Alzheimer’s: early intervention is key

The World Health Organisation (WHO) estimates that there are 50 million people with Dementia (PwD) and this number could reach 150 million by 2050, with cost of care estimated to be as high as $2 trillion by 2030. Alzheimer’s disease (AD) makes up for about 70% of all types of dementia.

Age is a major risk factor with one in 10 over 65 years suffering from dementia. Families, either spouse or adult children, are likely caregivers and bear a huge burden. Recognising this growing burden, in 2012 the WHO published the book Dementia, a Public Health Priority. Recently, our Union health minister announced that a National Dementia Strategy would be unveiled, in response to a call for action by the WHO and Alzheimer’s Society of India.

Dementia is a disease of the brain that impairs cognitive abilities such as memory, thinking, planning, calculation, speech and language, personality, behaviour, the ability to perform everyday activities. There is a gradual, progressive decline in the person’s level of cognitive ability. Other risk factors include sedentary lifestyle, obesity, unhealthy diet, abuse of alcohol or tobacco, diabetes, hypertension, loneliness and deafness.

In the early 20th century, Alois Alzheimer had described abnormal protein deposition in between the cells called plaques and inside the cells called tangles. These unregulated proteins kill cells and connections, ruining signal transmission. Typically, the family members say they first notice forgetfulness to short term events such as what they did few hours ago or events from the past week or where they kept things, with intact long term memory.

These correlate with deposition of plaques in the lower portion of the brain called temporal lobes. The deposits are later seen in other higher brain regions, which leads to forgetting names of near and dear ones, forget way around, days, dates, season, year, festivals, anniversaries and many start to slow down in movements and thinking.

Reduced emotional reaction and motivation called apathy causes more caregiver stress. In advanced stage, PwD have many behavioural problems and act out on their misperception or misinterpretation. Speech area fades resulting in inability to express pain, when to empty bladder or when unable to empty bowels, leading to aggression. Gradually, they need prompts to partial to full assistance, sometimes with resistance, in brushing teeth, washing, bathing, combing, dressing or undressing and eating.

Specialist psychiatrists or neurologists, preferably with special interest in managing PwD, leading a multi-disciplinary team could assess, diagnose and initiate early treatment. Screening tools to test memory for easy use by other health professionals to facilitate early referral and for diagnostic purposes, suited to a person’s culture and native language are being developed.

With PET amyloid brain scanning techniques, trained radiologists are able to identify the onset possibly even before any memory decline is noticed. Cognitive enhancer medications that slow down the decline and reduce behavioural problem are usually prescribed. Meanwhile, vaccines to prevent the cascade of process to halt the formation of unregulated offending proteins or to make them soluble or to wipe them away by antibodies have not yielded the required results in trials yet.

Identifying persons at high risk or those in pre-dementia stage is possible, and they may be offered health promotion activity package in daycare centres or elderly forums. While enhanced socialisation with peers could reduce loneliness, a structured daily schedule of appropriate fun games involving mental exercise may help too.

Persons with early signs may be administered the Cognitive Retraining Programme by trained professionals particularly in the areas of deficit. If practised regularly at home, this could delay the progression of AD. User-friendly low-cost GPS tracking devices, if tested and made available widely, could lower the chances of going missing and address the family’s distress. Guiding the person through artificial intelligence or cue-based reminders using technology to enhance autonomy could be developed.

The treating team should work in partnership with caregivers and address their difficulties. Regular self-help support groups can help learn practical aspects in managing. A small trial at Nimhans has shown some benefit with yoga and studies on effects of meditation are being planned in Europe. Improving sensory functions such as quality of hearing and vision are also being tried.

Planning for old age shouldn’t just be about finances, but one must also engage in healthy activities and hobbies. Seeking early consultation with specialist is also key.

(The writer is consultant psychiatrist and ad-hoc faculty in Geriatric Psychiatry, NIMHANS, Bengaluru)