Wednesday, September 2, 2009
How can you tell if a family member is showing early symptoms of Alzheimer's disease? And, what's the best way to talk about what your seeing with the affected person? We speak to Dr. Jack Schim about why it is important to identify dementia and Alzheimer's early.
MAUREEN CAVANAUGH (Host): I'm Maureen Cavanaugh, and you're listening to These Days on KPBS. It's one of the hardest things to confront with a loved one. You begin by noticing some absent-mindedness or confusion, or perhaps your mother or grandfather keeps repeating things. You may not be certain about what the problem is, but you know that something is not right. Well, experts in the field of Alzheimer's and dementia are beginning to urge people to follow up on those feelings. Early diagnosis is becoming more important as new medications are developed that may be able to slow the progress of disease. Right now, it's estimated that only 50% of people who have Alzheimer's are correctly diagnosed. To tell us more about the signs and symptoms and how to start talking about dementia and Alzheimer's is my guest, Dr. Jack Schim, local neurologist at the Neurology Center in Encinitas, and Chief of the Neurology Section at Scripps Hospital. Dr. Schim, welcome to These Days.
DR. JACK SCHIM (Neurologist): Thank you and good morning.
CAVANAUGH: Good morning. And we invite our listeners to call in. Do you have a story about a member of your family who was diagnosed with Alzheimer's? Maybe you're concerned about a loved one's failing memory. Give us a call with your questions and your comments. The number is 1-888-895-5727, that's 1-888-895-KPBS. You know, Doctor, I think that there is a confusion among people between dementia and Alzheimer's, so let's start out by clarifying. What is dementia? How is it different from normal memory loss as the result of aging?
DR. SCHIM: Well, dementia is defined as a loss of memory and other cognitive functions that is severe enough that it's starting to interfere with day-to-day activities, so all of us, in the course of aging, start having some decline in memory and I think that periodically we all observe that and wonder, gee, is that just a senior moment or am I in danger of losing it? When deterioration sets in to the point that someone is having functional difficulties in their day-to-day activities, in managing a checkbook, in remembering appointments, in knowing how to drive or brush their teeth or functions like that, that's likely to represent dementia.
CAVANAUGH: And is Alzheimer's a form of dementia?
DR. SCHIM: Yes, Alzheimer's is one subset of dementia. So it's actually the most common cause of dementia. It accounts probably for about 80% or thereabouts. There are other sorts of dementia that are also neurodegenerative as Alzheimer's is, so that includes things like frontotemporal dementia where people often have judgments and behavior problems quite early. It includes Lewy body type dementia which overlaps a bit in terms of its presentation with Parkinson's, so people may have inexpressive faces, shuffling gait but very characteristically they often have very vivid hallucinations early in the course of their disease, unlike Alzheimer's patients. And then, very importantly, is that in people who are presenting with a potential dementia, there may be very treatable causes and so that's really one of the key reasons why we urge people to take action when they start seeing concerning signs in their loved ones.
CAVANAUGH: Now just to clarify, we, in common parlance, often use the word senility or somebody's senile. And I wonder if that – is there a medical definition for senility? And does it involve any of this dementia or Alzheimer's disease?
DR. SCHIM: Well, I think what we refer to as senility largely represents dementia. But in a technically correct sense, it just means aging.
CAVANAUGH: Oh, I see.
DR. SCHIM: So, you know, we would consider that, for example, if someone gets a shaking in their hands at an old age, that might be a senile tremor but it doesn't imply that they have a dementia. But oftentimes when we refer to someone who's getting senile, what we're really saying is that they're becoming demented and concern is, of course, that Alzheimer's may be the specific cause.
CAVANAUGH: Now what are some of the early signs that you can look for in Alzheimer's disease?
DR. SCHIM: Well, from the point of view of us, individually, or for us looking at our family members or loved ones, frequently forgetfulness beyond what would be considered normal. I mean, after all, we always sometimes put the keys down and forget where we put them. But if you forget the appointment that you had this morning or you don't know what you had for breakfast this morning or dinner last night, that's beyond the bounds of typical memory aging. Beyond that, there are other portions of thinking and cognitive function that are likely to decline in someone who has Alzheimer's or any dementia in that sense. In other words, a pure isolated memory problem usually is not dementia yet, although it might be. But someone might have judgment difficulty, they may have – start remembering things that didn't happen and filling in the gaps and kind of making things up. They, as I suggested earlier, might have trouble with daily activities that we should be able to do like balance the checkbook or keep track of a shopping list and actually come home with most of the things that were on your list and not leave it in the store and come home with just the milk.
CAVANAUGH: Right. What about what I said earlier about repeating things and irritability. Are those also signs?
DR. SCHIM: Those can definitely be signs. A personality change is frequently one component of it and leads to at least part of the differential diagnosis of dementia includes pseudodementia, so someone who is developing depression may just kind of start shutting down, not paying attention, not putting out effort. And in that sense, they may have a presentation very much like dementia. So someone who presents and we believe medically they're having dementia, we need to evaluate. Do they, for example, have depression that needs to be treated? Do they have another medical condition that might present with dementia but might be very specifically treatable and not a deterioration. Example would be hypothyroidism, a vitamin deficiency, B-12 deficiency, syphilis, you know, we used to think that that had gotten rare, well it's not so rare anymore. Medications that a patient has been prescribed can sometimes interact and give cognitive difficulties. And so as a physician, we always have to go through a very broad list of potential causes before we say, well, no, most likely this person's dementia is a degenerative dementia and then based on both the statistics of most degenerative dementia is Alzheimer's and them not having features that would lead us towards another kind of degenerative dementia, this looks like it's probably Alzheimer's.
CAVANAUGH: I'm speaking with Dr. Jack Schim. He's a local neurologist at the Neurology Center in Encinitas and chief of the Neurology Section at Scripps Hospital. And we're taking your calls about how to recognize signs, early signs, of dementia or Alzheimer's disease in your loved ones. 1-888-895-5727, you can call us with your questions or your comments. The number is 1-888-895-KPBS. Now how early on can you actually track the development of Alzheimer's disease?
DR. SCHIM: That’s a tough question for me to answer because I observe it when someone brings a patient…
DR. SCHIM: …to me or an individual to me who's then my patient. But it's not infrequent for, in retrospect, us to be able to identify, oh, there were changes a year ago, or two years ago, that were just sort of glossed over. Ah, they're just getting old. So it's always of concern when someone is having behavioral changes, memory changes that are out of bounds for them. We think that the overall course of Alzheimer's is typically about eight or ten years. In other words, from the first identification to kind of the very end stages.
CAVANAUGH: And from the reading that I've done in some of the literature on the website that we're going to be talking about, I learned that although Alzheimer's is a gradual – it's a progressive disease, a degenerative disease, as you were saying, there are some forms of dementia that can come on suddenly.
DR. SCHIM: Absolutely.
CAVANAUGH: And what are they?
DR. SCHIM: Well, vascular dementia, of course, is – You know, we used to think of vascular dementia as very, very common before Alzheimer's was recognized to be so prevalent, and it was called hardening of the arteries in the brain. Well, it turns out that that actually is a significant component of dementia in an epidemiologic sense, in other words a significant fraction of people who have dementia, and it may overlap with Alzheimer's. So someone who has a stroke, in a usual sense is going to have an abrupt onset of a neurologic change, for example, sudden garbled speech, sudden paralysis, and so forth. But they might simply have a sudden confusional episode that doesn't completely clear, and then another, and then another. Or maybe even more subtle, if someone has very small vessels that are getting blocked off in the brain then essentially the brain may be starving for nutrients in those areas and it's not uncommon when we're evaluating someone for dementia, part of our evaluation includes brain imaging, to see signs that they may have had previous strokes that were not clinically evident. In other words, no one really knew they had a stroke other than to say, yeah, I remember dad was leaning to the left two weeks ago and there was really never a good explanation but then he stopped doing it after an hour or a few hours. And we look into it and say, ah, well, there's a little tiny stroke in the brain that might've accounted for that. So someone could have a vascular event, that would be probably the single most common cause for abrupt onset in the sense of he was fine yesterday. Another thing that we see very commonly in the hospital is someone who is admitted for some medical condition, whether it's a abdominal operation or hip surgery or something like that and they're extremely confused after their surgery. And the neurologist is consulted and looks into it and say, well, you know, part of it probably is the medical changes that just happened in the last 48 hours but maybe there's an underlying dementia that was sort of unmasked. In other words, someone may be in the very early stages of dementia and it really hasn't come to attention because it really hasn't gotten so obvious that people can no longer ignore it until something else comes along, takes away the body's, the brain's ability to compensate, which they're working as hard as they can, not consciously, but they're maintaining as best equilibrium as they're able to until they have a pain medicine or they get a urinary infection and suddenly kaput.
CAVANAUGH: That's interesting. We have a lot of people who want to join our conversation right now. Let's go to the phones and speak with Pam in San Diego. Good morning, Pam, and welcome to These Days.
PAM (Caller, San Diego): Good morning, and thank you for discussing this heartbreaking but so important issue. My father-in-law died two years ago of Alzheimer's but we realized, in retrospect, that he'd probably been ill for anywhere from ten to twelve years, our taking probably two to four, maybe longer, years to recognize that those little subtle changes in his behavior were, in fact, significant indicators of a major change going on in him. And so I – I'm simply reiterating the point that the doctor has already made, but the point I want to make most importantly at this time is that as time goes by and the frustrations and the fears and the – all the sadness that happens when you witness someone going through Alzheimer's and the decline, the most important thing I took away from it was that if you can maintain your patience and your compassion and remember the person behind the mask that is Alzheimer's and remember to touch that person as often as they're comfortable with, to hug them and tell them you love them, I think is something that gives them meaning even toward the end. I saw that with my father-in-law and I'm so grateful that I had the chance to do those simple things with him when nothing else was available. So that's the extent of my comment.
CAVANAUGH: Pam, thank you very much for sharing that, and, Doctor, would you like to comment?
DR. SCHIM: I just endorse exactly what she said. Thank you so much.
CAVANAUGH: Let's hear from Rick in Carmel Mountain. Good morning, Rick, and welcome to These Days.
RICK (Caller, Carmel Mountain): Good morning. Thank you for having me on. So I'm an only child and my mom is 81. Her mother died of Alzheimer's. And I am concerned that she's getting Alzheimer's or dementia. She has, since she turned 80, brought up some – a number of different things. She had had an affair when she was married to my father. She's now married to her second husband, my stepfather. The affair had happened anyway, oh, like thirty-some-odd years ago. I knew about it vaguely and she's kind of obsessed on it. And I'm concerned that she is getting Alzheimer's or dementia and I don't know what sort of diagnosis or tests can be done to determine whether or not she is getting it, indeed, and what sort of medications or things that can be given to her to, if she does like get a test and then what sort of treatment can she – would help her?
CAVANAUGH: Got it. Rick, thank you for that. And, Doctor.
DR. SCHIM: Well, Rick, I share your concern. I think the starting point in this sort of circumstance when we are seeing behavioral changes or memory changes in a loved one is to start off by having a conversation. Say, mom, I'm concerned. Here's something I've been observing. I think it's important that you see your doctor and get this evaluated. Bring her, hopefully with her cooperation, to see her physician and clue him in in advance, take notes in advance as to what you've seen. If you can get her to participate in some, you might say, pre-assessments, there are some simple tests such as a clock drawing task that can give a sense of what someone's capabilities beyond memory alone are. The physician will want to review their history and your observations and her observations and her medications. Typically, we would also recommend that there would be general medical assessments, meaning certain laboratory tests, a blood count, a chemistry panel, thyroid function, B-12, and anything else that might be relevant for your mom, and brain imaging. Typically, I advise MRI. It's much more sensitive to being able to see tiny strokes that might be a component of someone's decline. But the main purpose of brain imaging is to look for very specifically treatable things such as a brain tumor that could cause a behavioral change and memory change and might be a benign one, one that is not going to be cancerous and can be removed. Or hydrocephalus, which can cause memory problems and gait difficulties and difficulty controlling urination. Following that, there are a variety of medications. There are essentially two different classes of medicines that are presently useful for treatment of suspected Alzheimer's patients. One are what are called cholinesterase inhibitors and they help the brain raise the level of a brain chemical, a neurotransmitter, called acetylcholine that is depleted in a rapid fashion in people with Alzheimer's, and can stabilize and even improve memory and behavior. The other is a different category of medicine, the medicine – there's only one medicine of that category called Memantine and it has also been shown beneficial in Alzheimer's, and, in fact, in Europe is approved for treatment of Parkinson's disease. So there are various medication tools that are best used early if they're going to be used. There's evidence that if we start a medicine early, we can stabilize someone and be able to, hopefully, keep them independent for a longer period of time.
CAVANAUGH: Tell us a little bit more, Doctor, about that conversation, the conversation that you have with your relative, your loved one, when you're noticing that some things are going wrong. Because I would imagine that there is often some resistance about taking it the step further and perhaps going to the doctor's office or taking the tests. What can we learn about what techniques are useful in confronting a situation like this?
DR. SCHIM: It can be a tough dynamic. You know, it certainly depends on the relationships that are existing in the family and there may be some people in the family that might be better able to approach mom or dad and say, you know, we have some concerns. Have you been seeing any problems, mom? Because we see that you're more forgetful than we would expect and maybe there's something that can be fixed. You know, let's look into this. So I think trying to build an alliance and a team, we're in this together, helps quite a bit. There are some families or some affected individuals who have such denial, in fact that's a very common aspect of early phases of the disease. Now, I – This couldn't be happening because I don't want it to be happening. That occasionally I've had family members come to me absent the affected individual and say, we'd sort of like to do a pre-consultation and have some advice as to how to move this forward. And, well, you know, here are some blood test orders that should be done. You can get that done through the family doctor initially and then why don't you find a way to connect them back to me. Are they having any other symptoms that might be neurologic? Do they have – might be completely unrelated to their memory problems, do they have numbness or tingling or a headache or some other reason you can get them in the door and then let the physician, then let the specialist, try to draw out something and say, hey, you know, we just do these tests routinely. Do you mind if I lead you through a little mini-mental status score? Don't feel threatened. Everyone gets this.
CAVANAUGH: I see. We're taking your calls at 1-888-895-5727. And let's speak with Eleanor in Encinitas. Good morning, Eleanor, and welcome to These Days.
ELEANOR (Caller, Encinitas): Hello.
ELEANOR: I'm concerned about my 81 year old husband who has, I think, some significant memory loss, short term, and he usually has to write things down in order to remember that he needs to do it, or he has an appointment, etcetera. What is the hereditary possibility? He had a grandmother who had Alzheimer's into her eighties before she actually broke a hip and was – it was lethal for her. But I've talked to him about going for a screening at UCSD and he's been, well, over the last year, dragging his feet.
CAVANAUGH: Thank you for that, Eleanor.
DR. SCHIM: Well, the observation of forgetfulness in short term memory is one of the key things, one of the key features, of Alzheimer's but it can happen just as part of normal aging and we call that mild cognitive impairment or minimal cognitive impairment or another term is benign senescent forgetfulness, meaning the memory associated changes that occur simply with aging. On the other hand, if you're concerned then it's almost certainly a valid concern. Typically, people who have problems with short term memory and preserved long term memory are more likely to be developing a cognitive problem than someone who just doesn't remember much of anything, may not be paying very good attention. And an evaluation at UCSD might be too much of a threat to him. Perhaps the starting place would be, you know, we've been talking about this for a while, let's just get it checked out with your doctor.
DR. SCHIM: As far as your question about the hereditary component, the biggest risk is in someone who has family members who had Alzheimer's at a young age. So if someone has Alzheimer's at age 50, for example, which occurs, or even earlier, the hazard is much, much greater that direct family members will potentially inherit a strong tendency. Otherwise, the biggest risk factors for Alzheimer's are aging. So, for example, at age 90 or greater, half of people of that age have a significant dementia, most of whom have Alzheimer's. As the population ages, I think we're going to see a vastly increased prevalence of Alzheimer's and there are statistics that bear that out where we have evidence to say that roughly a half a million Californians currently have dementia, mostly Alzheimer's, and that number will double just over the next ten years or fifteen years.
CAVANAUGH: Let's hear from – Let's take another call right now, and Mike is calling us from Point Loma. Good morning, Mike. Welcome to These Days.
MIKE (Caller, Point Loma): Good morning. Doctor, I've read about a California company that's using a blood sample to compare their algorithm that they developed with different genetic markers to either analyze or diagnose Alzheimer or even possibly predict whether a person is likely to develop Alzheimer's. Are you aware of this or can you comment on it? And what is the prognosis for a definitive laboratory analysis for Alzheimer's to distinguish it, let's say, from the other types of dementia or mental deterioration?
CAVANAUGH: Thank you, Mike.
DR. SCHIM: Currently, I don't think there's any validated lab test that gives us the kind of accuracy that we would like to see, true specificity and sensitivity. There are no definitive biomarkers that are in the bloodstream but there is evidence that there may be some that we'll be able to identify and profile. There is – There are tests that can be done on spinal fluid but to get spinal fluid is an invasive procedure and it's not a very difficult one if you do them all the time, as I do, but we would rather make diagnoses noninvasively. There is noninvasive imaging that has got very high accuracy but is currently a research tool that actually is able to image the amyloid plaque within the brain, and at a certain degree of deposition of that in the right clinical context is highly likely to be, you might say, early Alzheimer's. In other words, if someone has mild cognitive impairment and on this sort of imaging has a excessive deposition of plaque they, you might say, have pre-Alzheimer's and the availability of pre-symptomatic screening will become very important when we get better medications and better tools.
CAVANAUGH: Right. Now speaking about the medications that we have now, there are two pharmaceutical companies sponsoring a website called YouCanBeTheOne.com and it has an awful lot of information about how to spot Alzheimer's and how perhaps to make an early diagnosis, how to go to your doctor for an early diagnosis. What do you find on that website, Doctor?
DR. SCHIM: Well, there are a variety of things. First of all, there's a lot of information regarding what Alzheimer's is about and the typical time course and what it looks like when it's mild, when it's moderate and when it's severe. There's, I think, very helpful information to allow us all to start the conversation and what sort of information is important to gather, how to try to broach the conversation with mom or dad or auntie that there's concern. Something looks like it's changing. And how to gather the right kind of information before a physician's visit, what sorts of questions to ask, what sorts of testing would be appropriate. What's the degree of confidence that a physician can have in making an Alzheimer's diagnosis, and so forth.
CAVANAUGH: I wonder what kind of medications are on the horizon? Is there anything in trials or anything like that that is a next generation of Alzheimer's drug?
DR. SCHIM: Well, I can tell you about studies that I'm aware of. Currently, we have a clinical trial in progress that is actually testing an Alzheimer's vaccine. It is a monoclonal antibody that is given intravenously to Alzheimer's patients and is investigated or being investigated to try to, you might say, leach out the amyloid deposition within the brain. And studies of it thus far have shown it to be effective in doing that in the sense of brain imaging done during the course of study shows a lessening amount of plaque. It's not yet clear whether that's the right molecular target. There are other studies looking at blocking enzymes that form – that allow the formation of these abnormal protein complexes within the brain. And I think we are, within the next five to ten years, likely to have some much better medication tools than we do presently. The current medicines treat the symptoms and can slow the progression and certainly can make people clinically better for a while but none of the medicines currently truly treat the underlying disorder.
CAVANAUGH: Well, I want to thank you so much for sharing so much wonderful information with us. Thank you.
DR. SCHIM: Thank you very much.
CAVANAUGH: I've been speaking with Dr. Jack Schim. He is a neurologist at the Neurology Center in Encinitas, and Chief of the Neurology Section at Scripps Hospital. I want to let everyone know we had a lot of people on the lines and we couldn't speak to them all. You can post your comments and continue this conversation online at KPBS.org/TheseDays. And, once again, that website address if you want to find out more, is YouCanBeTheOne.com. Stay with us for the second hour of These Days right here on KPBS.