Dementia - An Overview of Dementia/Alzheimer's Disease

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Guest: Dr. David L. Bachman – Neurology

Host: Sally Smith – Author

Sally Smith – Author: Welcome to Age to Age. I am Sally Smith. Let’s talk. Today, we are lucky enough to have Dr. David Bachman with us. Among other roles, he is a Professor of Neuroscience at the Medical University of South Carolina. He is also Co-Director of the Alzheimer’s Clinical Research Program and Director of the Clinical Core of the South Carolina Alzheimer’s Disease Clinical Center. So, you can well imagine that Dr. David Bachman is very well able to talk to us today trying to find out more about the disease of well, not the disease of dementia, but the situation of dementia and the diseases that go to make it up. David, I have heard dementia described as an umbrella term, describing symptoms that other diseases actually cause. What in lay terms does this mean?

Dr. David L. Bachman – Neurology: This means that dementia is a collection of symptoms, it is a collection of problems, memory being chief among them, but people may have difficulty with thinking, they may have difficulty with finding words, they may have difficulty with deciphering complex visual situations and when they have more than one of these types of symptoms due to a brain disease or brain injury, we tend to use the term dementia.

Sally Smith – Author: Does this make it anymore difficult to analyze as a doctor that it presents so many different ways that it could have symptoms that tined other diseases outside the field of dementia?

Dr. David L. Bachman – Neurology: Well, there are many - this is not an uncommon situation in medicine where someone who present with a syndrome, with a collection of symptoms and signs and that’s a part of the art of being a physician is to work through these symptoms and signs and come up with a more specific diagnosis.

Sally Smith – Author: One time when I heard you speak, you delighted me as a layperson by using the metaphor of a house with shingles of on roof to describe the different variances of dementia, Alzheimer’s. I think we all have heard senile dementia, we have heard all these terms and nobody quite understands what it is. Would you give us the benefit of that metaphor?

Dr. David L. Bachman – Neurology: Well, there is ? that’s a tall order, but very briefly. If you just look at the brain of somebody externally with Alzheimer’s disease, you really cannot make a diagnosis. The abnormalities of Alzheimer’s disease are at the microscopic level and traditionally, what one sees using typical sorts of studies that one would use under microscope, one sees these so-called senile plaques and neurofibrillary tangles and they are composed of specific types of protein particularly that we think are one of the key elements that cause abnormalities and Alzheimer’s disease. Now, one of these key biochemical abnormalities is related to a protein called APP, amyloid precursor protein, and one of the ? when this amyloid precursor protein or APP is cut into pieces by enzymes within the brain, one of the pieces that comes up is called beta-amyloid and it’s the accumulation of this beta-amyloid slowly overtime, may be over years or decades that we think is the primary bad guy here in terms of causing Alzheimer’s disease. Now, what happens as we all have APP, we all have beta-amyloid, and for most of this is APP turns over and it was the analogy that you like so much was if you had tiles on a roof and the tiles would get broken and you had a carpenter up on the roof who would be tossing these tiles, who would be replacing the tiles, and tossing the broken pieces of tile into the yard, but you may have a carpenter who is a little bit careless and is tossing some of these broken pieces into the attic of the house and over a period of time, these broken pieces of tile, which is the metaphor for beta-amyloid, may accumulate to an excessive degree and if you have a house, you know it is going to happen. The ceiling is going to sag, the ceiling may fall in, eventually the whole house may fall in, and one theory is that it is the accumulations of either beta-amyloid or other types of broken pieces from these proteins that are being metabolized like APP that are sort of choking the cell and eventually cause the death of the cell.

Sally Smith – Author: Well, that sounds a lot more easy to understand than the descriptions I have heard like lately and as I think you said that evening, sometimes when the cells, this metaphor of the shingles, when this particular compound goes into one room, it causes something like Parkinson’s, when it goes into another, it causes something more like what we would consider Alzheimer’s and so this connect, but ? so the goal would then be to keep clearing out the attic and is that what research is based on?

Dr. David L. Bachman – Neurology: Right, a lot of diseases as you mentioned Parkinson’s disease for instance, there is a different protein that accumulates there, protein called alpha-synuclein, but it’s the same idea. A lot of these cells called degenerative neurological illnesses like Alzheimer’s disease, Parkinson’s disease, Lewy body disease, and Huntington disease may be caused by an excess accumulation of particular proteins that the brain, particularly the nerve cells, just can't seem to metabolize, just can't seem to get rid of and so they accumulate to an excessive degree and eventually they caused problems.

Sally Smith – Author: So, is research geared more toward ? this is fascinating, so, is research geared more toward stopping the overproduction or may be it’s not even overproduction, may be it’s a normal production, or is it clearing out the attic and doing the spring cleaning on a more regular basis with some drug that keeps you sloughing these compounds. How does that stand?

Dr. David L. Bachman – Neurology: There are multiple approaches that are being taken. Some of the drugs that are being looked at, can prevent the ? can remove the beta-amyloid as if you had another carpenter who was trying to clear the tiles out of the attic, some of the drugs that are being looked at, are not affecting the beta-amyloid levels, but are preventing the beta-amyloid from sort of clumping together and that may be a critical event in terms of the beta-amyloid producing difficulty within the nerve cells. Other drugs are looked to see what sort of toxic affects. This beta-amyloid may have such a little bit more downstream. So, there is not one single approach that people are taking. There are multiple different approaches and nobody knows at this point, which approach is going to work best.

Sally Smith – Author: Well, I can certainly understand the drive for the multiple approach, because in some literature from the center on ageing, of course, here at MUSC, one the tables that is in the annual report is the projected number of Alzheimer’s patients in South Carolina, this is - listeners out there, this is just in South Carolina we are talking these numbers and listen to how quickly they go up, in 1995, they were around 31,000 people, 5 years later; there were almost 15,000 more people, then in 2005, it was almost 60,000 people, it almost doubled in 10 years. Then you go up 10 more years and it is almost doubled again, where it a little over 90,000 people; 90,000 people in one state alone we are talking here and in 2025, it is projected at over a 125,000 Alzheimer’s patients. Now, my thought here is, number one, we are looking at a gigantic problem that is growing by leaps and bounds and number two, why, are more people getting it, are more people living longer?

Dr. David L. Bachman – Neurology: I am often asked that question. People hear so much about Alzheimer’s disease; is Alzheimer’s disease occurring more commonly? And I think the answer is probably not. Alzheimer’s ? there are couple of things, I think that contribute to these numbers. First of all, back in the battle days, we used to refer old peoples getting senile, which basically was a polite term saying well, they are old, what do you expect? So, it wasn’t even necessarily viewed as a disease, in fact, just because somebody is in their 70’s and 80’s, doesn’t mean that they are having memory problems, especially severe memory problems that it’s a part of normal ageing, it’s a disease. Even though, it occurs more commonly in older people just because something occurs more commonly, doesn’t mean that it’s normal. About half of the men in their mid 80’s would develop prostate cancer; it doesn’t mean they have senility of the prostate. It means they have prostate cancer, which just happens to be very common in older men. So, we are making diagnosis of Alzheimer’s disease more commonly where when previously, the symptoms may have just been overlooked or shoveled under the rug and also where an ageing population and that more than anything else is driving the increase in Alzheimer’s disease.

Sally Smith – Author: Well, it is staggering really to read how much it is growing. Now, why do people get it?

Dr. David L. Bachman – Neurology: Very good question to which there are not a single good answer. We know that there are clear genetic predispositions to Alzheimer’s disease. There is one gene in particular called Apo E, apolipoprotein E that comes in different forms. Everybody has this gene, everybody has two forms of this gene, one from their mother and one from their father, but we know that people who have certain forms of this gene are much more likely develop Alzheimer’s disease than people who don’t, so that’s one key, but there are many people that have the bad form of this gene who don’t get Alzheimer’s disease. So, this gene by itself is not the answer. There are also clearly other factors that play a role. One of the things that people have been very interested in lately are risk factors that we commonly associate with heart disease, things like high blood pressure, diabetes, being overweight, and elevated cholesterol. These typically are factors that people are comfortable associating with heart disease, there is a very large growing body of evidence that suggest that these factors may influence risk of Alzheimer’s disease and so there is saying that is sort of developing now in the Alzheimer’s community and thinks that are heart healthy are probably brain healthy.

Sally Smith – Author: For people who are trying to avoid dementia by playing brain games and there were some very fascinating discovery, now what are your thoughts on that subject?

Dr. David L. Bachman – Neurology: This is a very, very hot topic, partly driven, in fact largely driven by the video game companies. They have sort of exhausted their typical target population, which is boys, 14 to 28 years of age and so they are looking around for other potential populations and their eyes lid upon all of us aging baby boomers and what are paranoid fears. Paranoid fear is Alzheimer’s disease, so they have come up with these various games that have different modules and the idea is that not only is mental stimulation good for you, which I think it is actually, but that there may be a specific pattern of mental stimulation, a specific pattern of games and if you follow those, that pattern, that you will enhance brain function and may be potentially prevent Alzheimer’s disease. There is some limited data to suggest that doing these sorts of games can be helpful. There is also some data to suggest that it doesn’t make any difference at all and there is no data to show that playing these games prevent Alzheimer’s disease, so time will tell, but in the meantime, if you love to play video games, they are out there.

Sally Smith – Author: I love that answer. What are the early warning signs? If you are a person living in a family and you begin to notice certain things what are usually the early warning signs?

Dr. David L. Bachman – Neurology: The Alzheimer’s Association has a very nice website I would refer you too, that is  HYPERLINK "" and on that website, you will find the 10 warning signs of Alzheimer’s disease, but just to give you some examples from those 10 warning signs, first of all obviously the most concerning thing for Alzheimer’s disease is memory. Now, as we age, we all have some minor memory problems. We all misplace our keys, our glasses, where did we park our car, those are not early signs of Alzheimer’s disease, but the person who has driven to the store not only can't find a car, but doesn’t remember that they had driven to the store. The person who misplaced personal items and they show up in odd places like a purse showing up in the refrigerator. The individual who is repeating themselves or asking the same question over and over again to family, perhaps somebody has been on a trip recently with the family and it’s not just a matter that they couldn’t remember what hotel they stayed at, but they have very dim recollections of even being away on a trip; those are much more concerning in terms of memory difficulty.

Sally Smith – Author: You know it’s interesting to me in another book that you recommended to me, the 36-hour a day. I was very taken with the facts as I read it that the authors were quite careful to say that the book was written not just for people who might have a family with an Alzheimer’s or these warning signs unfolding or these issues to deal with, but it was very much also written for the people who might be seeing themselves walking this road themselves, but that was very surprising to me and yet I see it with these huge numbers and the many different ways these things present. Obviously, there are going as to be many people who come in and out of it, as they progressed down and how much is it easier, if it just comes on heavily on to you or does it help people that have the disease to read these books and know that this is where they may be going. I was just very interested in that.

Dr. David L. Bachman – Neurology: That’s a tough question to answer. I would tell you that Alzheimer’s disease in general is a very slowly progressive illness. It’s not something that’s going to start just with in a few months or few weeks. So, if somebody has had very acute, very sudden onset of memory problems or thinking problems over just a number of weeks or months, it’s probably not Alzheimer’s disease and probably I would say certainly, they need a very thorough medical evaluation. There are things like vitamin deficiencies, thyroid problems, strokes, blood clots, or hydrocephalus; there is a whole slew of things that can mimic Alzheimer-type symptom, you certainly need a thorough evaluation. There are many patients that come to my clinic concerned about their memory. A very, very few of them turned out to have Alzheimer’s disease. Most of them are, what we call, the worried well. There is a group of people that sort of fall into a gray zone who have mild memory difficulties, but don’t have clear dementia and the term that is used now-a-days to refer to them something called mild cognitive impairment or MCI. This is a very interesting group of individuals. It’s a group that we are looking at in terms of various research studies as well.

Sally Smith – Author: If something, someone in your family you feel is you come to Sunday dinner and the purse is on the refrigerator and this is the 10th thing like this it’s happened. What are the first action steps that you as a concerned potential caregiver would take?

Dr. David L. Bachman – Neurology: This is a tough problem sometime because in more than half the cases, the person who has the problem will deny that they are having any problem at all and that’s very typical especially of early Alzheimer’s disease. Some patients with early Alzheimer’s disease do understand if they a problem, although they may sometimes underestimate the significance of that problem, but many patients with early Alzheimer’s disease deny that there is any problem and then it becomes difficult for the family to get help for them. Probably, the first step is to take that person to see their own family physician either with and either accompany the patient to the family physician or if the patient is reluctant to do that, you can certainly send a note to the family physician alerting that person as to your concerns and the family physician may undertake certain steps his or herself or they may refer that person to a specialist.

Sally Smith – Author: Is there a great deal of anger associated with the patient who is first having to be looked at with the idea of Alzheimer’s?

Dr. David L. Bachman – Neurology: There can be in many older individuals? resent the fact that people are questioning their memory or questioning their ability, they may become angry, they may become resistant, they may refuse to see the physician; it can be a very difficult situation. I have been involved in some situations where the patient refused to be seen, refused to get help. The patient’s condition deteriorated to the point where the family eventually had to go to court to get a court order to require that person to be evaluated. There have also been situations where the person has refused to get help, refused to be evaluated and then somebody unscrupulous has come in and take an advantage of them, so there are some very sad stories out there.

Sally Smith – Author: I would think on flip side of the anger might be real depression.

Dr. David L. Bachman – Neurology: Some depression can be a feature of early Alzheimer’s disease, usually not a feature of mid to late Alzheimer, although it can be and that can be confusing sometimes. What some physicians will do in certain cases where there is a question between depression or early dementia is that I will treat the person for a period of time with an antidepressant, see how that affects their mood and then see if the memory or some of the other cognitive difficulties improve.

Sally Smith – Author: Well, I was thinking if the depression from that point of view too in that if you went in and you found that you did have early Alzheimer’s, but you had enough moments of clarity where you saw the picture with some overview and normalcy would you - sort of ? do people tend to give up and just quite down and just feel defeated, may be that’s a better word than depression.

Dr. David L. Bachman – Neurology: We actually did a study a number of years ago looking at the issue of whether patients with Alzheimer’s disease should be told that they have Alzheimer’s disease and what we found was that, although a small percentage of patients did become upset when they were told the diagnosis, this was generally very short-live. Most patients actually welcome to know that there was a reason they are having difficulties, they knew that they were having some sort of problem, they were concerned that they were ?losing their mind,? and I think this was very helpful for them. I tell you little story that I think was very instructive to me. This was from a many years ago, I had a an older women and her husband who came to see me and I evaluated her for Alzheimer’s disease and the husband was very prominent guy, very outspoken guy and we sat down like we ordinarily do and I went over all the test results and I told them together, as I think you have Alzheimer’s disease, this is what Alzheimer’s disease, these are the treatments that are potentially available for Alzheimer’s disease, this is where we go from here, this is what we need to do, these are the steps we need to take and the husband came up to me later and in private he said you know, I was very angry with you when you told my wife that she had Alzheimer’s disease, but then I realized that we have been together for more than 50 years and we have never had any significance secrets and now we don’t have to.

Sally Smith – Author: You know, I love that story because I know with my mother-in-law who lived with us for a time that she felt so churning, I guess that’s the word that I want to say so upset about some of these things that weren’t right like she couldn’t remember if she fed the dog or she couldn’t get in the bed and she was having it and once it was out there the times when ? of course there was -- she was unusual, I think and that she real periods of clarity where she would say it’s like every night I go to sleep and someone is erasing my memories and on wake up the next day, she would have a wonderful, beautiful insights like that, but then also she think her house was on fire the next day. So, in these moments, she ? of clarity - she could be free and also I think sometimes someone in your position David, as the authority, the professional wearing the white coat in the hospital environment can say to these people, this is what needs to happen in a way, but that fabulous husband of 50 years could have a very difficult time saying.

Dr. David L. Bachman – Neurology: No, I do think it’s the physician’s responsibility to inform the patient of what’s going on and it also does a couple of things that really empowers the patient. The patient can potentially choose to participate in research studies or to take medication or otherwise you are making a secret about why you may want to put them on medication. It also empowers the family to take other legal steps or financial steps or to start planning and doing certain things, so I do think that having as specific diagnosis as possible as important, and I think everybody in the family including the patient should be on the same path.

Sally Smith – Author: Do you find often that was one of my thoughts that people do get their legal affairs, did they take that seriously once they hear that and make sure they have the will and different things situated properly?

Dr. David L. Bachman – Neurology: Well like many things in life, some people do and some people don’t. The thing though that’s important to remember is that after the diagnosis of Alzheimer’s disease is made, you can’t get long-term care insurance, so those are the types of things you have to actually do beforehand, but there are other things that can be done especially in a patient with early Alzheimer’s disease can certainly participate in making a will, certainly participating making advanced directives, can usually participate in doing a durable power of attorney, or durable healthcare power of attorney, so there are many things that somebody with early Alzheimer’s disease can do so. I certainly strong there may be certain types of financial trust that need to be set up looking ahead to the financial needs of that individual, there are many things that can still be done.

Sally Smith – Author: Well, when you say participate in making a will or participate in making a durable of power of attorney, I mean are they as having been diagnosed with early Alzheimer’s, are they in the position to sign that document?

Dr. David L. Bachman – Neurology: I actually just talked to the Elder Law Section of the State Bar Association just about a month or so go on this topic, it varies a little bit from patient to patient, but in general in patients at the very early stages of Alzheimer’s disease, they are still able to carry out these tests. In fact in doing little researches, I was fascinated, there is a certain level where you are still able to carry out your financial affairs, then you deteriorate further, there is a certain level where you can still make a will that you are pretty impaired and below that according to Texas State Law, below that you are still competent to get married.

Sally Smith – Author: They have got a right (laughing).

Sally Smith – Author: So, a (voice overlap) lowest level of competency in the competency to get married and I am just ? that’s no editorial comment here, I want you to know that.

Sally Smith – Author: The world is a fascinating place; I think we both agree on that. Let me ask you this, what skills do you bring into play to be able to take on a situation like this, it’s pivotal to people’s happiness and yet you can offer them care really.

Dr. David L. Bachman – Neurology: Well, there is no cure for Alzheimer’s, that is certainly true, but there are number of drugs in the market that may make a big difference in someone’s life in terms of stabilizing their symptoms for a period of time. There was a study done sometime ago in with particular drug looking at moderate-to-severe Alzheimer’s disease and one of the things that the drug showed is over the course of a month that those patients who were on the drug, the caregiver required 40 hours a month, less time to work with that patient than without the drug and that’s a big difference in the quality of life not only the patient but the quality of life for the caregiver as well. Some times patients with Alzheimer’s diseases have depression and you can treat that, sometimes they have anxiety and you can treat that. Certainly, part of my job is to helping patients and their families recognizing importance of staying mentally active and physically active, also to advice them on safety issues such as driving for instance is an important part of what I do. So, there are many supportive elements to caring for somebody with Alzheimer’s disease.

Sally Smith – Author: I want to thank you so much. There is so much we can talk about and I hope you will come back to and talk with me.

Dr. David L. Bachman – Neurology: Oh, thank you Sally and I want to thank you for having me.

Sally Smith – Author: Well, it was a delight and I would like to thank you for taking the time to come. I would also like to thank my producer Betsy Reves and thank all of our listeners for joining us. Please note that your suggestions are very welcome. We have a Website where you can make suggestions, comments, topics you would like to hear about and we would like to have those very much. This is Sally Smith on Age to Age saying good bye and wishing you courage and joy on your journey. We are all connected.

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