Online Health Chat with Po-Heng Tsai, MD, and Gabriel Léger, MD

April 28, 2016


Description

Forgetfulness is often a normal part of aging in adults as the brain and body slow down. However, severe loss of memory and other mental abilities is a sign of something more serious. Alzheimer’s disease is the most common type of dementia, a general term used to describe the loss of mental functioning such as thinking, memory and reasoning that is severe enough to interfere with a person’s daily activities. In the United States, 5.3 million individuals suffer from Alzheimer’s disease, and there is currently no cure.

Symptoms of the disease include:

  • Memory loss
  • Misplaced things
  • Changes in personality and behavior
  • Poor judgment
  • Problems with language
  • Difficulty perceiving spatial relationships or finding one's way

About the Speakers

Po-Heng Tsai, MD, is a neurologist and director of the Brain Health and Dementia Program at the Cleveland Clinic Lou Ruvo Center for Brain Health in Weston, Florida. Dr. Tsai received his undergraduate degree in biology from Brown University and obtained his medical degree at Tufts University. He then completed his neurology residency and behavioral neurology fellowship at the University of California, Los Angeles. He is board-certified in neurology with additional certification in behavioral neurology from the United Council for Neurologic Subspecialties. He has served as an investigator in clinical trials involving patients with Alzheimer’s disease, frontotemporal dementia and traumatic brain injury.

Gabriel Léger, MD, is a neurologist and director of the Early-onset Dementia Program and director at Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas, Nevada. Dr. Léger completed his training in clinical neurology at the Montreal Neurological Institute, where he also conducted research in imaging of neurodegenerative diseases. He completed a clinical fellowship in cognitive and behavioral neurology at Northwestern University. Committed to patient care and clinical research, he is also dedicated to medical education. Before coming to Cleveland Clinic, Dr. Léger was assistant professor and director of the neurology residency program at the University of Montreal.


Let’s Chat About Alzheimer’s Disease


Alzheimer’s Awareness

bbofranpd: If someone is diagnosed with early dementia, how long does it take to become Alzheimer’s?

Po-Heng_Tsai,_MD: First, we need to clarify the terms of "dementia" and "Alzheimer’s disease." Dementia refers to the condition when a person has had a decline in their cognition that is severe enough to interfere with their ability to operate independently on a daily basis (such as financial management, driving, taking medications, etc.). There are many causes of dementia. Alzheimer’s disease is one possible cause of dementia.

Billagio: When AD reaches its advanced term, how long is the patient expected to survive?

Gabriel_Léger,_MD: In the most advanced stages of the disease, individuals become much more dependent on others for simple tasks such as toileting, feeding and personal hygiene. As long as there is diligent care of these needs, an individual can live many years in this "stage." When mobility, toileting hygiene and swallowing become compromised, bed sores, UTIs and pneumonia often follow, and these are more likely to lead to life threatening infections.


Mental Functioning

VegasNicole: I have heard that a failing of "executive function" is a sign of memory problems. What is that?

Po-Heng_Tsai,_MD: Executive function refers to our ability to plan and initiate activities, adapt to novel situation and reason abstractly. You could think of it as the "CEO" of our cognition.

Billagio: Could you expand on the symptoms and ultimate outcome (timing of the outcomes) of frontal dementia, with a total loss of executive function exhibited.

Gabriel_Léger,_MD: When disease strikes younger individuals (either young-onset AD or frontotemporal dementia - FTD), frontal deficits may be more common. The frontal lobes are a "huge" part of the brain, and many different deficits can result from damage to them. These include personality changes, language deficits, judgment and many others. Executive function is a complex ability that depends on many parts of the frontal lobes and often tends to appear early. People appear disorganized, unable to focus on a particular task (often leaving multiple chores started but unfinished (we all experience this, but it becomes overwhelming in the context of disease) and cannot compete more complex tasks such as finances. When these difficulties become severe, the person will require structure and guidance, including allowing only one task to be done at once, and simplifying more complex tasks into single steps. Ultimately, most tasks will need to be taken over by loved ones.


Causes and Prevention

Xandro: My mother has Alzheimer's and has been in a memory care facility for two years. We became aware of her beginning to show signs of the disease around the age of 80 after breaking her hip and having surgery. Her lifestyle certainly did not reflect the current guidelines for helping keep the brain strong. However, my father is 92 and is doing quite well, although he has two first cousins in their nineties with Alzheimer's. What are my chances of avoiding this horrible disease? I am 63 and following the current recommendations to maintain a healthy brain.

Gabriel_Léger,_MD: Alzheimer's disease (AD), particularly when it begins in later life (that is after 65), is a complex disease that is influenced (when it starts, how quickly it progresses, what the initial manifestations will be, etc.) by many factors. These include the genes you were given by your parents, your general health, how much education you have had and many other factors (including "vascular risk factors" – hypertension, high cholesterol, diabetes, etc.). The most important factor is age: At age 80, almost 1/3 of living individuals will have some form of dementia. You can't (at least not yet) change your genes or stop aging, but you can address almost all the other risk factors. This will reduce the impact of the disease and push its manifestations further and further out. Many recommendations on how to address these factors through lifestyle changes are discussed on https://healthybrains.org.

mardove7: How is this passed on, from a parent or relative? Or is it not passed on?

Gabriel_Léger,_MD: Please refer to the question from Xandro. For most "late-onset" cases of AD (older than 65), the "inheritance" is not simply the same as blue eyes or brown hair. It is not the consequence of a simple "bad" gene that you get or not get from one of your parents, but a large combination of genes (a little like how intelligence is determined) that influence whether, when and how you might start experiencing difficulties. The best we can do is to prepare our brains for these changes and make it more resilient. In some younger-onset disease, there can be a single "bad gene" that is passed on (with a 50/50 chance of getting it) from affected parents to the children. These "mutations" are exceedingly rare, probably less than five percent of cases.

principal11: What are the best practices for prevention of Alzheimer's? Anything specific that can be done at a young age, in your 30s or 40s, that can help prevent future cases? Thank you.

Po-Heng_Tsai,_MD: Currently, there are no medications or supplements that have been proven to prevent dementia. However, there is some evidence that doing the following could help:

  • Maintaining an active lifestyle physically (goal of 20 to 30 minutes of physical activities daily), cognitively (reading, puzzles, games, etc.), and socially
  • Eating a heart/brain healthy diet such as a Mediterranean-style diet with emphasis on whole grains, vegetables, fruits, white meat (especially fatty fish like salmon, char, mackerel, herring, lake trout, sardines and albacore tuna), nuts and olive oil

anniebananas: Does supplementation with Vitamin B12 or Vitamin D prevent or slow the process of dementia?

Gabriel_Léger,_MD: In evaluating patients with memory loss, we generally look for the presence of certain vitamin deficiencies, including Vitamin D, B6, B12, thiamine and folic acid because low levels of these vitamins have been associated with memory loss. If the levels are low, then we recommend supplementation. Unfortunately, there is not currently convincing evidence that simply taking extra vitamins, in that absence of any deficiency, can prevent or slow the process of memory loss.

Bruce: My mother has early-stage Alzheimer’s. Is there anything we can do at this point to slow down or otherwise ameliorate her memory decline? Also, can it be hereditary, and is there a test or other step I can take to see if I will develop Alzheimer’s? Thank you.

Gabriel_Léger,_MD: Please see previous questions concerning heritability. If the illness is not of young onset (less than 65), we do not currently recommend any genetic testing. Things to do to help slow or prevent memory decline are just as true for people who have memory loss as those who want to prevent it. We recommend addressing all "vascular risk factors" – high blood pressure, cholesterol, diabetes – getting regular exercise, eating a healthy diet (we recommend the Mediterranean diet), maintaining social engagement and interaction, and reducing stress. Please visit https://healthybrains.org.


Symptoms and Diagnosis

needs answers: Hello doctor. I am a 59-year-old female whose brain MRI showed lesions. I also received an abnormal result on an ambulatory brain wave test. I have had numerous episodes of confusion, such as forgetting how to use the handle of the car door, to exit. I also found myself forgetting (maybe four or five different times) that my mother had already visited me on vacation, during which I saw her every day for two weeks. There are several other examples that I could give, but to clarify, these episodes pass quickly and last only seconds. They are scary nonetheless. I was diagnosed with multiple sclerosis (MS) based solely on the brain MRI lesions, as all other MS tests were normal. A second neurologist disagreed with the MS opinion. So my question is this: Would the brain lesions due to MS look any different from brain lesions due to early Alzheimer's on a brain MRI? Thank you so much for any information. I appreciate this opportunity.

Po-Heng_Tsai,_MD: People with multiple sclerosis have lesions on the MRI of the brain involving the white matters, which are mostly connections between different parts of the brain. Alzheimer’s disease itself does not lead to lesions of the white matters. I recommend you talk to your MS doctor about seeing a cognitive/behavior neurologist for further evaluation of your memory concerns.

anniebananas: Is there something that can be seen on an MRI to diagnose Alzheimer's disease?

Gabriel_Léger,_MD: The diagnosis of AD is still a clinical diagnosis. (There needs to be as assessment of memory and function by an expert.) The MRI can support this diagnosis. It can exclude other conditions that might look like AD (stroke for instance), but it can also show very specific changes that increase our confidence that we are dealing with AD. In particular, the MRI may show "shrinkage" or "atrophy" of the "memory center" (hippocampus or hippocampi - plural, there are two, left and right). When this is present and there are clear difficulties with memory, then the diagnosis of AD is much more likely. An important point here is that the diagnosis of AD really requires an evaluation by a physician with expertise in memory disorders, and this evaluation represents the first, most important step (and should be done as early as possible).

roman0321: What is the cost of the test to determine if a person has the defective genes that lead to Alzheimer's disease?

Po-Heng_Tsai,_MD: Currently, there are two types of genes that could be tested that are associated with Alzheimer’s disease. Three genes are associated with autosomal dominant type of Alzheimer’s disease. People with this type of genetic mutation, we would see in about 50 percent of every generation. They would develop symptoms associated with Alzheimer’s disease, usually in their 30s to 40s. If a person does not have such a family history, it is usually not recommended to test for the genes. Another type of risk gene is the APOE4, which if a person possesses, increases the risk of developing Alzheimer’s. However, it is currently not recommended to test for the risk genes because 1) having the gene does not guarantee development of Alzheimer’s disease; and not having the gene does not mean a person won't develop Alzheimer’s. 2) Also, there is currently no treatment to prevent Alzheimer’s disease.


Timely Treatment

DGies8: My 87-year-old mother has shown signs of dementia and was moved to an assisted living facility. Other than being placed on some behavioral medications, she is not being treated for dementia. Should she be given something to help manage the dementia or lessen the effects, or should she just be left as is. What would you recommend?

Po-Heng_Tsai,_MD: There are many factors to consider in determining whether to start medication for cognitive impairment associated with Alzheimer’s disease. These include stage of the disease, whether the person will be able to take the medication consistently, other medical conditions the person might have, etc. I suggest you bring your mother to see a neurologist to help determine whether medications are recommended.


Contributing Factors

davidX: Is heart arrhythmia associated with Alzheimer's?

Po-Heng_Tsai,_MD: Certain heart arrhythmias such as atrial fibrillation, have been associated with increased risk of cognitive impairment, but not necessarily Alzheimer’s disease. Atrial fibrillation increases the risk of stroke. After a person has had a stroke, his or her cognition could be affected. It depends on the parts of the brain that are affected by the stroke.

mardove7: Do all or most Parkinson’s disease patients get this disease eventually?

Po-Heng_Tsai,_MD: At least 75 percent of patients with Parkinson’s disease with disease duration of more than 10 years have dementia. This is referred to as Parkinson’s disease dementia. It is possible that the person has dementia for other reasons such as Alzheimer’s disease.

gm3: Can infections like urinary infections have an effect on the behavior of an individual with dementia or Alzheimer’s disease?

Po-Heng_Tsai,_MD: When a person has dementia or Alzheimer’s disease, infections, including bladder infection, could lead to more confusion and changes in behavior, including agitation or aggression.

davidX: How can you distinguish co-occurring Alzheimer’s with clinical depression?

Po-Heng_Tsai,_MD: Consultation with a psychiatrist/psychologist could help determine if a person with Alzheimer’s disease could have co-existing depression. It is common for a person with Alzheimer’s disease to have co-existing mood disorders.

ellie7: Can uncontrolled diabetes cause or hasten Alzheimer symptoms, and can control reverse or improve this.

Gabriel_Léger,_MD: Yes. Diabetes is a vascular risk factor and can also independently worsen memory decline. Some have suggested that AD is a third form of diabetes. With your primary care physician or endocrinologist, it is critical to actively control diabetes and to try to keep blood sugar as normal as possible.


Research Roundup

ercs: Hello. There is so much information on the cause of Alzheimer’s that it's a bit confusing. But with so much info, do we have any light in the tunnel to find some treatment. Do you know of any studies that are going on with possible treatment? Do we know if we can prevent it?

Po-Heng_Tsai,_MD: For things to do to prevent Alzheimer’s disease, please refer to my previous answer. Multiple clinical trials are being conducted to find treatments for Alzheimer’s disease. Cleveland Clinic is also actively involved in AD clinical trials. For more information, you could go to www.clevelandclinic.org/brainhealthtrials.


Closing

I'm sorry to say that our time with Dr. Po-Heng Tsai and Dr. Gabriel Léger is now over. Thank you both for taking the time today to answer our questions about Alzheimer’s disease.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at my.clevelandclinic.org.

Po-Heng Tsai, MD: Thank you for joining our web chat today. We’re glad to have started a conversation about the aging brain that we hope you’ll continue with your family and with a neurologist if appropriate.

For Appointments

To make an appointment with Po-Heng Tsai, MD, or any of the other specialists in the Neurological Center at Cleveland Clinic Florida, please call 877.463.2010. You can also visit us online at clevelandclinicflorida.org.

To make an appointment with Gabriel Léger, MD, or any of the other specialists in the Lou Ruvo Center for Brain Health in Las Vegas, Nevada, please call 702.483.6000. You can also visit us online at clevelandclinic.org/brainhealth.


For More Information

Cleveland Clinic

Cleveland Clinic Lou Ruvo Center for Brain Health is a medical center dedicated solely to the pursuit of more effective treatments for brain diseases and to the provision of state-of-the-art care for patients affected by these diseases and their families. Across our four locations: Cleveland and Lakewood, Ohio; Las Vegas, Nevada, and Weston, Florida, the Lou Ruvo Center for Brain Health provides a patient-focused, multidisciplinary approach to the diagnosis and treatment of cognitive disorders.

Our specialty trained team, including neurologists, neuropsychologists and research coordinators, collaborate to provide every patient with an individualized treatment plan and can offer a new approach to delay the onset of Alzheimer’s disease, dementias and other cognitive disorders. With comprehensive testing, our expert team can diagnose probable dementias with almost 90 percent accuracy.

For additional information about maintaining brain health, please download our Brain Health Information and Treatment Guide.

Cleveland Clinic Health Information

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