Alzheimer's disease
This is the commonest cause of dementia, the state in which a person gradually loses memory, language and the ability to manage without help.
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Medicines commonly prescribed for Alzheimer's disease
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: MODIFIED-RELEASE CAPSULE, 16 mgActive substance: galantamineManufacturer: Laboratorios Cinfa S.A.Prescription requiredDosage form: CAPSULE, 4.5 mgActive substance: rivastigmineManufacturer: Laboratorio Stada S.L.Prescription requiredDosage form: TRANSDERMAL PATCH, 9.5 mgActive substance: rivastigmineManufacturer: Almirall S.A.Prescription required
This is the commonest cause of dementia, the state in which a person gradually loses memory, language and the ability to manage without help. It is not part of normal ageing: someone can reach ninety with a clear mind, while in others the first changes turn up in their fifties. There is no quick cure, but a great deal hangs on how early somebody works out what is going on — including whether the cause turns out to be treatable.
What happens in the brain
Two proteins build up: amyloid gathers outside the cells as plaques, and tau twists into tangles inside the neurons. Connections break, cells die and the brain loses volume, first where recent memories are stored and then across wider areas. At the same time the level of acetylcholine falls, the messenger neurons use to signal each other; part of today's medication is built on that.
The process runs for fifteen to twenty years before the first complaints: while the store of connections is large the brain makes up for the losses. Symptoms appear once that store is spent, which is why the illness never begins "suddenly, after a shock". After sixty-five the risk roughly doubles every five years, though in about one patient in twenty it all starts earlier, sometimes as young as forty.
Early signs and ordinary forgetfulness
Forgetting a name, losing your keys, walking into a room and not remembering why — that happens to everyone. The difference lies not in the forgetting itself but in how it works.
- with age-related forgetfulness the memory comes back later, unprompted or with a hint; in the illness the whole episode is gone and hints do not help;
- the same question is asked several times an hour, and each answer is received as new;
- finding the right word gets harder and conversation detours around the missing term;
- multi-step tasks — bills, cooking from a recipe, packing for a trip — start going wrong;
- objects turn up in improbable places: glasses in the fridge, money inside a book;
- the person gets lost on routes they have walked for years;
- irritability, anxiety, suspicion and withdrawal from company appear.
One more detail is telling: with ordinary forgetfulness people worry about their own memory, whereas in Alzheimer's disease they often do not notice the changes at all and it is those around them who become alarmed.
When memory loss is not Alzheimer's
This is the most valuable part of the discussion, because some causes are reversible and it would be a shame to miss them.
- depression in older people often presents exactly as loss of memory and loss of interest in everything; it is treatable, and the memory returns;
- an underactive thyroid and vitamin B12 deficiency, both found by an ordinary blood test;
- medicines: sleeping tablets, sedatives and some drugs for allergy or travel sickness cloud the mind, especially in combination;
- alcohol, dehydration, too little sleep and untreated sleep apnoea;
- an infection, most often urinary or in the chest, can bring on confusion and hallucinations in an older person within a day: this is delirium and needs urgent care;
- a chronic haematoma under the coverings of the brain after a fall, sometimes a minor and forgotten one: it builds up over weeks and is treated surgically;
- normal pressure hydrocephalus, where an unsteady walk with feet that seem stuck to the floor comes together with urinary incontinence and failing memory; some of these people return to their old life after an operation.
If the decline develops over weeks or a couple of months, it is not Alzheimer's disease. That pace points to another cause — inflammatory, vascular or a tumour — and calls for urgent investigation.
There are other dementias too. Vascular dementia worsens in steps, after small strokes. In Lewy body dementia visual hallucinations come early, the state fluctuates from hour to hour and stiffness of movement is added; these patients react badly to antipsychotic drugs. Frontotemporal dementia starts younger, and what changes in it is not memory but personality and speech.
How the illness changes over time
The course stretches over years, the speed differs from person to person, and the borders between stages are blurred.
In the early stage a person copes alone but needs reminders and a safety net around money and paperwork. That is exactly the time to settle legal and financial matters, discuss driving, and talk about how they would want to be looked after: afterwards there will be nobody left to ask.
In the middle stage help is needed with dressing, washing and eating. Disorientation in time and place grows, along with a tendency to leave the house, night-time confusion and suspicions that things have been stolen when the person moved them themselves; speech thins out and familiar faces are not always recognised.
In the late stage a person depends entirely on care and loses speech and the ability to walk. Food starts entering the airway, and repeated chest infections become the main threat to life. What matters here is less the fight against the disease than comfort — pain relief, care of the skin and mouth, a calm setting and support for the family.
What is done to reach a diagnosis
There is no single test or scan that answers yes or no. The main thing is a detailed conversation: what changed, when it began, how it went on. An account from someone close is worth more than any test, which is why it is best to attend with the person who sees them every day.
Then come cognitive tests of memory, attention, language and orientation; their results depend on education, language, hearing and mood, so a diagnosis is never made on a score alone. Blood tests rule out the reversible causes: thyroid, vitamin B12, glucose, calcium, kidney and liver function. A brain scan — computed tomography or magnetic resonance imaging — shows tumours, haematomas, traces of strokes and the pattern of shrinkage. In difficult or very early cases a study of the spinal fluid or a positron emission scan is added; blood tests for amyloid and tau have also appeared, though they are not yet available everywhere.
What can help
The disease cannot be cured, but symptoms can be slowed and life made better, starting on day one.
The medicines used are cholinesterase inhibitors in the early and moderate stages and memantine in the moderate and severe ones. The effect is modest: a few months in better shape, more for some people and nothing for others. Nausea, loss of appetite, a slow pulse and fainting are reasons to review the prescription rather than to put up with it. Antibodies against amyloid are licensed in a number of countries: only in the very earliest stage and only where a build-up of the protein is confirmed, with a moderate effect and regular scans because of the risk of brain swelling and small bleeds.
The part without tablets matters just as much: a steady daily routine, a home that is easy to understand and safe, labels on cupboard doors, a clock showing the date. A hearing aid and glasses sometimes restore contact with the world better than any drug. Cognitive stimulation groups, talking about the past over photographs, whatever physical activity is manageable, and treatment of depression and pain all help.
If someone becomes agitated or aggressive, look for the reason first: pain, constipation, an infection, thirst, noise, darkness, too many people around. Antipsychotic drugs are a last resort in short courses: they raise the risk of stroke and death, and in Lewy body dementia they are especially dangerous.
What genuinely lowers the risk
Nothing offers a guarantee, but a sizeable share of dementia is linked to things that can be changed, and they act in middle age, long before any symptoms.
- treat hearing loss and do not put off a hearing aid;
- keep blood pressure, blood sugar and weight in check, do not smoke, and limit alcohol;
- move regularly — whatever exercise you will actually keep doing for years;
- protect the head: helmet, handrails, and clearing away anything to trip over;
- treat depression, get enough sleep and keep a living social life;
- learn new things at any age: a language, an instrument or a craft build that reserve in the brain.
Online consultation
A remote appointment suits the first step, the one many people put off for years. The doctor goes through what exactly you or your relatives have noticed, separates a worrying picture from what is normal for the age, draws up the list of tests needed to rule out reversible causes, and explains which specialist to see and how urgently. It is also a good setting to go over reports you already have, sort out side effects of medication, find approaches to difficult behaviour, and talk about the exhaustion of the person doing the caring. Examination, cognitive testing and scans happen in person, and sudden confusion in an older person is not something a remote appointment covers: that is a reason to call emergency services.
This material is for information only and does not replace medical advice.
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