Expert: Mary Gordon - 7/19/2005

Question
First of all, thank you for your community service. This was my first day of research and you handle the answers with kindness. My question regards my 73 year old mother in law. There are some circumstances that I would like to predicate this with. First she has a hereditary depression problem that has been largely ignored by her, but addressed by three daughters whom have inherited it as well as two grandchildren for sure, two others possible. She has refused it until the last two months and is finally being treated. The second is her husband of three years has been supplying her with many many supplements over the last three years and limited her caloric intake severely (she is a slender woman to begin with). He just recently suffered a stroke after not taking heart medicine he was prescribed instead using his supplements. Now to the question. Could depression and the reaction to multiple supplements combine to give the similar reactions and symptoms of level 5 Alzheimers. As a result of his stroke my wife and sisters were able to go in and rescue my mother in law. She had recently been diagnosed with dementia. Very bad memory problems, sometimes can't find the bathroom or other simple tasks, tried to plug a blender in to a concentrated fruit can. At other times remembers the words spoken at a dinner 50 years ago. Cannot bath herself and needs help dressing. Forgets to dress on occassion. Used to be a fastidious house keeper and now really does not care. Reads like a level 5 to 6 but would really like to find out that it is treatable depression and ending supplements. Wishful thinking. She is being taken in for the tests that have been recommended and we will soon know for sure I guess. How does this affect her physically and how long will she have to live under these circumstances? She is otherwise pretty healthy or at least was a year ago. thanks, Randy

Answer
Randy, I'm assuming when you say level 5-6, you are referring to the Reisberg definition of the "stages" of Alzheimers. I've pasted a copy below my signature just for reference.

From your description of what is going on with your mother in law, it does sound more typical of Alzheimer's, than depression or a related mental illness. Early Alzheimer's often has symptoms that look like depression (such as apathy, neglect of appearance, loss of appetite, withdrawal from activites etc. ). As well, many people with early to mid stage dementias are self aware enough to realize they are "losing it" and get depressed about their situations. My mother in law, for example, thought she was "going crazy" and was certainly aware of her own declining abilities and was embarrassed and humiliated by them - certainly a very upsetting and depressing realization.

Because of that, It is not uncommon to give Alzheimer's patients antidepressant medications. You mention that the doctor is trying your mother in law on some to see what happens - you have nothing to loose. However, my instinct tells me you might see improvement in mood, rather than any meaningful recovery of abilities. What you describe is certainly far beyond anything depression alone would cause. So, she may perk up in terms of how she feels, but don't expect major improvements to cognitive function. If there IS any improvement, you will likely see it in the first month or so.

Poor nutrition certainly can impact cognitive abilities - B12 deficiency is a good example - people with this deficiency (pernicious anemia) can develop a form of dementia. Restriction of calories alone is likely to produce lethargy, but not major mental impairment like you describe. You mention she was taking supplements - vitamins? If she had a really poor diet that could have potentially impacted her mind, you will see whatever improvement is likely in a relatively short time frame. I'd expect some improvement in her physical condition, perhaps more alertness, but don't get your hopes up for much beyond that, even with an excellent diet.

I hate to say it, but your description really does sound like fairly typical mid to later AD, including the fluctuations in abilities. My mother in law lost the ability to speak about two years before she died - all that came out were garbled nonsense syllables. She slept all the time and did not know who any of us were. On one visit, we took along a photo album, and we were stunned when she suddenly came out with a series of intellible sentences, correctly pointing out several relatives and making comments about them. The next day, she was back to oblivion, so go figure. I guess the neurons just lined up and fired correctly out of the blue.

You ask how long your mother in law may live - its very, very hard to say - which I know is not what you need to hear. She is relatively young at 73, and if she is otherwise healthy, it may be many more years before her life is ended by the Alzheimer's itself. My mother in law was diagnosed at that age, and survived about 6 years to the end of her life from Alzheimer's.

Experts used to think that was a fairly typical survival time  - 6-9 years from diagnosis to the end. However, more recent research has suggested that average survival is more like 3 years. This is really due to the serious problems that Alzheimer's brings in diagnosing and treating OTHER health problems in the elderly, particularly in those older and frailer than your mother in law. As you can imagine, as brain damage progresses, the person may not feel typical symptoms such as pain or discomfort, and even if they do they can't necessarily tell anyone how they feel, much less answer questions from a doctor. They may not be able to understand the purpose of treatment and cooperate with medical procedures. Families can be very reluctant to put their loved one through medical procedures including tests that may be frightening or uncomfortable, much less surgeries or therapies that may be painful. Many families make the decision for palliative care alone - that they will keep the person free from pain, but not attempt to actively deal with health problems (i.e. not bother to put a person in late Alzheimer's through cancer tests or treatments). So, having Alzheimer's can mean being carried off sooner from health issues quite apart from the dementia. Not to be glib about it, but having seen what the brutal and gruelling natural end of Alzheimer's itself means, many of us would pray that some other health issue took our loved one before that point.

Does the family have any idea how fast her condition has advanced or how long she has been showing symptoms? Looking back, can your wife recall when she first realized her mother was slipping mentally? This might give you a clue - obviously, since Alzheimer's is a progressive and fatal disease, it will come to its natural end much faster in someone whose illness is moving fast.
I have seen people whose disease moved very slowly and others whose AD just galloped. It also can plateau for periods of time.

If I had to put money on it, I'd say you are likely looking at a couple of years. The later stages are extremely difficult for home caregiving because the care becomes heavy, relentless, and thankless - the person is really unaware of where they are or what is happening to them. It's also very hard because many do survive so long  - so its not like looking after a terminal cancer patient (for example) where the time frame can be relatively well defined and planned for.

This must be very hard for your wife and her siblings. I can't think of anything more painful, particularly given the situation with her husband.  

Hope this helps. Please feel free to ask me anything else, or to get back to me if I haven't adequately covered your question.

Mary G.
Toronto



Stages of Alzheimers

In 1982 Dr. Barry Reisberg published what was to become the best and most widely accepted description of the stages of Alzheimer's disease. Even today, years later, when experts refer to a person being in stage 5 or stage 6, they are referring to Dr. Reisberg's scale of seven stages.

Adapted from Reisberg, B., Ferris, S.H., Leon, J.J. & Crook, T. The global deterioration scale for the assessment of primary degenerative dementia. American Journal of Psychiatry, 1982

Level 1

No cognitive decline - (or Normal Adult). No subjective complaints of memory deficit. No memory deficit evident on clinical interviews.

Level 2
Very mild cognitive decline (forgetfulness or normal older adult). Subjective complaints of memory deficit, most frequently in the following area:
(a) forgetting where one has placed familiar objects;
(b) forgetting names on formerly knew well.
No objective evidence of memory deficit on clinical interview. No objective deficits in employment or social situations. Appropriate concern regarding symptoms.

Level 3
Mild cognitive decline (early confusional or Early AD). Earliest clear-cut deficits. Manifestations in more than one of the following areas:
(a) patient may have gotten lost when traveling to an unfamiliar location;
(b) co-workers become aware of patient's relatively low performance;
(c) word and name finding deficit becomes evident to intimates;
(d) patient may read a passage of a book and retain relatively little material;
(e) patient may demonstrate decreased facility in remembering names upon introduction to new people;
(f) patient may have lost or misplaced an object of value;
(g) concentration deficit may be evident on clinical testing.
Objective evidence of memory deficit obtained only with an intensive interview. Denial begins to become manifest in patient. Mild to moderate anxiety accompanies symptoms.Deficits noticed in demanding employment situations.

Level 4
Moderate cognitive decline (Late Confusional or Mild AD). Clear-cut deficit on careful clinical interview. Deficit manifest in following areas:
(a) decreased knowledge of current and recent events;
(b) may exhibit some deficit in memory of one's personal history;
(c) concentration deficit elicited on serial subtractions;
(d) decreased ability to travel, handle finances, etc.

Frequently no deficit in the following areas:
(a) orientation to time and person;
(b) recognition of familiar persons and faces;
(c) ability to travel to familiar locations.
Inability to perform complex tasks. Denial is dominant defense mechanism. Flattening of affect and withdrawl from challenging situations occur.

Level 5
Moderately severe cognitive decline (Early Dementia or moderate AD). Patient can no longer survive without some assistance. Patient is unable during interview to recall a major relevant aspect of their current lives, e.g., an address or telephone number of many years, the names of close family members (such as grandchildren), the name of the high school or college from which they graduated. Frequently some disorientation to time (date, day of week, season, etc.) or to place. An educated person may have difficulty counting back from 40 by 4s or from 20 by 2s. Persons at this stage retain knowledge of many major facts regarding themselves and others. They invariably know their own names and generally know their spouse's and children's names. They require no assistance with toileting and eating, but may have some difficulty choosing the proper clothing to wear.

Level 6
Severe cognitive decline (Middle Dementia or Moderately Severe AD). May occasionally forget the name of the spouse upon whom they are entirely dependent for survival. Will be largely unaware of all recent events and experiences in their lives. Retain some knowledge of their past lives but this is very sketchy. Generally unaware of their surroundings, the year, the season, etc. May have difficulty counting from 10, both backward and sometimes forward. Will require some assistance with activities of daily living, e.g., may become incontinent, will require travel assistance but occasionally will display ability to familiar locations. Diurnal rhythm frequently disturbed. Almost always recall their own name. Frequently continue to be able to distinguish familiar from unfamiliar persons in their environment. Personality and emotional changes occur. These are quite variable and include
(a) delusional behavior, e.g., patients may accuse their spouse of being an impostor, may talk to imaginary figures in the environment, or to their own reflection in the mirror;
(b) obsessive symptoms, e.g., person may
continually repeat simple cleaning activities;
(c) anxiety symptoms, agitation, and even previously nonexistent violent behavior may occur;
(d) cognitive abulla, i.e., loss of willpower because an individual cannot carry a thought long enough to determine a purposeful course of
action.

6a - Requires Assistance dressing
6b - Requires Assistance bathing properly
6c - Requires Assistance with mechanics of toileting
6d - Urinary incontinence
6e - Fecal incontinence

Level 7
Very severe cognitive decline (Late Dementia or Severe AD). All verbal abilities are lost. Frequently there is no speech at all - only grunting. Incontinent of urine, requires assistance toileting and feeding. Lose basic psychomotor skills, e.g., ability to walk, sitting and head control.
The brain appears to no longer be able to tell the body what to do. Generalized and cortical neurologic signs and symptoms are frequently
present.

7a - Speech ability limited to about a half-dozen intelligible words
7b - Intelligible vocabulary limited to a single word
7c - Ambulatory ability lost
7d - Ability to sit up lost
7e - Ability to smile lost
7f - Ability to hold up head lost