- Clinical science
Alzheimer disease (AD) is a chronic neurodegenerative disease and the leading cause of dementia. Several causative gene defects (e.g., amyloid precursor protein gene mutations) and various risk factors (e.g., old age) have been identified, although the exact mechanism that causes dementia is still unknown. Histopathological evidence of AD primarily includes senile plaques from the deposition of beta-amyloid protein (Aβ protein) and neurofibrillary tangles from the accumulation of tau protein. The most common presenting symptom is short term memory loss. During the course of the disease, many cognitive functions are affected, such as attention control and reasoning, orientation, and language. Patients are typically capable of maintaining a social façade as the disease progresses. The diagnosis is primarily based on clinical examination, but neuropsychological tests, cerebrospinal fluid (CSF) analysis, and imaging are sometimes used as well. To date, there is no curative therapy. Symptomatic therapy can be attempted with cholinesterase inhibitors (ChEIs) and N-methyl-D-aspartate (NMDA) antagonists (e.g., memantine). AD features a highly variable progression, with the mean survival following diagnosis between 3 and 10 years.
- Alzheimer disease (AD) is a progressive neurodegenerative type of dementia that features the pathological hallmarks of neuritic plaques and neurofibrillary tangles.
- AD shares some epidemiological, pathological, and clinical properties with other types of dementia, particularly with vascular dementia (VD) and frontotemporal dementia (FTD).
- AD is the leading cause of dementia; and the 6th most common cause of death in the US.
Incidence and prevalence increase with age.
- ∼ 200/100,000 in patients 65–74 years of age
- ∼ 3700/100,000 in patients 85 years of age and older
- Prevalence: up to 20–40% in patients ≥ 85 years
- Sex: ♀ > ♂
- In the US, AD is more common in African Americans and Hispanics than in whites.
Epidemiological data refers to the US, unless otherwise specified.
|Amyloid precursor protein (APP) gene (chr 21)|| |
|Presenilin-1 (chr 14)||PSEN1|| |
|Presenilin-2 (chr 1)|| |
|Apo ε (chr 19)||Apolipoprotein E (ApoE)|
Other risk factors
- Family history of dementia
- Low socioeconomic and/or educational status
- Down syndrome
- Diabetes, obesity, dyslipidemia
- Lack of physical activity (independent risk factor!)
- Hypertension, peripheral atherosclerosis, and cerebrovascular disease
- Traumatic brain injuries
- Environmental factors (e.g., secondhand smoke)
- Extracellular senile plaques: composed of Aβ protein
- Intracellular neurofibrillary tangles: composed of hyperphosphorylated tau protein
- Damage to the hippocampus and parahippocampal cortex (medial temporal lobe structures) is the earliest gross pathological change → diffuse cortical atrophy occurs as the disease progresses
- Degeneration of cholinergic neurons in the nucleus basalis of Meynert (basal forebrain structure); → impaired cholinergic transmission to cortex, reduced levels of choline acetyltransferase and acetylcholine → overall reduction of cholinergic function
Common order of cognitive impairments
- Short term memory (insidious onset and slow progress with episodic memory affected first)
- Language (typical sequence: impaired naming → impaired comprehension → impaired fluency)
- Temporal and spatial orientation (e.g., disorientation, inability to judge distances)
- Less common symptoms
- Patients are usually not oriented to person, place time and events (e.g., in earlier stages, patients may get lost while driving home).
- Behavioral changes
- Aggression, irritability, and agitation
- Mood disorders
- Earlier stages: usually symptoms of depression
- Later stages: patients are often unconcerned and happy and tend to downplay their cognitive impairments
- Anxiety and mutism
- Hallucinations and paranoia
- Late stage
Patients with mild to moderate Alzheimer disease are often able to maintain a social facade and preserve certain skills (e.g., dressing, hygiene routines)!
- Diagnosis of dementia: in patients with memory loss, cognitive and/or functional decline
- Neuropsychological testing (e.g., ): screens for patients with dementia
- Fullfilment of DSM-5 criteria
- Rule out reversible causes of dementia
- Definitive diagnosis of AD is only possible via neurohistopathological examination, which is only conducted post mortem.
Synopsis of diagnostic criteria
- Insidious onset
- Objectively confirmed progressive loss of function in at least two cognitive domains (usually, but not necessarily, including memory impairment)
- Impairment of activities of daily life (e.g., difficulties at the workplace)
- No other plausible explanation (e.g., delirium)
- ↑ Phospho-tau protein
- ↓ β-amyloidproteins Aβ1-42
EEG: slower basic rhythm
- Evoked potentials: long latency
- PET: temporoparietal hypometabolism
Neuropsychological testing: (e.g., MMSE) repeat measurement of performance on such tests is helpful to track the progress of the disease in individual patients over time.
- Cognitive testing: Alzheimer disease assessment scale – cognitive behavior subscale (ADAS-Cog), Mini-cog, Blessed Information-Memory-Concentration Test (BIMC), Clinical Dementia Rating Scale (CDR)
- Functional testing: e.g., Functional Assessment Questionnaire (FAQ), Physical Self-Maintenance Scale (PSMS)
- Global testing: e.g., Global Deterioration Scale (GDS)
- Caregiver-based testing: e.g., Neuropsychiatric Inventory (NPI)
- Cerebral atrophy: particularly in the temporal lobe (cortex and hippocampus) and the nucleus basalis of Meynert
Amyloid beta (Aβ): stains with Congo red under polarization
- Cerebral amyloid angiopathy (can cause intracerebral hemorrhages)
- Intracellular neurofibrillary tangles
- Extracellular senile plaques
- Axonal degeneration
The differential diagnoses listed here are not exhaustive.
There is no curative therapy available; only symptomatic therapies.
Pharmacological treatment of dementia
- Mild to moderate (defined as Mini-Mental State Examination score of 19–26 for mild disease, 10–18 for moderate disease): donepezil, galantamine, rivastigmine (acetylcholinesterase inhibitors)
- Moderate to severe (may be given in addition to acetylcholinesterase inhibitors): memantine (NMDA-receptor antagonist)
Supportive care (nonpharmacological treatment)
- Lifestyle modifications; (behavioral interventions for patients and care-givers): for example, adhering to a regular sleep schedule, maintaining a consistent and familiar environment, removing ambient noise
- Cognitive rehabilitation: memory training (e.g., puzzles, interactive games) to maintain memory and develop strategies to compensate for cognitive and functional decline
- Physical exercise: improve physical strength and decelerate the functional decline
- Occupational therapy: develop coping skills and behavior to improve functionality and performance of activities of daily living
Pharmacological treatment of associated symptoms
Indicated in patients with poor response to supportive care. Examples:
- Agitation, hallucinations, insomnia: atypical antipsychotics (e.g., risperidone)
- Depression: SSRIs (e.g., citalopram)
- The reported mean survival varies from approximately 3 to 10 years after diagnosis
- The median survival following diagnosis is 3 years.