Alzheimer's Knowledge

It’s often argued that telling people that they carry genes increasing their risk of Alzheimer’s will simply upset them to no purpose. A new study challenges that idea.

The study, involving 648 middle-aged adults tested for the “Alzheimer's gene” APOe4, found that 4% were in the highest risk group (carrying two copies of APOe4), while 34% had a single copy, and 62% had none. A year later, APOe4 carriers did not experience more anxiety, depression or distress than non-carriers, and were more active in efforts to reduce their risk of Alzheimer's disease — by exercising, eating a healthy diet and taking recommended vitamins and medications.

However, a more recent study of older adults has found that being told of their genetic status affected their cognitive performance. Specifically, those told they had the Alzheimer's gene judged their memory more harshly, and performed more poorly on a verbal memory test, than those who had the gene but had chosen not to be told. Similarly, those told they did not have the Alzheimer's gene judged their memory more positively, and performed better on the memory test, than those who didn't have the gene but didn't know that.

This is, of course, entirely in keeping with research showing that a person's beliefs about their memory have a significant effect on their cognition.

The study involved 144 cognitively normal older adults (aged 52–89), of whom 74 knew their genetic status (25 had the gene vs 49 without), and 70 did not (25 with vs 45 without).

Taking the findings from both these studies together, it seems likely that providing appropriate advice and support to those informed of their negative genetic status is vital, and that this may be particularly crucial for older adults, who may be more vulnerable to negative results.

http://www.eurekalert.org/pub_releases/2013-07/uops-hra071513.php

http://ajp.psychiatryonline.org/article.aspx?articleID=1819677

Karlawish et al. 2013. What is the experience of being an APOE4 homozygote? Findings from the REVEAL Study. Presented on July 16 at the 2013 Alzheimer's Association International Conference.

Lineweaver  TT;  Bondi  MW;  Galasko  D;  Salmon  DP:  Effect of knowledge of APOE genotype on subjective and objective memory performance in healthy older adults.  Am J Psychiatry 2014; 171:201–208

Dementia is a progressive illness, and its behavioral and psychological symptoms are, for caregivers, the most difficult symptoms to manage. While recent research has demonstrated how collaborative care can reduce these symptoms and reduce stress for caregivers, the model requires continuous monitoring of the symptoms. What’s needed is a less arduous way of monitoring changes in symptoms.

A new questionnaire for assessing dementia progression has now been validated. The Healthy Aging Brain Care Monitor is simple, user-friendly and sensitive to change in symptoms. Its 31 items cover cognitive, functional, and behavioral and psychological symptoms of the patient, as well as caregiver quality of life, and takes about six minutes for a caregiver to complete.

Some of the specific items that may be of interest include:

  • Repeating the same things over and over
  • Forgetting the correct month or year
  • Handling finances
  • Planning, preparing or serving meals
  • Learning to use a tool, appliance, or gadget

You can see the full questionnaire at http://www.indydiscoverynetwork.org/HealthyAgingBrainCareMonitor.html. The HABC Monitor and scoring rules are available without charge.

The four factors (cognitive; functional; behavioral and psychological; caregiver quality of life) were all significantly correlated, with one exception: cognitive and caregiver quality of life.

The validating study involved 171 caregivers, of whom 52% were the children of the patients, 34% were spouses, 6% were siblings, and 4% were grandchildren. The participant group included 61% identifying as white, 38% African-American, and 1% other. Only 1% was Hispanic.

The study found good internal consistency (0.73–0.92); good correlations with the longer and more detailed Neuropsychiatric Inventory (NPI) total score and NPI caregiver distress score; and greater sensitivity to three-month change compared with NPI “reliable change” groups.

The value of this new clinical tool lies in its brevity. Described as a ‘blood pressure cuff’ for dementia symptoms, the one-page questionnaire is designed to fit into a health visit easily.

The researchers note some caveats, including the fact that it was validated in a memory care practice setting and not yet in a primary care setting, and (more importantly) only over a three-month period. Future projects will assess its sensitivity to change over longer periods, and in primary care.

Functional impairment good indicator of mild cognitive impairment

Evaluation of 816 older adults, of whom 229 had no cognitive problems, 394 had a diagnosis of amnestic mild cognitive impairment, and 193 had a diagnosis of mild Alzheimer’s, has revealed that most of those with aMCI (72%) or AD (97%) had trouble with at least one type of function on the Pfeffer Functional Activities Questionnaire. Only 8% of controls had any difficulty. In both impaired groups, those who had the most difficulty functioning also tended to score worse on cognition tests, have smaller hippocampal volumes, and carry the APOe4 gene.

Two of the ten items in the questionnaire were specific in differentiating the control group from the impaired groups. Those items concerned "remembering appointments, family occasions, holidays, and medications” and "assembling tax records, business affairs, or other papers." Only 34% of those with aMCI and 3.6% of those with AD had no difficulty with these items.

The findings suggest that even mild disruptions in daily functioning may be an important clinical indicator of disease.

Early-onset Alzheimer’s poorly diagnosed when initial symptoms aren’t memory related

Post-mortem analysis of 40 people diagnosed  with early-onset Alzheimer’s has revealed that about 38% experienced initial symptoms other than memory problems, such as behavior, vision or language problems and a decline in executive function, or the ability to carry out tasks. Of these, 53% were incorrectly diagnosed when first seen by a doctor, compared to 4% of those who had memory problems. Of those with unusual initial symptoms, 47% were still incorrectly diagnosed at the time of their death.

The mean age at onset was 54.5 years (range 46-60). The average duration of the disease was 11 years, with an average diagnostic delay of 3 years.

GPs misidentify and fail to identify early dementia and MCI

A review of 30 studies involving 15,277 people seen in primary care for cognitive disorders, has found that while GPs managed to identify eight out of ten people with moderate to severe dementia, they only identified 45% of those with early dementia and mild cognitive impairment. Moreover, they were very poor at recording such diagnoses. Thus, though they recognized 45% of the MCI cases, they only recorded 11% of these cases in their medical notes. Although they identified 73% of people with dementia, they made correct annotations in medical records in only 38% of cases.

But the problem is not simply one of failing to diagnose — they were even more likely to misidentify dementia, and this was particularly true for those with depression or hearing problems.

The findings point to the need for more widespread use of simple cognitive screening tests.

Prevalence of dementia & MCI in 'oldest old' women

Data from 1,299 women enrolled in the Women Cognitive Impairment Study of Exceptional Aging suggests that the incidence of dementia almost doubles with every 5 years of age and prevalence rises from approximately 2-3% in those 65 to 75 years to 35% in those 85+.

Among those with mild cognitive impairment, amnestic multiple domain was most common (34%), followed by non-amnestic single domain (29%). Amnestic single domain (affecting only one type of cognitive function, including memory difficulty) affected 22%.

Alzheimer's disease and mixed dementia accounted for nearly 80% of dementia cases, and vascular dementia for 12.1%.

Those with dementia tended to be older, less likely to have completed high school, more likely to have reported depression, a history of stroke, and to have the APOEe4 gene.

The women in the study had an average age of 88.2 years and 27% were older than 90. 41% had clinical cognitive impairment (17.8% with dementia and 23.2% with mild cognitive impairment).

The high prevalence of cognitive impairment in this age group points to the importance of screening for cognitive disorders, particularly among high-risk groups.

A small study suggests that the apathy shown by many Alzheimer's patients may not simply be due to memory or language problems, but to a decreased ability to experience emotions. The seven patients were asked to rate pictures of positive and negative scenes (such as babies and spiders) by putting a mark closer or further to either a happy face or a sad face emoticon. Closeness to the face indicated the strength of the emotion felt. Although most of the time the Alzheimer’s patients placed their mark in the appropriate direction, they did make more inappropriate choices than the control group, and typically also gave less intense judgments.

Both comprehension problems and depression were ruled out. A lower emotional response may result from damage to brain areas that produce neurotransmitters, which typically occurs early in Alzheimer’s. It may be that medication to replace or increase these neurotransmitters would improve emotional experience.

This finding is a warning that apathy should not be automatically taken to mean that the patient is depressed. The researchers, enabled by the small size of the study, tested more thoroughly for depression than is usually the case in large studies. It may be that in these studies, this apathy has often been confounded with depression — which may explain the inconsistencies in the research into depression and Alzheimer’s (see the news item just previous to this).

The finding may also help caregivers understand that any emotional indifference is not ‘personal’.

Older news items (pre-2010) brought over from the old website

Poor Understanding of Alzheimer's Link to Heart Health Risk Factors

An online survey of 690 adults (average age 50; well-educated, with 87% having had some college) found that 64% did not realize there was an association between Alzheimer's and obesity or high blood pressure; 66% didn’t know that high stress is a risk factor for dementia; 34% didn’t know that physical exercise is a protective factor.

Jackson, C.E. et al. 2009. Dementia literacy: Public understanding of known risk factors. Presented at the Alzheimer's Association International Conference on Alzheimer's Disease July 11-16 in Vienna.

Misconceptions about Alzheimer's common

A recent survey of nearly 1200 people has found a high degree of misconceptions about Alzheimer’s in America. Half the respondents were unaware that anything could be done to maintain cognitive functioning and reduce Alzheimer's risk. Although there were no significant differences among races in the level of concern about getting Alzheimer's, many more blacks and Hispanics than whites responded that they believe that Alzheimer's is a normal part of aging. However, blacks and Hispanics were also more likely than whites to report changing their diet or lifestyle to avoid developing Alzheimer's.
http://www.eurekalert.org/pub_releases/2007-09/uom-maa091807.php

Connell, C.M., Scott Roberts, J. & McLaughlin, S.J. 2007. Public Opinion About Alzheimer Disease Among Blacks, Hispanics, and Whites: Results From a National Survey. Alzheimer Disease & Associated Disorders, 21(3), 232-240.

Survey reveals ethnic differences in knowledge about Alzheimer's

The Alzheimer's Foundation of America's (AFA) second Investigating Caregivers' Attitudes and Needs survey has revealed that African-American and Hispanic caregivers of people with Alzheimer's disease are significantly more likely (37% and 33%, respectively) than caregivers of other races (23%) to consider the disease a normal part of the aging process and also more likely (70% and 67%, vs 53%) to dismiss its symptoms as part of getting older, thus delaying diagnosis. They were also more likely (67% and 63%, vs 49%) to report that they did not know enough about the disease to recognize the symptoms.

Fears of stigma also play a part in delaying diagnosis, with around one-third (33%) of respondents reporting that their loved one's concern about stigma delayed diagnosis, and about a quarter (26%) indicating that their own concern about stigma contributed to the delay. African-American caregivers were significantly more concerned about stigma (36%) than Hispanic (22%) and other race (18%) caregivers.

Races other than African-American and Hispanic were far more likely to consider placing their loved one in a facility: 32% compared to African-American (19%) and Hispanic (21%) caregivers. African-American and Hispanic caregivers were more likely to use a support groups than other races (47% and 50%, vs 29%). Yet only around half of African-American respondents and a little more than one-third of Hispanic respondents said that they felt the support groups they were able to access were appropriate to their specific religious or ethnic background. At diagnosis, caregivers overall wished they had received more information about Alzheimer's disease (75%) and treatment options (75%), with African-American caregivers (83%) significantly more likely than Hispanic (73%) and other (68%) caregivers to wish they had received more information.
http://www.eurekalert.org/pub_releases/2007-03/fi-srm030907.php