results with prevention of disease, some physicians believe the over-utilization is obsessive and linked with female “psychological issues.” For instance, in one medical center, there were reports of 75 percent of women with endometriosis being dismissed after multiple treatment failures. While all of the women had verified chronic pelvic pain, their physicians virtually wrote them off as over-utilizers of the healthcare system and dismissed their pain as being “neurotic.” In another survey, women with fibromyalgia syndrome (FMS), a chronic pain-related ailment, averaged seeing four to five physicians before receiving a proper diagnosis. Because there are no laboratory tests for FMS, the doctors told the women the “pain and symptoms were in their heads.”
No matter what anyone tells you, Alzheimer’s is very real. The signs and symptoms of memory loss are not imagined. If you notice that you’re more forgetful than normal or start having episodes of memory loss or feel highly anxious or depressed, call your doctor immediately. Don’t slough it off as being stressed or tired or think it’s related to aging. Talk with your spouse or other family member about your concerns, and make an appointment to see your physician with this family member.
Early treatment may help you to feel normal again. If the symptoms are determined to be Alzheimer’s disease, then you and your family members need to take this seriously and discuss the future.
The Schulman Study Gives Insight
Perhaps the Schulman study explains why women’s complaints are often under diagnosed and treated inadequately. This comprehensive report published in 1999 in the New England Journal of Medicine studied the relationship of race and gender to physicians’ recommendations for managing chest pain. The results of the study were quite revealing and may apply to any medical problem, including Alzheimer’s disease.
The study investigators concluded that physicians assessed female patients as being less intelligent, less self-controlled, and more likely to over-report symptoms than male patients. While this bias was not intentional, it often results in misdiagnosis and under treatment for women. In addition, for women who may suffer with anxiety, depression, or signs of memory loss, under treatment of these types of problems sometimes means no life at all.
I urge you to love yourself enough to call your physician if you have signs and symptoms of Alzheimer’s disease-or any illness. If your physician does not take your symptoms seriously, please find a doctor who does.
Is Your Brain Really Healthy?
If you remember nothing else, please remember this: early diagnosis of Alzheimer’s disease gives a better chance for treatment. If you have a reversible memory problem, taking care of it quickly when treatment is most effective is the best step you can take. If you do one thing for yourself, you owe it to yourself to be certain that your brain remains as healthy as possible. The Academy of Neurology estimates that 75 percent of patients with clear evidence of dementia are not diagnosed in a timely enough manner.
That said, by making smart diet and lifestyle choices, you can begin to slow the degradation of the brain, and, in effect, slow down your body’s biological clock. I believe this is an exciting promise. To be honest, this is the only hope we have right now for preventing Alzheimer’s disease.