Recognizing Signs and Symptoms of Alzheimer's Disease in Earlier Stages Can Lead to Diagnosis

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1 A joint publication of the Illinois Health Care Association and CE Solutions November 2015 Recognizing Signs and Symptoms of Alzheimer's Disease in Earlier Stages Can Lead to Diagnosis Early diagnosis can improve treatment options and may slow progression of AD By Deb Martin, RN, BSN Alzheimer's disease is the most common type of dementia found in people over age 60 and the risk of Alzheimer's disease significantly increases as we age. Alzheimer's disease is currently the sixth leading cause of death in the United States and is the only disease in the top 10 that cannot be prevented or cured. As Alzheimer's disease progresses, the patient may require a health care setting or need a 24/7 private in-home caregiver. Because baby boomers are expected to live longer than any previous generation, there will be a drastic increase in the number of Americans living with Alzheimer's disease and in need of care. Currently, there are an estimated 5.3 million Americans living with the disease, with the majority ages 65 or older; only an estimated 200,000 have younger-onset Alzheimer's disease. By 2040, when baby boomers will be between the ages of 76 and 94, the number of Americans with Alzheimer's disease is estimated to double to 10.3 million. Why diagnose early Although Alzheimer's disease cannot be cured, early and accurate diagnosis can improve treatment options and may potentially slow the disease's progression. Even when a patient has been diagnosed, the diagnosis and treatments prescribed can be misplaced or delayed when the patient moves into a facility. In daily interactions with residents, gradual changes in cognitive and physical abilities may go unnoticed until significant decline is realized and the disease has significantly progressed. 1

2 Current diagnosis relies on documenting mental decline. We know that Alzheimer's disease has already caused severe brain damage in individuals who are diagnosed this way. One of the most active areas of research is on new strategies for earlier diagnosis. Following are the areas of research that are proving to be the most promising to assist in early diagnosis: biomarkers neuroimaging cerebrospinal fluid (CSF) proteins proteins in blood or other parts of the body genetic risk profiling Stages of Alzheimer's disease Alzheimer's disease does not progress in the same way or at the same rate with each person. However, symptoms typically develop in three general stages. Mild Alzheimer's disease (early-stage) May function independently. A person may feel they have memory lapses. Friends and family begin to notice difficulties such as problems coming up with the right word or name, losing things or problems with organizing things. Moderate Alzheimer's disease (middle-stage) Typically, the longest stage. A greater level of care will be required as the disease progresses. The person may become frustrated or angry. Symptoms will be noticeable to others and may include the inability to recall names or addresses, confusion about day and time and increased risk of wandering. Severe Alzheimer's disease (late-stage) Memory and cognitive skills continue to worsen. Personality changes take place and individuals need assistance with daily activities. At this stage, a person with Alzheimer's disease becomes more susceptible to infection. Onset of true Alzheimer's happens earlier than other types of dementia. Most people are diagnosed in the mild/early stage. Not diagnosing early enough can also be a safety issue. For example, a person may continue to drive but become disoriented and unable to navigate and become lost in their travels or panic behind the wheel and crash. Another possible scenario is forgetfulness when cooking that leads to burns or fires. Remember, a recent relocation may cause an increase in confusion and temporary cognitive decline. You are likely to notice some confusion as new residents move from their home or another facility into your location. The death of a close family member or friend can lead to depression and a decline in cognitive function. Even in these known situations, it's important to assess the patient more fully to rule out Alzheimer's or other illness. Signs and symptoms Recognizing the signs and symptoms of Alzheimer's in the mild/early stage can improve treatment options. There is some research indicating early treatment may even slow the progression of the 2

3 disease. Mild cognitive impairment Memory loss is the most common symptom of Alzheimer's disease, and the warning signs can be gradual and subtle. Be alert for memory problems that go beyond what can be expected as part of the normal aging process. Problems may include: inability to handle money or pay bills wandering and getting lost repeating questions losing or misplacing things in unusual places Initially, a person in the early stages of AD will know that they are becoming more forgetful, and may use coping mechanisms or tools to cover up symptoms. They may become strategic in how they respond to situations and questions. The person may be fearful that admitting they need help will cost them their independence. A person may also believe the forgetfulness is temporary, rationalizing that the cause is depression or a busy lifestyle that's stealing their focus. Decrease in ADLs Difficulties in performing tasks that we don't normally have to think about, our activities of daily living, such as bathing or eating, can be a sign of Alzheimer's disease. They may take much longer to perform these tasks or avoid task altogether. Movement difficulties A person in the later stages of Alzheimer's disease may experience difficulty in moving their arms and legs, which can cause difficulty in walking. They may experience an increase in falls that cannot be explained by other known issues. Language function decline Struggling to find the right word or using the wrong word can be a symptom of Alzheimer's disease. Listen for overuse of vague terms such as "thing" or "it." If they can't remember the answer to a direct question, they may give an answer that skirts the issue. Behavioral and personality changes A person may become more impulsive or experience rapid mood changes. They may become interested in get-rich-schemes that never interested them before, or may go on spending sprees. They may become paranoid or much more fearful in situations that previously did not bother them. Diagnosing Alzheimer's disease There is not one specific diagnostic test available for people living with Alzheimer's disease. Before expensive diagnostic tests are ordered, there are steps to take to assess the patient's physical and cognitive health and rule out other treatable causes of symptoms. Cognitive Impairment Screening Annual cognitive testing is important to assess the cognitive decline in older adults. Recently, a panel of experts in aging recommended that people over the age of 70 receive routine annual brain 3

4 health screenings. According to the article published September 2015 in Journal of American Medical Directors Association, the panel cited studies that found 30 percent of people in this age group had memory problems. Of people 70 or older, 4.2 percent of those tested suffer from dementia and another 4.8 percent have mild cognitive impairment. (Wood, 2015) A common test used to assess cognitive function is the Mini-Mental Exam Status (MMSE), which takes about 10 minutes to complete. It's designed to test global cognitive function, assessing orientation, word recall, attention and calculation, language abilities and visuospatial ability. But there are also simple tests that take five minutes to incorporate into a wellness visit or any examination that do not need to be administered by a physician. (Medscape, 2012) There is no need to wait until an annual wellness exam if the patient is exhibiting possible symptoms of Alzheimer's disease. The Alzheimer's Association offers a free Cognitive Assessment Toolkit for health care providers to use during Medicare Annual Wellness Visits. The association recommends the process for detection of cognitive impairment. The validated patient assessment tools provided offer several options for assessment. General Practitioner Assessment of Cognition (CPCOG) Screening Test This screening test is comprised of six questions that indicate time orientation, name and address recall, and information about current events. A clock drawing test is included. Each question is asked only once. The highest possible score is nine; a low number of correct answers indicates the need for further testing. Memory Impairment Screen (MIS) This six-step test involves showing the patient a list of four words, asking them to categorize the words, distracting them for a few minutes with another activity then asking them to recall the words. A low score indicates possible cognitive impairment. Mini-Cog This is a three-part test in which the person is asked to recall a list of three unrelated words, followed by drawing a clock face at a specific time, and concluding with asking the patient to recall the three words again. If the patient is unable to recall any of the words, they are considered to be positive for cognitive impairment. Informant assessment of patient If cognitive impairment is indicated by any of the preceding tests, a second, more involved step is to ask a friend or relative of the patient questions that compare the patient's current level of competence with their abilities in the past. Available questionnaires and assessments include Short Form of the Informant Questionnaire on Cognitive Decline in the Elderly (Short IQCODE) and AD8 Dementia Screening Interview. A PDF document of the Cognitive Assessment Toolkit is available for download. Rule out other treatable etiologies With true Alzheimer's, memory loss is typically gradual. A sudden decline in memory or cognitive functioning may be related to an illness other than dementia or Alzheimer's that can be treated and reversed. Infections such as urinary tract infection or pneumonia can cause extreme confusion. A change in medication may cause drug interactions that create Alzheimer's-like symptoms. It's important to do a physical exam and run labs to rule out any treatable causes of the patient's 4

5 symptoms. If exam and lab work do not present a cause, it falls back onto the patient's physician to rule out other etiologies, such as an unnoticed stroke. Disclosing diagnosis to patient There is widespread agreement among physician organizations that patients have the right to know and understand their diagnosis. However, less than half (45 percent) of older Americans diagnosed with Alzheimer's disease - or their caregivers - are told about the diagnosis. This compares to 90 percent or greater of people diagnosed with cancer or cardiovascular disease being told by a health care provider of the diagnosis. Disclosing an Alzheimer's diagnosis to the patient and their caregivers has many benefits including the opportunity to evaluate treatment options that may slow the worsening of symptoms and improve quality of life for the patient and caregivers. Sources 2015 Alzheimer's Disease Facts and Figures. (2015). Retrieved November 4, 2015, from Alzheimer's Association: AAIC. (2015, July 20). New Analysis Shows More than 28 Million Baby Boomers Will Develop Alzheimer's Disease; Will Consume Nearly 25% of Medicare Spending. Retrieved October 28, 2015, from Alzheimer's Association: Alzheimer's Disease Education and Referral Center. (n.d.). About Alzheimer's Disease: Symptoms. Retrieved October 28, 2015, from National Institute on Aging: Cordell C.B., (2012). Cognitive Assessment Toolkit (PDF document]. Retrieved November 4, 2015, from Alzheimer's Association: Medscape. (2012). Alzheimer Disease Diagnosis in the Long-term Care Setting: Case Illustration. Retrieved October 27, 2015, from Medscape, LLC: NIA. (n.d.). About Alzheimer's Disease: Symptoms. Retrieved November 4, 2015, from Alzheimer's Disease Education and Referral Center, National Institute on Aging, National Institutes of Health, U.S. Department of Health & Human Services: Tejada-Vera, B. (2013, March). Mortality from Alzheimer's Disease in the United States: Data for 2000 and Retrieved October 28, 2015, from Centers for Disease Control and Prevention: Wood, J. (2015). Routine Brain Screening for People Older Than 70 Recommended. Retrieved November 4, 2015, from Psych Central: Spotlight on Quality 5

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