My doctor says that I have white flakes showing up in an MRI of my brain, but he did not explain further. What do the flakes mean? [ 01/06/11 ]
Your MRI may have shown 'flecks' of brighter areas on the MRI that reveal a condition called 'white matter disease.' There are many different causes of 'white matter disease,' and some are more serious than others. In older adults, disease of the small blood vessels can lead to characteristic 'white matter disease findings' on the MRI. When the small vessel disease is serious, it can be associated with cognitive changes, but the presence of mild white matter changes does not necessarily mean that severe cognitive impairment is present. Some causes of 'white matter disease' are treatable, so your doctor should discuss this finding with you further. Making the most likely diagnosis will require your doctor to consider your age and medical history as well as any current symptoms. He or she may also refer you to a neurologist for a more detailed further examination.
My wife has been taking Namenda and galantamine for about 4 years. Is there any evidence that these medications are still working to slow the progression of her Alzheimer’s disease? [ 01/06/11 ]
Galantamine, the generic form of Razadyne, is a cholinesterase inhibiting medication approved by the FDA for treatment of mild to moderate symptoms of Alzheimer's disease (AD). Namenda, the brand name for memantine, works through a different mechanism that improves glutamate neurotransmission, and is also approved by the FDA for treatment of moderate to severe symptoms of AD. Studies have shown that these medications continue to benefit patients for at least up to 2 to 3 years. An encouraging study found benefits of combination therapy in AD patients followed for an average of 30 months, but we don't have enough information to prove that treatment for 4 years remains beneficial. Clinicians who continue these medications do so based on the absence of other helpful treatment approaches, the belief that such combination treatment is not harmful, and the possibility that continued treatment may help in various ways such as slowing cognitive deterioration, slowing loss of ability to perform activities of daily living, delaying the emergence of disruptive behaviors, and reducing caregiver burden. On the other hand, some patients and clinicians decide to discontinue treatment on the basis of unwanted side effects such as fatigue or dizziness, apparent lack of benefits, or cost considerations.
How should someone respond when someone with Alzheimer's disease discusses things that are not accurate, such as thinking they are someone else, mistaking their husband for a boyfriend, or asking to return to their home when they are actually already at their home. [ 01/05/11 ]
Like everything else, it depends on what is being asked or stated by the patient. Generally, it is best to avoid correcting inaccurate statements to avoid getting into an argument with the patient. Arguing is often futile, and only serves get the patient agitated. Even if the patient does not become outwardly upset, he or she may lose confidence and self-esteem if his or her statements are constantly being corrected. Instead, you can try playing along briefly and then redirect his or her attention to a different subject. For example, if the patient thinks she is a famous actress, say “I am so lucky to have you here today because I'm a big fan. You know who else are fans? Those people over there, and I bet they'd love for you to sit and play some cards with them.” Or in the case of the patient who thinks her husband is a boyfriend, say “So you're not married yet? What are you waiting for? Now what types of flowers/decorations would you want to have at your wedding? What is your favorite cake flavor?” Then change the subject to baking or something else.
Asking to return home is a common theme amongst Alzheimer's patients. Often this stems from a desire to be somewhere where they felt needed and safe, such as their childhood home or a home they raised a family in, etc. In this case you can ask them to tell you about their home and what they like best about it. If you try to discern the underlying emotion in their stories (fear, loneliness, frustration, etc.), this might provide you with a clue about why they keep asking to go home. Then reassure the patient that he is loved, that he is not a burden, and that he will be well cared for. Finally, try to redirect their attention to another topic or activity.
My brother was diagnosed with Stage 1 Alzheimer's disease about 18 months ago, and his wife put him in a home. He has never been violent until the one time he shook her. He has suffered from depression for many years, and he is again talking about suicide. He says that he doesn’t want to go on with life. I live 6 hours away from my brother, but try to visit him once every few months and email him once a week. I love him very much. Are the depression and suicidal thoughts typical symptoms of the Alzheimer’s disease? [ 01/04/11 ]
Depression is a fairly common problem in Alzheimer's disease patients, particularly those in the early stages of the disease who are aware of their own cognitive decline. One study found that a diagnosis of Alzheimer's disease by itself increases the risk of both depression and suicide in elderly patients. This study reported that people who had a higher level of daily functioning (that is, they generally had mild symptoms or were in the early stages of the disease) and had previous suicide attempts were at an elevated suicidal risk. In agreement with these findings, a more current study (Draper et al. Alzheimers Dement. 2010 Jan; 6(1):75-82) also indicated that early diagnosis of Alzheimer's disease or other dementia may actually increase the risk of suicidal thoughts.
Therefore, if you have not already done so, please talk to your sister-in-law about your concern for your brother. You or your sister-in-law should also alert the staff at his care facility that your brother has been having thoughts of suicide. The staff may already be aware of this, but it won't hurt to relay your concern. Talk to his doctor as well; your brother's antidepressant medication may need to be adjusted. You or your sister-in-law may also consider insisting that your brother see a mental health professional who has experience with the elderly and with dementia.
Finally, continue to visit, write or call your brother as much as possible. In addition to the weekly emails, consider calling him once or twice a week and sending him a hand-written letter. A paper letter is something he can actually hold, touch, and re-read whenever he wants, not just when he has access to a computer. And when you speak to him, be sure not only to seem genuinely interested in what he has to say, but also tell him that you love him and are concerned about him. Additionally, you might consider contacting a suicide hotline on behalf of your brother for more assistance and advice.
Is there a relationship between drinking alcohol and getting Alzheimer’s disease? [ 12/30/10 ]
A recent extensive review prepared for the Agency for Healthcare Research and Quality (www.ahrq.gov) concluded that light to moderate alcohol users benefited from a small protective effect against Alzheimer's disease. Heavier drinkers did not appear to be at greater risk than the general population; however, two important cautions should be considered:
- In cognitively impaired individuals, alcohol can have a significant influence on the ability to think and reason, and therefore someone with dementia should limit if not abstain from use of alcohol.
- Heavy alcohol use can impair cognitive function without causing Alzheimer's disease. A syndrome called "alcoholic dementia," which significantly affects memory and other cognitive functions, describes the severe effects that alcohol has in some heavy drinkers.
Alcohol consumption should always be discussed with a physician who is familiar with a patient's medical history and current medication regimen.
Read all of our recent Ask an Expert responses.
Can you simplify the process of how plaques and tangles affect the brain during Alzheimer’s disease without using medical terms? Does a healthy brain have any plaques or tangles forming at all? [ 12/29/10 ]
Plaques seem to occur because an abnormal kind of protein clumps together, causes a reaction from the blood and immune system, and results in globs of dead brain cells that no longer can process information or make the body do what it should. Tangles result when the inner workings of brain cells are chemically altered, get all twisted and cannot do what they are supposed to, which is to help the cell function properly. Plaques and tangles can be seen in the brains of older adults who do have dementia, but patients with dementia due to Alzheimer's disease have lots more plaques and tangles, especially in certain parts of the brain involved with memory and other kinds of thinking.
My co-worker has had increasing difficulty with memory loss over the past 2 years. Her son has also noticed changes in her memory and advised her doctor to test for Alzheimer's disease during her last office visit. Of course, the doctor mentioned this request to his mother and she denied any problems. She feels that she has always had issues with poor memory and that these symptoms are not unusual for someone who is 76 years old. After she told me of that incident, I felt obligated to tell her that I too have noticed that she has had difficulty remembering things, and received the same response that she gave her doctor. Is there any way that her son can help her? [ 12/28/10 ]
It is common for minor cognitive changes to accompany aging, and your co-worker may be experiencing normal changes or more significant changes. Difficulty with memory can be a longstanding issue or a new problem and there are many potential causes, so Alzheimer's disease is only one of the possible explanations. Some of the conditions that interfere with memory, such as use of certain medications, can be helped relatively easily, but without evaluation the opportunity to help will be missed or inappropriate treatment may be recommended. Perhaps your co-worker can appreciate the importance of assessing her memory more formally in order to reassure everyone that the memory difficulties are normal for her age, or to make sure that a potentially harmful but treatable medical condition is not overlooked and allowed to progress. Otherwise, it may be necessary to wait until her job performance is impaired enough to require the intervention of a work supervisor to discuss this with her.
My mother keeps asking about her children and thinks that they are still young. How can I help to calm her down when she wants to be with them? [ 12/22/10 ]
The fact that your mother thinks that her children are still young is not that uncommon for an Alzheimer's disease patient, who often confuse the past with the present. Your mother may be remembering a time when she felt needed and valued, and therefore may have a desire (a subconscious one, granted) to return to this “happier” time in her life. This is probably why, when you inform her that her children are grown now, she becomes upset. There isn't much point trying to reason with or use logic on a dementia patient—they often are so far into their own reality that arguing with the patient will only serve to agitate them even more. In this instance, therefore, it might be best to play along with your mother's questions for a while, then try to change the subject to something less distressing.
Additionally, you might want to consider doll therapy as a means to help your mother. Doll therapy involves giving a doll baby or teddy bear to a dementia patient and allowing them to interact with the doll in whatever way they want (i.e., dressing the doll, feeding it, rocking it to sleep, etc.) One formal study found that patients given dolls to “care for” tended to be more communicative with caregivers and less prone to negative behaviors, such as agitation or anxiety. Doll therapy seems to bring out the nurturing instinct in many dementia patients, particularly females, who may be reliving memories of being a mother of an infant, a time in their lives when they were very much needed and useful.
Non-formal observations by caregivers recommend that the doll be as lifelike as possible, and be introduced to the patient while he or she is still in the early stages of the disease to allow time for bonding with the doll. Given in the later stages, the doll may be less effective.