Expert: Mary Gordon - 4/28/2005

Question
How do you know if someone has Alzheimer's?  I'm concerned about my mother-in-love.  She's been repeating herself for some time now.  My husband has taken her to her primary care who basically dismissed it and said that she was not old enough to have Alzheimer's.  My mother-in-love is 74 years old.  Can you recommend somewhere we could take her to be tested for the disease?

Thank you for your time.
Serina  

Answer
Serina, OH MY GOODNESS!!

Time for a new family doctor, and I absolutely mean it. 74 is NOT too young to get Alzheimers - in fact, my own mother- in-law was diagnosed at 73. It is a disease that becomes more common with age - between age 63 and 74, about 3% of all people are affected (which makes it not rare - 3 in 100 is a actually a LOT), but by the time you reach 75-84, a full 19% of the population has Alzheimers or other progressive dementia, and for those over 85 - close to 50% have it. So, her doctor really is not on the ball at all. There are actually forms of the disease that hit in middle age (so called early onset Alzheimer's).

Your mother-in-law is obviously NOT fine, and her doctor is not giving her appropriate care. Memory loss and confusion are always caused by SOMETHING - it is never a "normal" part of aging, or something we should accept without proper exploration. Do you think he would be so dismissive if she was 54 instead of 74?

What you are describing could be the early stages of Alzheimer's (the most likely explanation) but it could be a lot of other things.  You need to get her to a doctor who is going to take this more seriously and get a proper diagnosis.

Alzheimer's is only diagnosed by ruling out everything else it might be. Confusion and memory problems can stem from small strokes (so small the person may not show other signs of stroke), drug interactions or side effects, thyroid problems, pernicious anemia, depression - and a stack of other things.  So, the first step is to make sure she isn't suffering from some other problem that might affect her memory - especially if the "something" might be treatable.  A good assessment includes a full physical with assorted blood tests, some psychiatric evaluation to rule out depression, a review of history and medications, a neurological work up, usually including a CAT or other brain scan to rule out strokes, tumors etc. Usually a family doctor will then refer the person to a psychiatrist with a geriatric specialty, or to a neurologist with expertise in dementias.  The fact he has not done so seems to me to be negligent and irresponsible given that Alzheimers is not only a progressive neurological disease, but one that is considered a terminal illness.

A good assessment will also check out the extent of your mother-in-law's deficits.  Alzheimer's doesn't just affect memory. Because it affects the entire brain, reasoning, judgement and personality can be affected early in the disease. Things families notice first often include memory lapses, trouble with numbers or time, getting disoriented in familiar places (i.e. getting "turned around" on the way to the store), trouble thinking of words, asking the same question repeatedly,  getting upset easily or frustrated, changes in routine (i.e. they sometimes stop participating in things they previously loved), difficulty solving simple problems (i.e. not being able to figure out what to do when something goes wrong). It can be subtle, but if the alarm bells are going off in your head, I'd listen to them.  Just based on what you are describing, your mother-in-law is likely quite a bit more impaired than you realize. My husband went with his mother when they put her through some cognitive testing (sort of like what they do with a child when they are looking for learning disabilities). The results were shocking. She seemed much more together to us than she actually was, based on what the testing showed.

Clearly, something is really wrong - and all of you need to know exactly what is causing the symptoms you are seeing so you can figure out what you can do about it - and also make plans for what will happen next.  There are medications that can slow down the disease in some people in the early stages, and others that improve mood, reduce anxiety, delusions that may develop etc. - but to get the right meds, you need to know what you are treating.

If she is living alone, you will have to start making plans for other arrangements shortly, because if she has Alzheimers, it is a one way street down hill, and she will likely need supervision and support in short order.  Certainly legal things like powers of attorney, wills, estat planning etc. need to be in order, and steps taken to consolidate her finances to permit you or someone trusted to manage her affairs when she reaches the point she needs help with them (probably not far from now).

Just to give you an idea of what may happen next if this IS Alzheimer's I've pasted the most commonly used description of the stages of Alzheimer's below my signature.

Hope this helps.  Get your skates on and get a better doctor - or ask to be referred to a specialist who can give you some real answers and advice.

Mary Gordon
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 orient in 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., paatients 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