When memory dies...

With an increasing ageing population, Sri Lanka is likely to have more patients being diagnosed with Alzheimer's Disease

Memory loss is now an increasingly common brain related condition worldwide. Recent reports reveal how once vibrant, self reliant persons, have been reduced to total dependency, requiring help for even simple daily chores such as using the toilet, brushing their teeth, or eating. Although on-going research studies have shown promising results, curing Alzheimers however remains an elusive dream.

Consultant Neurologist, Sri Jayawardenepura Hospital, Dr. Harsha Gunesekara discusses treatment options available to Lankan patients in this interview with the Sunday Observer.

Q: The number of Alzheimer patients, seem to have risen dramatically in recent years. What contributes to this?

A: The most important reason for this is the increase in the ageing population, which could also be seen in developing countries like Sri Lanka, as the greatest known risk factor for Alzheimer's Disease (AD) is advancing age. So it is likely that more patients with AD will be detected. Improved awareness of the disease among the public also contributes to increased detection of patients.

A: Dementia is a group of symptoms characterized by a decline in intellectual functioning severe enough to interfere with a person's normal daily activities and social relationships. There are different types of dementia and Alzheimer's Disease is the most common type of dementia in older people.

A:The other common types of dementia include Vascular Dementia (decline in memory skills caused by conditions that block or reduce blood flow to the brain), Fronto-temporal Dementia (caused by progressive nerve cell loss in the brain's frontal lobes - the areas behind your forehead and its temporal lobes - the regions behind your ears) and dementia associated with other diseases such as Parkinson's. More than one type of dementia may exist in the same person (mixed dementia).

A: Most experts believe that the majority of Alzheimer's Disease occurs as a result of complex interactions among genes and other risk factors. Age, family history and heredity are all risk factors we can't change. Now, research is beginning to reveal clues about other risk factors we may be able to influence through general lifestyle and wellness choices and effective management of other health conditions. Growing evidence links brain health to heart health. The risk of developing Alzheimer's or vascular dementia also appears to increase when certain pre- conditions damage the heart or blood vessels, such as high blood pressure, heart disease, stroke, diabetes and high cholesterol. Studies have found an association between lifelong involvement in mentally and socially stimulating activities and reduced risk of Alzheimer's disease. These include higher levels of formal education, a stimulating job, mentally challenging leisure activities, such as reading, playing games or playing a musical instrument and frequent social interactions.

A: The likelihood of developing Alzheimer's doubles about every five years after age 65. After the age of 85 years, the risk reaches nearly 50 percent. People with rare genetic changes may develop Alzheimer's symptoms as early as in their 30s.

A: A common symptom is memory loss, especially forgetting recently learned information. Others include forgetting important dates or events and asking for the same information repeatedly. Some people may experience changes in their ability to develop and follow a plan (e.g. a recipe) or work with numbers (e.g. bills).

Apathy and depression are also often early symptoms. Late symptoms include impaired communication, poor judgment, disorientation, confusion, behavioural changes and difficulty speaking, swallowing and walking.

A: Pathological changes in the brain probably start 10-20 years before any visible signs or symptoms of the disease appear. Memory loss, the first visible sign, is the main feature of mild cognitive impairment (MCI).

A: Currently there is no cure for Alzheimer's Disease. However, some drugs may help delay the progression of symptoms associated with the disease. Also, some medicines may help control behavioural symptoms, such as sleeplessness, agitation, wandering, anxiety, and depression. Treating these behavioural symptoms often makes people with Alzheimer's more comfortable and makes their care easier.

A: The first step in the process is to diagnose AD. There is no single test that can show whether a person has AD or not. While doctors can almost always determine if a person has dementia, it may be difficult to determine the exact cause. Diagnosing Alzheimer's requires careful medical evaluation and tests (such as blood tests and brain imaging) to rule out other causes of dementia-like symptoms. Among drugs recommended for treatment in AD, only two drugs are available in Sri Lanka. These drugs are recommended only for mild to moderate disease.

A: As AD progresses, brain cells die and connections among cells are lost, causing symptoms to worsen. While current medications cannot stop the damage AD causes to brain cells, they may help lessen or stabilize symptoms for a limited time by affecting certain chemicals involved in carrying messages among the brain's nerve cells.

A. Strongest evidence for antioxidant protection against Alzheimer's Disease rests with high food intake of vitamin E. The richest food sources of vitamin E include vegetable oils, margarine, nuts (especially almonds), and seeds (especially sunflower seeds). Moderate amounts of vitamin E are found in whole grains, egg yolk, and a limited number of vegetables (eg, cabbage, broccoli) and fruits (eg, avocados, apples, melon).

A: 95% of patients have sporadic AD (without a family history and onset after 65 years) and their family members are not at increased risk of developing AD.

The most common gene associated with late-onset Alzheimer's disease is called apolipoprotein E (APOE). Presence of this gene increases the risk of AD but does not cause AD. 5% of patients with AD have familial Alzheimer's disease, which is an early-onset form of the disease that appears to be inherited. In familial Alzheimer's Disease, several members of the same generation in a family are often affected.

A: Alzheimer's Disease damages and kills brain cells. Early in the disease, destruction of neurons is particularly widespread in parts of the brain that control memory, especially the hippocampus (this is in the area marked as memory in the diagram comparing normal and brain affected by AD).

Providing the needed care

The Lanka Alzheimer's Foundation, through its modernized centre at Ketawalamulla lane, at Maradana, provides day care and rehabilitation, mind and brain stimulating activities to dementia patients to give care givers time to engage in other activities. Founding Executive Director & President Lanka Alzheimer's Foundation (LAF), Lorraine Yu says the centre also conducts lectures by experts, for caregivers who list communication problems as one of their greatest challenge when interacting with Alzheimer's patients, and raises awareness about the disease with its annual walks, on Alzheimer's Day in which thousands of people participate. "There will be one this month as well" she says.

The other part of the brain that sustains major damage is the cerebral cortex, particularly the areas responsible for language, reasoning, perception, and judgment (the temporal, frontal, and parietal lobes).

A: Several clinical trials of investigational drugs targeting the disease process are underway. In addition to investigating these experimental drugs, many clinical trials are in progress to find various brain imaging studies and testing of blood or spinal fluid for a biomarker to diagnose Alzheimer's Disease in its earliest, most treatable stages - possibly even before symptoms appear. Several professional organizations have published updated guidelines on management of AD and are available for use locally.

A: Patients with AD should be managed by a multidisciplinary team including Neurologists, Psychiatrists, Neuropsychologists, Specialist Nurses, Occupational Therapists, Social Workers and Care Givers. Non-availability of new drugs and treatment cost are some shortcomings.

From a diagnostic and monitoring point of view, lack of Neuropsychologists in the country is a major problem in managing patients with AD. Patients own family members or relatives are the main care givers in Sri Lankan society. At present, the biggest burden on the health sector is from diseases affecting the elderly. Out of this, Stroke and Dementia (of which 60% is Alzheimer's) are the commonest, and impose a major burden on the family members as care givers.

Q. Does your hospital have any plans to meet these challenges? Does the Health Ministry?

A:The emerging threat of health issues concerning a rising elderly population has been foreseen by the Health Authorities in many countries including Ministry of Health in Sri Lanka. Strategies are already underway to meet this threat in terms of both prevention and care, but a lot more needs to be done. Non-communicable diseases (NCD) unit of the Ministry has set up island wide NCD prevention clinics through surveillance.

National Organizations such as Stroke Association and Alzheimer Society needs to carry on awareness programs on promoting brain health among the public.

Furthermore, Geriatrics (Care of the Elderly) needs to be recognized as a medical sub specialty (a diploma programme has already been started by the Postgraduate Institute of Medicine). Some hospitals (including Sri Jayewardenepura General Hospital) have started special clinics for Elderly Care.