We've all been touched by memory loss, whether it affects us personally (TBI, Post-COVID, Dementia) or someone we love. However, most people with memory loss do not have a specific diagnosis. The thing is, there is a lot we can do if we are empowered with information. I trained in both psychiatry and neurology because all aspects of how we experience memory loss are important. This includes feeling depressed or anxious, all the way to how we diagnose specifically what kind of memory loss we are experiencing, and what to do about it. In my experience, the more specific I can be with someone about what is going on with their memory, the better. Nobody likes feeling uncertain about something, and memory loss is scary. Once we are given specific information, we can act and do something about it. Autonomy and choice are central to being human. Therefore, it's important to understand how Alzheimer's affects the brain, what signs to look for, and what options one has to minimize the damage of the disease.—Dr. Reza Hosseini Ghomi is a practicing neuropsychiatrist, focused on neurodegenerative disorders and is serving as Chief Medical Officer at BrainCheck.
The First Stage | Subtle Brain Changes
The initial influence that Alzheimer's disease has on the brain may be traced back to the disease's earliest pathological stages. These stages can occur anywhere from ten to twenty years before typical clinical signs, when a person tells their doctor, "I think I have a memory issue", or someone else notices a problem with memory. The main thing we know is there is a buildup of proteins, called amyloid and tau, and this buildup is toxic for the brain. These proteins build up in a way that kills neurons, which disrupts the pathways in the brain we use to think and the brain shrinks. Therefore, the very first effect that Alzheimer's disease has is at the microscopic level, where it begins to form this accumulation. We are not completely sure where in the process these proteins start building up and how many steps come before this stage. However, we are aware of the kind of substances that become visible when seen via a microscope, such as amyloid and tau proteins, amongst other things.
The Second Stage | Preclinical Alzheimer's
After the initial stage, the pathology accumulates over the years and tends to affect the brain in predictable locations. This means that in the case of Alzheimer's disease, it is in the medial temporal lobe part of the brain, which we often call the memory centers, and the hippocampus, which tends to process memory, or in your parietal lobe, which helps you with complex tasks like navigating your environment. A 2020 study by Kahn, Barve and Kumar states that plaques and tangles are two names for the same type of structure that can be produced in the brain by a protein. The brain identifies these plaques as foreign material, which triggers an inflammatory and immunological response. This reaction involves the activation of microglia and the production of cytokines, both of which eventually result in the death of cells and neurodegeneration, or brain shrinking. At this stage, specialized imaging such as PET scans or other biomarkers can reveal a specific diagnosis of Alzheimer's, however, these tests are not widely available yet and there are several barriers with being able to use them as screening tools.
The Third Stage | Mild Cognitive Impairment
The third stage occurs when one has reached a point when the accumulation has reached a clinically significant stage. At this level, there is sufficient disease or and a large amount of neurons may have already died in the memory centers and other areas. During a brain exam or any sort of neuropsychological testing; patients, family, or providers will start to detect some subtle but early indicators of memory loss, such as an impairment of short-term memory. A variety of cognitive tests are used to assess different areas of the brain. Other deficits you might find include struggling with processing a busy picture and identifying important parts of it. There are many examples of tests that tend to bring out the cognitive issues for someone at this stage. The important thing to understand about this stage, is that now disease development and cognitive impairment is starting to show up on cognitive testing. However, in day-to-day life, the individual is still operating normally, with any cognitive deficit going undetected by others for the most part. The afflicted individual may have the impression that something is amiss or off, but most others don't notice. No one is reaching out to ask, "What is going on with you?"
The Fourth Stage | Clinical Alzheimer's
Moving into the fourth stage is when Alzheimer's reaches the point where it starts to impede functioning ability. Enough of the brain is injured; testing is clearly demonstrating that cognition has hampered the patient's short-term memory, and the functional impairment is now to the degree where patients are missing appointments, double paying a bill, forgetting where they are going, not remembering how to get to the grocery store, or leaving the stove on. These are some of the typical types of Alzheimer's symptoms.. At this point, the Alzheimer's disease is considered to be dementia in its early or mild stage. Before this stage, although Alzheimer's was present and building, the person did not have dementia because they were able to function normally. Only when functioning is impaired can dementia be diagnosed.
The Fifth Stage | Progressive Cognitive Decline
The fifth stage of dementia is the slow, persistent decline over years of the disease, given that there is already functional impairment. The person with Alzheimer's will move into the middle or moderate stage and then the late or severe stage of disease where they need a lot of help with their day to day activities.The brain is shrinking over time, and the protein accumulation grows with the severity of the disease. Patients ultimately become worse and worse.
The person's ability to operate normally is increasingly impaired, which means the likelihood is that they will require assistance more and more in the future. Patients need encouragement to do things like eat a healthy, well-balanced meal and perhaps need help figuring out how to dress correctly. As the disease further progresses, the impact spreads to other sections of the brain. Core functions such as food preparation, exercise, and mobility are impaired, and ultimately day to day functions such as eating, drinking, and walking are difficult. Without considerable assistance, these tasks are extremely difficult, if not impossible. In this final stage, patients lose their appetite, and become indifferent to the world around them. Lack of mobility then leads to other problems such as pneumonia, other infections, falls and fractures.
What are any other effects of Alzheimer's?
Those who have Alzheimer's disease tend to have a significant loss of interest in their activities, otherwise known as apathy, and often have other psychological or behavioral symptoms such as anxiety. Sometimes, in a minority of people with Alzheimer's, you may see more severe symptoms such as confusion and agitation. Sundowning will likely occur at some point in the disease which is the tendency to be confused and upset more in the evenings when the sun is going down. People with dementia have a hard time tracking time and without the light of day, can become scared and confused. They can become irritable, easily nervous, melancholic, and experience other negative emotions. Therefore, patients should expect and anticipate that there will be some noticeable behavioral and psychological changes, such as sadness and anxiety, as the disease advances. These changes become more apparent with time. It's not unheard of for people to have psychosis, such as visual hallucinations or paranoia. Additionally, there are often motor symptoms such as stiffness, and difficulty moving.
In the early phases, patients normally don't have as much change with their physical health, but then as things advance, there will be mental, behavioral, and physical changes. Patients walk less, which leads to further weakness, and as the sickness develops, they start to lose coordination such as the ability to ride a bicycle. This is why it's critical to diagnose the disease early and put into place a comprehensive plan to help the person live to the fullest and prevent injury.
What should a person do if they notice these signs?
If people observe any symptoms, it is imperative that they consult a medical professional as soon as possible and begin the diagnostic process. There is no need to wait. It is vital for patients to get motivated and start doing things to improve overall health. Managing risk factors is critical to both prevent or modify the course of the disease. For example, hearing impairment is a significant problem if unmanaged and is a significant risk factor for dementia. Eliminate other risk factors such as inflammation, and work to enhance overall health. In most cases, there is a direct correlation between vascular illness and dementia. Because of this, people should do their best to treat vascular disease, including changing their diet and getting more exercise. Cut back on sugar consumption if you already consume a lot of carbohydrates. Put an end to your smoking habit, get help for depression, reduce the amount of time spent alone, manage diabetes, etc. All these factors contribute quite a deal especially when added together. Remember, focus on one thing at a time, otherwise it can feel overwhelming and hard to get started. The Alzheimer's association provides many free educational and community support resources to help families affected by the disease—be sure to utilize those as well.
Alzheimer's is a terrible disease that can take away what matters most; what makes a person themselves. Their ability to move, process and even remember is greatly affected. But it is important to understand that an individual still has a lot of control over Alzheimer's. A 2020 Lancet report states as much as forty percent of dementia is preventable or can be slowed by addressing 12 risk factors during key developmental periods throughout life. Encouraging a child to learn new things in different ways and further their education beyond high school will reduce their probability of developing dementia later in life by seven percent. Struggling with hearing in midlife? Make sure you get those hearing aids to preserve that section of your brain and reduce your chance of getting dementia by eight percent. Pushing 65? Stop smoking now, make time for physical activity and keep socializing to reduce your risk factor by eleven percent. Reducing risk factors equates to millions of preventable dementia cases. It is never too late to take steps towards improving your health.