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Caring for Alzheimer's Disease

Online Health Chat with Dr. Jagan Pillai

June 11, 2012

Introduction

Cleveland_Clinic_Host: Alzheimer’s disease is the most common cause of dementia. Alzheimer’s disease is a progressive disease in which nerve cells in the brain degenerate and brain volume shrinks, resulting in impaired thinking, behavior and memory.

Alzheimer’s is primarily a disease of aging, although it can occur in younger adults. One in 10 people over the age of 65 — and nearly half of all people over 85 — have Alzheimer’s. Roughly 5 million Americans have Alzheimer’s disease and the prevalence of Alzheimer’s disease is increasing, perhaps because of increased awareness of its symptoms or because people are living longer.

Memory loss is the first and primary symptom of Alzheimer’s disease. In the disease’s early stages, patients become forgetful — misplacing car keys, forgetting to take medications, not remembering how to drive to familiar places. As the disease progresses, patients often cannot remember what they did earlier in the day, or even five minutes before. In later stages, patients do not recognize loved ones and have difficulty taking care of themselves.

Alzheimer’s disease is thought to be caused by an abnormal accumulation of beta amyloid proteins in the brain that leads to cell death. The greatest risk factors for developing the disease are aging and genetics. People with a strong family history of the disease, or the presence of the genetic marker ApoE4, are much more likely to develop Alzheimer’s than people without these risks.

In addition to aging and family history/genetics, other risk factors for Alzheimer’s disease include:

  • High blood pressure
  • High blood cholesterol
  • Head trauma

Jagan Pillai, MD, PhD, recently joined Cleveland Clinic Lou Ruvo Center for Brain Health, specializing in cognitive and geriatric neurology. He obtained his medical degree from the University of Kerala and later trained in neurology at Albert Einstein College of Medicine. He further specialized in cognitive and geriatric neurology at the University of California San Diego before joining Cleveland Clinic. His specialty interests include cognitive changes arising from medical illness, including multiple varieties of dementia, Parkinson’s and Huntington’s disease.

To make an appointment with Dr. Pillai or any other staff in the Cleveland Clinic Lou Ruvo Center for Brain Health, please call 866.588.2264. For more information, please visit our website: clevelandclinic.org/brainhealth.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Dr. Jagan Pillai. We are thrilled to have him here today for this chat on Alzheimer's disease. Let’s begin with some of your questions.


RISK FACTORS

nutzy: I worked as a pharmacologist. I like to search everything connected to neurology. I am worried about my chances of developing Alzheimer’s disease due to a previous stroke and chronic atrial fibrillation.

Dr__Jagan_Pillai: Strokes or atrial fibrillation do not go on to cause Alzheimer's. Poor management of these conditions over a period of time does lead to a form of dementia called vascular dementia.

western: Is Alzheimer’s disease hereditary?

Dr__Jagan_Pillai: Fewer than 5% of cases have genetics as the single predominant factor, and these tend to occur early in life.

lfreem02: Is there an increased risk of Alzheimer dementia in people with orthostatic hypotension/intolerance at an early age? Is there a long-term impact on memory for people with chronic fatigue syndrome/postural orthostatic tachycardia syndrome and other syndromes?

Dr__Jagan_Pillai: There is no clear data on this; we do not think that people with orthostatic hypotension are at increased risk for Alzheimer's.

CPA: I recently read in a women's magazine that 50% of women who start hormone therapy after age 60 get Alzheimer’s disease. Is this correct?

Dr__Jagan_Pillai: There is a lot of research being done in this area, but we do not have a clear answer for that yet.


LIVING WITH DEMENTIA

MyMom: Good day, Dr. Pillai. My mom has just turned 80 years old. She is physically able and active; was diagnosed with mild dementia in 2008; is on 10 mg per day of donepezil (Aricept®) and 10 mg two times per day of memantine (Namenda®). Her neurologist said that her dementia is fairly stable. She has recently been found to have an ascending aortic aneurysm and aortic stenosis, both at the stage requiring surgery. I have 2 questions and would really appreciate your expert opinion: 1. I have noted a gradual decline in memory which I think is to be expected. However, her cognitive function, as related to her processing abilities, varies from time to time. Is this normal? 2. I've been trying to stimulate new learning with some success. Would you have other suggestions to help delay her decline in cognitive functions?

Dr__Jagan_Pillai: The answer depends on the type of dementia your mother was diagnosed with, as different types of dementia have different courses of progression. Therefore, I am not able to provide a complete answer to your first question without knowing more about her dementia.

MyMom: In your experience, will brain functions be further compromised in patients with dementia after an open heart surgery involving a cardiopulmonary bypass machine? The part of aorta needs to repaired/replaced is from the aortic valve to the ascending aorta, but not involving the aortic arch where the brachiocephalic artery is. Thank you so much for your time.

Dr__Jagan_Pillai: Regarding question two, in general, people with moderate to severe degrees of dementia do not tolerate extensive surgical interventions, especially in the post-op period. Careful discussion regarding risk/benefit needs to be made with both her cardiologist and her neurologist before undergoing this procedure.

Dakota: What is “sundown syndrome”? Is it part of Alzheimer’s or a separate problem?

Dr__Jagan_Pillai: Sundowning is a common descriptive term used to describe confusion during the evening and night when there are fewer cues in the person's surroundings to orient themselves. This is seen very often in people with dementia, but it is not specific to Alzheimer's disease.

concerned_daughter: Do you have a list of simple things to do to make life easier for my mom, who was just diagnosed with Alzheimer's

Dr__Jagan_Pillai: There's isn't a standard list, but a few things to keep in mind that might help:

1. Understand the nature and course of the disease so that you are better prepared for changes along the way.

2. Become part of a support group to find out more about the daily realities of living with someone close to you who has Alzheimer's.

3. Find opportunities to keep your mother engaged in an active social and engaging lifestyle throughout the course of the disease. 4. Follow up with a neurologist who specializes in treating patients with Alzheimer's disease for any changes that may come along.

lfreem02: Are bladder and bowel issues linked to Alzheimer dementia?

Dr__Jagan_Pillai: Bladder and bowel issues may be noted in late stages of dementia but are not specific to Alzheimer's disease.

jojo: Is it better not to correct a person with Alzheimer's or try to keep them in the present? It's frustrating for everyone. We don’t know what to do!

Dr__Jagan_Pillai: Understanding better the nature of Alzheimer's disease provides you with skills to handle difficult situations with your loved one with Alzheimer's. Often because of poor short-term memory, they forget what you have just said to them. Therefore, it may not be possible for you to answer and correct them at every point. You can give them some room to make the mistake and not feel forced to answer every question of theirs.

TC: Is Alzheimer’s and dementia the same thing?

Dr__Jagan_Pillai: Dementia is a broad term that describes a person's ability to undertake tasks of daily living and self care. There are a lot of reasons one can have dementia. The most common one is Alzheimer's disease. However, not everyone with dementia has Alzheimer's.


BEHAVIORAL ISSUES

velcro: My dad has Alzheimer's, and he's very difficult to talk to. He is constantly repeating himself, or saying something that makes no sense to me. He gets very upset when I can’t understand him. I am very frustrated, sad, and discouraged. Is there anything that I can do to help communications with my dad?

Dr__Jagan_Pillai: Caregiver's stress while taking care of a loved one with Alzheimer's is a huge challenge, and you are understandably frustrated. It is time to step back and realize this is normal. One cannot find solutions for this in a short chat discussion. I encourage you to talk to an Alzheimer's specialist to make sure that your parent gets appropriate care and support and discuss ways you can reduce caregiver stress. I would also encourage you to contact the Alzheimer's Association for more information for caregiver support.

great_things: How do you deal with an Alzheimer’s patient and cooking?

Dr__Jagan_Pillai: When a person is diagnosed with dementia by a neurologist they necessarily would have difficulties in self-care. Cooking in any situation other than in a supervised setting may not be a good idea.

loved_it: I take care of my mother who has Alzheimer’s. Something will set her off and she will bite (among other things). Is there anything that can be done to change this behavior? If she does bite, what do I do?

Dr__Jagan_Pillai: I would recommend you to see a neurologist specializing in dementia to understand if your mother has Alzheimer's or other kinds of dementias, and if she would be an appropriate candidate for medications for her concerning behaviors.

lfreem02: My mother was diagnosed with mild to moderate Alzheimer dementia, and denies that she has it. Is this normal? How do we help her to accept this diagnosis so that she can be part of her medical decisions before she is too far along?

Dr__Jagan_Pillai: Lack of insight into their ability to function normally is often seen in people with Alzheimer's. At this point, if your mother is not able to accept the diagnosis, I would encourage you to engage with her without insisting and try to guide her into avenues where she gets the most appropriate care for her condition.


MEMORY QUESTIONS

tally_ho: I can’t remember a name, but it may pop into my mind during the next day or so even though I am not thinking about the person. Why? How could I speed up this recall? This happens with anything I may be trying to recall.

Dr__Jagan_Pillai: People can have recall problems for a variety of reasons. Some of them are related to changes in your brain structure. It can also be related to other reasons, including lack of sleep, stress, medications, and other medical problems. One needs to carefully go through all the parallel issues before answering why you are having difficulty recalling. One way that you can improve recall is by improving attention during the recall task. You can also try decreasing stress, and/or adding physical exercise, or meditation; these all appear to help attention if there are no other medical problems.

goldie: Are people who have memory problems when they are younger more likely to get Alzheimer's as they get older?

Dr__Jagan_Pillai: People can have changes in their memory or other aspects of thinking as they age. This is considered a normal part of the aging process and does not imply that such people will go on to develop Alzheimer's.

KMK_1: Can you identify the difference between memory loss in a person with Alzheimer’s disease as compared to someone with Parkinson’s?

Dr__Jagan_Pillai: The difference between the memory loss in Alzheimer's and Parkinson's can be reliably distinguished by a detailed neuropsychological testing. In general, people with Parkinson's perform better on short-term recall, unlike people with Alzheimer's.


EARLY-ONSET ALZHEIMER'S

Paul: What is considered early Alzheimer’s disease?

Dr__Jagan_Pillai: An early change in short-term recall is commonly noted in early Alzheimer's disease. To make a diagnosis of Alzheimer's disease, we need to rule out other reasons for recall problems in addition to noting changes in the brain structure consistent with Alzheimer's through the use of MRI and/or PET scan.

Hope: What are the earliest signs of Alzheimer’s? If my husband’s father and grandfather both had early-onset AD, is it more likely that my husband will also have early-onset Alzheimer’s? He is now 53 and I am starting to see some memory issues in him.

Dr__Jagan_Pillai: We discussed the early signs of Alzheimer's before; the first and primary symptom is memory loss. Young onset Alzheimer's, which comes on when the person is younger than age 65, may have a genetic reason, so following up with the neurologist to evaluate your husband may be appropriate at this time.

Mendd: Can I, an 18-year-old male, have Alzheimer's disease?

Dr__Jagan_Pillai: The youngest described cases of Alzheimer's disease are in the 20- to 30-year old age group and are extremely rare, but it is possible one could have early changes before that. These young-onset Alzheimer's disease cases have a strong genetic reason for developing the disease.


CARE FOR ALZHEIMERS PATIENTS

Lisa: What do you think about adult day care for Alzheimer’s patients?

Dr__Jagan_Pillai: Improving cognitive function in people with Alzheimer's is a process of continuous engagement with them. Adult day care centers where the person can interact with other people of the same age and/or disabilities in a safe and controlled environment is a very good option. It also can decrease caregiver stress as the person has some time away from home.

dark_night: My mom has Alzheimer’s. My dad is her sole caregiver. I don’t live close enough to be very much help. It is not a happy household. My father is very tense, critical, and getting more and more impatient with my mom. My mom seems to be getting depressed. What advise can I give them that can help?

Dr__Jagan_Pillai: This is a very difficult situation, but often seen in families where someone has Alzheimer's. There are two things you could do: One, make sure your mother has regular follow ups with a physician specializing in Alzheimer's so that they can provide the care needed at each stage of the disease. Treat the depression if that is an underlying part of the problem. The second is for you or your dad to contact the Alzheimer's Association and find out local services available that would be appropriate to take some caregiver stress off of your dad.

CG:My mother is upset about putting her father into a nursing home. She is afraid of losing her connection with her father. What can she do to keep it going? The two have always been very close.

Dr__Jagan_Pillai: If your mom can undertake care of your grandfather safely and without overburdening herself at home, that would be recommended. A nursing home is usually chosen when the family is unable to provide 24-hour care and supervision. Choosing a care facility close to home, and visiting the facility before making a decision, may make it easier on your mother to visit her father more often.

Fishing: What factors do you need to consider when seeking long-term care for Alzheimer’s patients?

Dr__Jagan_Pillai: Three features I would definitely check include:

1. Does the facility haves a strong record of providing a safe environment and good medical care? Does it have staff and physicians on call for adequate support?
2. Does it provide adequate avenues of social interaction for the patient while in the facility?
3. Is the facility close enough to your home for frequent visits and checking on your loved one?
More information on selecting appropriate patient care and list of facilities that have a good track record can often be found by contacting your local Alzheimer's Association chapter.

Hollyh: How do you decide it is time to move a family member into long-term care?

Dr__Jagan_Pillai: A nursing home is usually chosen when the family is unable to provide 24-hour care and supervision. Further, each family has a different threshold on making the decision towards moving a family member towards long-term care depending on their capabilities (financial, emotional, other commitments) and the needs of the family member (type of dementia, other medical comorbidities, severity of dementia, need for 24 hour supervision and help, etc.).


TREATMENTS

Paulette: My husband has been diagnosed with Alzheimer’s disease and is being treated with medication. Are there any herbal supplements that you know of that can help him, in conjunction with or as a replacement to prescribed meds?

Dr__Jagan_Pillai: You may look on the Internet, but clinical trials demonstrating their clear benefit is often lacking. I therefore do not commonly recommend them.

runner: My mom is taking Aricept for Alzheimer’s, and I am trying to figure out if having nightmares is a side effect. Do you have any ideas? My mother has been having frequent nightmares since starting this medication.

Dr__Jagan_Pillai: People on Aricept sometimes describe very vivid dreams but less often scary dreams or nightmares. I would encourage you to talk to your mom's neurologist to find out more about the nature of her nightmares and if it is related to her dementia or to Aricept.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialist Dr. Jagan Pillai is now over. Thank you, Dr. Pillai, for taking the time to answer our questions today about Alzheimer's disease.

Dr__Jagan_Pillai: Thank you so much for all of these great questions, I hope I answered some of your questions and concerns. Please don't hesitate to make an appointment with our Center if I can be of help to you.


More Information

To make an appointment with Dr. Pillai or any other staff in the Cleveland Clinic Lou Ruvo Center for Brain Health, please call 866.588.2264. For more information, please visit our website: clevelandclinic.org/brainhealth.

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