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Protecting your memory

Advances in treating (and avoiding) Alzheimer's disease

Consumer Reports on Health: January 2009

Alzheimer's shrinks areas of the brain involved in thinking, planning, and remembering.
Illustration: Stacy Janis

After years of dashed hopes and diminished expectations, researchers now have guarded optimism in the battle against Alzheimer's disease. Two drugs typically used separately against the disease, for example, show unexpected benefits when taken together, a 2008 study has found. And advances in understanding how Alzheimer's develops is helping researchers zero in on new ways to combat the disease. At least as critical, they've identified lifestyle changes that might help prevent cognitive decline in the first place. "There is every reason to be optimistic and excited about the momentum of Alzheimer's research," says Gary Kennedy, M.D., director of geriatric psychiatry at Montefiore Medical Center in New York City.

Better treatment options

Standard treatment for Alzheimer's has been limited mainly to either cholinesterase inhibitors (CIs) such as donepezil (Aricept) and galantamine (Razadyne), or another drug, called memantine (Namenda). CIs and memantine regulate different brain chemicals, which are important to memory. Taken separately they slow the progression of the disease in only about 10 to 20 percent of patients, and even then only modestly.

But the new study, published in the journal Alzheimer Disease and Associated Disorders, found that over the course of three years the combination therapy, on average, cut the rate of decline in half compared with a CI alone. And the longer the patients took the drugs, the more dramatic the benefits.

"The combination won't cure the disease," said Alireza Atri, M.D., Ph.D., lead author of the study and a memory disorders specialist at Massachusetts General Hospital. "But if you want the best chance of preserving as much cognitive and functional ability as you can, my advice for patients with Alzheimer's disease is to get on combination therapy and stay on it until we have more powerful treatments." Experts not involved in the study agree. "I've been treating people with Alzheimer's since the 1980s," Kennedy says. "Now I routinely have patients on a CI and memantine, and I think they're doing much better."

If you're considering the drugs for yourself or someone you care for, remember that even the combination won't reverse the disease, just slow its progression. They're also expensive, ranging from about $1,700 to $2,600 a year per drug. Side effects can include constipation, diarrhea, and headache, but they're usually mild. Our consultants think it makes sense to try the drugs for a year or more under the scrutiny of a doctor and family members.

Researchers hope that other drugs being tested in clinical trials may go further to actually reverse cognitive decline. For example, in a study published in the July 19, 2008, issue of the journal Lancet, 183 people with Alzheimer's were given a placebo or an antihistamine used in Russia, called Dimebon, which might also help prevent the death of nerve cells. After six months, those on the drug showed improved cognition, function, and behavior. The most common side effects were dry mouth and depression. For information about enrolling in a trial of the drug, go to www.clinicaltrials.gov.

Diagnosis vs. denial

Because current drugs only slow the progression of Alzheimer's, it's important to identify the condition before problems become severe. Prompt diagnosis is crucial for other reasons as well. Detecting it when patients still have fairly good mental function allows them to participate in making treatment decisions. And memory problems can stem from reversible causes, such as depression, thyroid problems, vitamin deficiencies, and side effects from certain medications. But people commonly deny or cover up early signs of Alzheimer's for fear of being stigmatized, according to a 2008 report by the Alzheimer's Association. That leads to lengthy delays in diagnosis. A recent Harris Interactive survey found that when symptomatic people or their caregivers worried about stigma, diagnosis occurred up to six years later.

A standard diagnostic workup should include a complete physical including lab tests and often an MRI, to rule out other causes, as well as cognitive tests to assess mental status. "The accuracy of diagnosis is best at centers that specialize in Alzheimer's disease or geriatrics,"says Samuel Gandy, M.D., a professor at the Mount Sinai School of Medicine in New York City. To get a referral, go to the Geriatric Mental Health Foundation or the American Geriatrics Society or contact a local teaching hospital.

Prevent mental decline

Of course, prevention is even better than early diagnosis or treatment. And recent research suggests several helpful strategies. For example, a 2008 Swedish study of about 2,200 men found that those at increased risk for type 2 diabetes in midlife were more likely to later develop Alzheimer's. And a Brazilian study of some 420 older adults, presented at the 2008 International Conference on Alzheimer's Disease, showed that those with multiple heart-disease risk factors had a higher level of cognitive impairment compared with a similarly aged group of healthy people.

In general, anything that protects the heart and blood vessels, thereby facilitating blood flow to the brain, might help fend off Alzheimer's. That makes it doubly important to adopt a heart-healthy lifestyle and to work with your doctor to control cardiovascular risk factors. Other evidence indicates that the following measures might also help.

Stay fit. "Physical activity increases the maturation of nerve cells in the hippocampus, the area that's responsible for forming new memories," Kennedy says. In another study presented at the same conference, researchers from the University of Kansas measured brain size and cardiovascular fitness in 63 people with early Alzheimer's. Those who were more fit had greater volume in brain regions that are important for memory. In another 2008 study, researchers assigned 170 older people at risk for Alzheimer's to increased exercise or standard care. After six months, the exercisers showed improved cognitive function compared with the control group.

Recommendation:
Aim for 30 minutes of moderate-intensity aerobic activity, such as brisk walking, daily or most days.

Flex your brain muscles. Socially and intellectually stimulating activities might also increase brain function. For instance, MRI scans revealed that regions of the brain responsible for learning were enlarged in London cab drivers, who train for up to two years to memorize thousands of streets and locations. And in a 2008 study, researchers from Johns Hopkins and Duke University found that men who participated in mentally and socially engaging activities in midlife had a lower risk of dementia.

Recommendation:
Stay connected with family and friends, join a hobby group, or do volunteer work. Cultivate a variety of mental pursuits, such as playing chess or bridge, doing crossword puzzles, or learning a language.

Feed your brain. Several 2008 trials failed to find cognitive benefits in fish oil or ginkgo biloba supplements. But people over the age of 50 might benefit from more B12, from fortified foods or supplements, since many lack an enzyme needed to digest that brain-boosting vitamin when it comes from food. And research suggests that regular consumption of fish and fruits and vegetables might support brain health.

Recommendation: Include fish in your diet and aim for at least five servings a day of fruits and vegetables. Avoid saturated and trans fats, which may hasten cognitive decline and consider extra vitamin B12 if you're older than age 50.

Is it Alzheimer's disease—or part of normal aging?

Alzheimer's cells, left; healthy cells.
Illustration: Stacy Janis

Not all memory glitches signal Alzheimer's. Use this list, adapted from the Alzheimer's Association, to help you decide whether to seek a professional opinion.

1. Memory loss

Normal: Occasionally forgetting appointments or names of acquaintances, books, or movies.

Worrisome: Forgetting names of close friends or family members, being unable to remember things just learned, and being unaware of the memory loss.

2. Difficulty with familiar tasks

Normal: Occasionally forgetting why you came into a room or what you planned to say.

Worrisome: Frequently being unable to perform everyday tasks, like cooking a meal, making a phone call, or playing a game.

3. Language problems

Normal: Sometimes having trouble finding the right word.

Worrisome: Often forgetting simple words or substituting unusual ones. For example, someone looking for a toothbrush might ask instead for "that thing for my mouth."

4. Disorientation

Normal: Forgetting the day of the week or where you are going.

Worrisome: Getting lost in the neighborhood or forgetting how you got somewhere.

5. Poor judgment

Normal: Making a questionable decision from time to time. For example, anyone might choose not to wear a hat or gloves in cold weather.

Worrisome: Frequently making clearly inappropriate decisions, such as forgetting to wear pants or a shirt, wearing several layers of warm clothes in hot weather, or giving away large sums of money to a stranger.

6. Problems with abstract thinking

Normal: Having a hard time balancing a checkbook.

Worrisome: Forgetting what numbers are for or how to do simple addition and subtraction.

7. Misplacing things

Normal: Occasionally losing a wallet or keys.

Worrisome: Putting things in unusual places, like keys in the freezer or a wallet in the sugar bowl.

8. Mood changes

Normal: Occasionally feeling moody or sad.

Worrisome: Rapid mood swings—from calm to tears to anger, for example—for no apparent reason.

9. Personality changes

Normal: Gradual, modest changes as you age.

Worrisome: Dramatic personality shifts, becoming, for example, suspicious, fearful, or dependent.

10. Loss of initiative

Normal: Sometimes feeling weary of work or social obligations.

Worrisome: Extreme passivity, for example, sitting in front of the TV for hours or sleeping much more than usual.

Talking to people with Alzheimers

People with Alzheimer's often become agitated when you address them in "baby talk," according to a 2008 study. The nonprofit Family Caregiver Alliance suggests some tips for better communication.

Focus attention. First turn off the TV, close the curtains, or move to quiet surroundings. Before speaking, address the person by name, identify yourself, and use touch and eye contact to maintain focus.

Be respectful. Don't make your voice higher or lower than normal or use infantile language. But do speak slowly and distinctly.

Keep it simple. Ask one question at a time, preferably one that requires a yes or no answer. If that's not possible, limit the choices. For example, ask, "Would you like to wear your blue shirt or the red one?" and show options at the same time.

Be patient. Repeat your message or question if necessary. It's OK to suggest the words that the person might be struggling to remember.

Show affection. If the person becomes confused or angry, don't try to correct him. Instead, offer comfort and support. Hold hands, hug, smile, nod, and offer praise and reassurance.

Distract and redirect. If the person becomes upset, first acknowledge the feelings, then change the subject or the environment. For example, say, "I see you're feeling sad. I'm sorry. Let's go for a walk."

Discuss the past. Many people with dementia can't remember what happened 45 minutes ago but can clearly recall their lives 45 years earlier.

Laugh. People with dementia tend to retain their sense of humor and like to laugh along with you as long as it's not at their expense.

Editor's Note: This article first appeared in the Consumer Reports on Health newsletter.
   

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