Diagnosing Alzheimer's can be a frustrating experience for both the patient and the physician. That's because no simple test exists for diagnosing Alzheimer's. There's no way to see physical evidence that may exist in the brain while the patient is still alive.
Much research is focused on developing reliable tests to make it easier to diagnose the disease as early as possible. For example, people with Alzheimer's have a higher level of a protein called tau and a lower level of a plaque called beta-amyloid in the cerebrospinal fluid (CSF) that bathes the brain and the spinal cord, than unaffected people. Some researchers believe a combination test to detect high CSF levels of tau and low levels of beta-amyloid may become a powerful tool for diagnosing the disease.
Even though no drugs can stop the disease, being able to recognize the warning signs early is extremely important. An early diagnosis gives individuals a better chance of benefiting from existing treatments and allows them to participate in planning for their future before time runs out.
What are the warning signs?
Family members, friends and co-workers are usually the first to notice the warning signs. The affected person may or may not be aware of any changes. According to the Alzheimer's Association, a person exhibiting several of the following symptoms should see a family doctor, a gerontologist or a neurologist right away for a complete exam:
- Memory loss that affects job skills
- Difficulty performing familiar tasks
- Problems with language
- Disorientation to time and place
- Poor or decreased judgment
- Problems with abstract thinking
- Misplacing things
- Changes in mood or behavior
- Changes in personality
- Loss of initiative
Is it normal or is it Alzheimer's?
Most of us forget to do things at times. Many of us misplace our keys or eyeglasses on occasion. Usually these are just normal glitches in how our memories work. Healthy people, in fact, experience just about every warning sign sometime in their lives and increasingly so as they age. How can these normal events be distinguished from Alzheimer's warning signs?
It's a matter of degree, frequency and awareness. As Steven T. DeKosky, M.D., director of the Alzheimer's Disease Research Center at the University of Pittsburgh, explains: "You need to look at the functional consequences of what someone can't remember. If mom forgets where she put her car in the parking lot at the mall, that's not abnormal. But if she walks home from the mall because she forgot she took her car, that's not normal."
Let's look at each warning sign individually.
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Memory loss that affects job skills. It's normal to occasionally forget an assignment or a colleague's phone number, but it's not normal to frequently forget such things or to be so confused or unable to concentrate that you can't do your work.
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Difficulty performing familiar tasks. Once again it's normal to go to the store and forget to buy an item you wanted. But it's another matter to forget to pay for purchases at the store.
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Problems with language. Just about everyone's pulled a blank on a person's name as they're about to introduce him, but forgetting names on a regular basis or forgetting simple words and substituting inappropriate ones may be a sign of Alzheimer's.
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Disorientation to time and place. It's normal to lose track of the time or momentarily get disoriented in an unfamiliar setting, but people with Alzheimer's can forget what year it is or get lost in their own home.
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Poor or decreased judgment. Not bringing an umbrella when it looks like rain is an ordinary oversight. Not knowing to bring an umbrella is a warning sign. So is wearing a winter coat on a hot day, wandering along a busy highway in the middle of the night or leaving a young child all alone.
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Problems with abstract thinking. Many people can't balance their checkbook or have trouble figuring out fractions in a recipe, but people with Alzheimer's may forget how to add and subtract or fail to recognize numbers.
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Misplacing things. Being careless or disorganized may make it hard to find your car keys or eyeglasses. But people with Alzheimer's may put the car keys in the freezer, then not recall where they are. Or they may look for their glasses in strange places, such as the fish bowl, and not think their behavior is odd.
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Changes in mood or behavior. Everyone feels moody at times, but it's not normal for a person to exhibit such rapid changes in mood that he or she is laughing one moment and shouting in anger the next, all without cause.
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Changes in personalities. As people mature and age, their personalities may gradually change. A person with Alzheimer's, however, undergoes dramatic, often sudden, changes. For example, a cheerful outgoing person may become timid and suspicious.
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Loss of initiative. It's normal to get bored with the daily grind of work and home every so often and lack the energy to start chores. It's not normal to have to be prompted and encouraged to do even the most ordinary tasks, such as dressing or swallowing food.
Why it takes so long to get Alzheimer's diagnosed
Researchers at the Oregon Health Sciences University in Portland found that it took an average of 30 months starting when family members noticed warning signs to get a diagnosis. After interviewing 244 caregivers and close relatives of people with Alzheimer's, they reported the reasons for the delay in the April 1999 issue of the American Journal of Alzheimer's Disease. The reasons indicate why it's so important to understand Alzheimer's and know the warning signs.
The most common reason, cited by 72 percent of the caregivers, was that they did not know about Alzheimer's and did not think the changes they saw in the person were the result of a disease. Half of the caregivers thought the changes were just a normal part of aging. Other reasons included not knowing what kind of doctor to see (44 percent), not knowing how to explain the problems to the doctor (38 percent) or not being able to see the doctor in private (27 percent). Sometimes the response of the doctor was the problem: 29 percent of caregivers complained that the doctor didn't take their concerns seriously, while 25 percent said the doctor told them the problems were due to normal aging.
What to expect at the doctor's office
The patient should see the family physician or internist first and then one or more specialists, perhaps a gerontologist or a neurologist. In diagnosing Alzheimer's, the doctors follow a set of guidelines and criteria developed by such organizations as the American Psychiatric Association and the Alzheimer's Association. These procedures help detect and rule out more than 60 other disorders that can cause warning signs. The more common disorders that may cause Alzheimer's-like symptoms include multiple strokes, brain tumors, late-stage Parkinson's disease, severe clinical depression, AIDS, chronic alcoholism, Picks' disease and Creutzfeld-Jakob disease (similar to mad cow disease). Even certain medications can cause a patient to exhibit some of the symptoms. Studies show that doctors are correct in diagnosing Alzheimer's about 90 percent of the time.
- The doctor will first take a medical history to gather information about the patient's current and past health problems and a family history of illnesses. By interviewing the patient and close family members separately and together, the doctor is able to piece together a detailed description of what symptoms are exhibited and when they appeared.
- Next the doctor may use special questionnaires in a mental status evaluation to assess the patient's sense of time and place, level of understanding, memory, and ability to do simple calculations. The patient's education, occupation and ethnic background are accounted for.
- By evaluating the person's blood pressure, pulse, general condition and nutritional status, a physical examination to assess the patient's sense of time and place, level of understanding, memory, and ability to do simple calculations. The patient's education, occupation and ethnic background are accounted for.
- The doctor tests the nervous system during a neurological examination to rule out other disorders that can cause dementia-like symptoms, such as stroke, brain tumor and Parkinson's. During this exam, the doctor also will evaluate coordination, muscle tone and strength, eye movement, speech, and sensory abilities.
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Laboratory tests on blood and urine can help tell whether the symptoms are due to anemia, infection, diabetes, kidney or liver disorders, abnormal levels of thyroid hormone, or nutritional deficiencies.
- Doctors may employ various brain imaging exams, such as an MRI, CT or PET/CT scan, or brain activity tests, such as an EEG or PET, to rule out tumors, strokes and blood clots in the brain.
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Psychological and psychiatric evaluations are used to provide more information on the patient's ability to remember, reason, write and express ideas than the mental status evaluation can. They also help rule out certain illnesses such as depression that can cause symptoms similar to Alzheimer's.
This article was reviewed and updated June 2007.
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