By Dr. CHRISTOPHER J. MORGAN
According to the Ontario Alzheimer’s Society, one in 20 Canadians over age 65 and one in four of those over age 85 are affected by Alzheimer’s disease. With Canada’s aging population, dementia and Alzheimer’s is predicted to be a major health concern in the coming decades. With a provincial election to be held in a couple of weeks and a federal election next fall, we should be asking our political hopefuls what polices and resources do we have or plan to have in place in order to effectively care for individuals living with Alzheimer’s and provide proper support for their families and care-givers.
In 2013 I shared my families’ personal experience with Alzheimer’s, in particular, some challenges we faced at home, with family relatives and within the health care system. I promised to include a medical specialist’s insight on this topic.
To gain a geriatrician’s perspective on the topic of dementia and Alzheimer’s, I invited Dr. Mireille Norris to join the conversation. Dr. Norris, originally from Haiti, completed her medical degree at the University of Montreal in 1993 and went on to complete her general internal medicine in 1996 and specialized geriatric certification at University of Toronto in1999. She then completed a Master’s Degree in Health Science from the School of Health Policy Management and Evaluation in 2001, also at the University of Toronto. Dr. Norris is cross-appointed in the Internal Medicine and Geriatric Divisions at Sunnybrooke Hospital in Toronto. Below, Dr. Norris provides answers to a few questions on Alzheimer’s disease.
What is dementia?
Dementia is a syndrome as opposed to a disease. It literally means out of mind. In order to meet the criteria of dementia in relation to normal aging there has to be a demonstrated loss of memory plus one or more of the following: executive function, language, insight, judgement and complex coordinated movement (apraxia). These impairments must result in loss of function, such as social function and independence related to the loss of cognitive changes, in other words not caused by any known disease (stroke, pneumonia, heart failure, etc.). Dementia is a chronic condition, typically it has been developing over 2-3 years before the person is brought to the doctor. Some possible causes of dementia include alcohol, the effects of prescription and non-prescription drugs, viral infections, HIV, multiple head injuries and anoxic brain injury (injury to the brain because of lack of oxygen).
What is Alzheimer’s disease?
Alzheimer’s is a disease as opposed to a syndrome. It is slow and insidious in development, it too is related to cognitive impairment and aging. To diagnose Alzheimer’s, we must eliminate other causes of dementia. This is why we need to do blood work, imaging and testing to rule in (or rule out) these possible causes (viral infections, stroke). Because Alzeheimer’s is slow and progressive, people can get used to grandma’s change in behaviour and falsely attribute these changes to normal aging.
What are some of the early signs and symptoms of Alzheimer’s?
Deficits in memory, however it is normal to have difficulty with encoding information such as remembering names, license plate and phone numbers with normal aging. With Alzheimer’s, in addition to failing to remember where the keys are and cousin Earl’s name, one begin to forget events, such as a sister’s birthday, or a brother’s wedding, one also begins to have difficulty finding the right words, become repetitive in speech, and is vague in description. One may want to tell a story but forget the beginning of the story.
Another characteristic of Alzheimer’s is the loss of function in the reverse order in which the skill was achieved in relation to the normal level of function. It is fundamental to know the prior level of function as well as level of education of the individual when diagnosing Alzheimer’s. For example, my first language is French, then I learned English and finally Spanish. In my case I would lose function in Spanish first, then as the disease progresses I would loss efficiency in English and finally in French. This is not always easily detected.
Who is at risk of developing Alzheimer’s?
The greatest risk factor is age. Above 65 it’s 8 per cent, above 85 its 38 per cent, above 90 its 50 per cent. Other risk factors include family history, head injury, low education, alcohol and substance abuse, smoking and some medical conditions such as stroke, diabetes, hypertension, multiple sclerosis, Parkinson’s, Down’s syndrome and depression. There is no cultural predisposition in the literature. Women are also at greater risk but that may be related to them living longer.
How is a diagnosis made?
A diagnosis of Alzheimer’s is based on ruling out other possibilities such as stroke, alcohol, HIV, etc. The diagnosis is then determined by pathology. Alzheimer’s has been around for over 100 years. Many patients have donated their brains after death, and upon examination of the brains we have found characteristic damage to brain cells. The big problem is that we do not know is what triggers the damage of brain cells.
If I believe someone in my family may have dementia or Alzheimer’s, what would be my first step towards helping them?
Bring them to the family doctor to begin to determine if the changes are related to a treatable disease or if it is in fact Alzheimer’s. This is the first step.
As a geriatrician when does someone typically come under your care and what types of treatment and care do you provide?
Typically I see someone when it is not clear they have Alzheimer’s because there may be other comorbidities. For example it may not be Alzheimer’s but actually depression. I usually see people who are very sick and I have to determine if any of the prescribed meds or other comorbidities (disorder or disease) is contributing to their condition.
What tips can you share with us to help family members and care-givers deal with some of the challenging behaviours like increased irritability or wandering?
Try to identify any antecedents (triggers) to behaviour (acting out) and any consequences. Document and observe the behaviour, then bring the information to the doctor. For example, are they more irritable when there is more noise in the house? What were the triggers and what can calm the behaviour. For example, does their favourite music help calm them? If we can help modify the environment or behaviours we can help them without the use of drugs which can come with side effects or complications including increase morbidity and mortality.
In the patients that you serve, what are some of the barriers to addressing Alzheimer’s and how do you overcome them?
I think one big barrier to diagnosing dementia is the stigma associated with the condition. It is sometimes seen as a mental health issue instead of a neurological condition. I believe there is misinformation also which contributes such as it is seen as a normal part of aging and therefore families do not seek help in a timely way.
What area(s) of Alzheimer’s (or dementia) research are showing promise for the future?
Presently there is much research in the molecular aspect of the disease as well as research into vaccines that can alter the progression of the disease. There is also much research in neuroimaging.
What (if any) recommendations would you make to improve how our health care system addresses Alzheimer’s Disease?
Part of the problem is how our society values older people. As a society we need to counter ageism and value older people more. If we do so we will increase education and awareness of Alzheimer’s. Also, before putting money and effort to finding a drug solution we need more emphasis on an effective public health campaign similar to what we are seeing now around mental health.
In my view the better strategy is prevention. Efforts in good nutrition, exercise, good sleep, lowering the risk of head injuries, role of concussion in sports in general, awareness around stroke and so forth is very important. Lastly, we must remember that when an older person is sick, there is a family impact and an economic impact. Over 50 per cent of care-givers experience depression, loss productivity, and stress leading sometimes to heart attacks.
Thank you, Dr. Norris for your insights and comments. If you wish to contact Dr. Norris, her office is located at Sunnybrook Health Sciences Centre. She can be reached at 416-480-6100 x 7840.
Dr. Christopher J. Morgan is the director of Morgan Chiropractic & Wellness, an interdisciplinary health centre in Toronto, and the Past President of the Black Health Alliance, a network of community organizations, health professionals and community members working in partnership to advance the health and well-being of the Black community. He can be reached at 416-447-7600 or firstname.lastname@example.org