Clinical Care Program of The Alzheimer Center

It is estimated that roughly 5.3 million Americans have Alzheimer's disease. And, according to the Alzheimer’s Association, this number includes 5.1 million people over the age of 65, as well as 200,000 to 500,000 people younger than 65 who have early-onset Alzheimer's and other types of dementias. The specific cause of Alzheimer’s disease is not entirely known but suspected causes include:

• Age and family history
• Certain genes
• Abnormal protein deposits in the brain
• Environmental factors
• Immune system disorders

Although the cause is not known, research has revealed information on Alzheimer’s disease. Brigham and Women’s Hospital researcher Dennis Selkoe, MD, has shown that build-up in the brain of a protein called amyloid beta is largely responsible for the degenerative effects of the disease, but there is still much to be learned.

What is known is that amyloid-beta forms plaques and clumps, inhibiting the brain's neurons and damaging their connections to one another. Other researchers are investigating the role of a protein called tau which causes "tangles" inside nerve cells, leading to the cells' death. Though less is known about tau’s significance and its interaction with amyloid-beta, researchers are confident that the cognitive decline associated with Alzheimer’s disease is related to the abnormal processes of these two proteins.

It is important to find specialists who are experts in the complexities of Alzheimer’s care and who have access to the latest discoveries in the diagnosis and treatment of this disease.

Each individual may experience symptoms differently. The most common symptoms of Alzheimer’s disease include:

• Memory loss that affects job skills, especially short-term memory loss
• Difficulty performing familiar tasks
• Problems with language
• Disorientation to time and place
• Poor or decreased judgment
• Problems with abstract thinking
• Misplacing things
• Changes in mood or behavior
• Changes in personality
• Loss of initiative
• Loss of ability to recognize who people are

Many older individuals may complain of memory problems, but still manage to independently perform all of their day-to-day tasks. Because their memory problems do not interfere with daily activities, these people do not meet criteria for a diagnosis of dementia or Alzheimer's disease. This cluster of symptoms, in which a person experiences significant problems with memory, language or other functions severe enough to be noticeable to other people and show up on tests of memory, but not serious enough interfere with daily life, is called mild cognitive impairment (MCI). Patient’s with MCI have problems with memory or thinking that are greater than those anticipated for his or her age.

The symptoms of Alzheimer’s disease may resemble MCI or other medical conditions. However, people with MCI do not have the more severe cognitive problems or functional changes that characterize Alzheimer's disease.

In the last few years, there has been a substantial increase in the number of studies focusing on patients with complaints of early memory loss. Although much more work still needs to be done, doctors and researchers have made significant progress in characterizing these early memory problems and their potential outcomes.

There is not a single, comprehensive test for diagnosing Alzheimer's disease. By ruling out other conditions through a process of elimination, a specialist can obtain a diagnosis of probable Alzheimer's disease — the only way to confirm a diagnosis of Alzheimer's disease is through autopsy.

Comprehensive care of our patients begins with a thorough evaluation. By establishing an accurate diagnosis from the beginning and identifying all the conditions that may be contributing to a patient’s impairment, we lay the groundwork for an effective treatment plan.

During the first meeting, one of our physicians will take the time to gather a comprehensive medical history from the patient. We encourage patients to bring family members to appointments and include them in this process as they can be a vital part of the evaluation and treatment plan. Patients and family members will be given ample opportunity to express their concerns and ask questions. The clinician who initially meets with patient often serves as the team leader and key contact person throughout the time a patient is receiving care at our Center.

After a detailed history is obtained, a series of assessments will be performed to further understand a patient’s condition. The goal is to carefully define a patient's pattern of deficits in order to identify the underlying neurological condition. The assessments are used to methodically narrow the field of possibilities until a definitive diagnosis is reached. Additional tests may be performed to determine whether other medical conditions are contributing to a patient's cognitive impairment.

These evaluations may include:

• Neurological exam – This exam assesses physical capacities, such as muscle strength, coordination, and gait (ability to walk), which can be impacted by injury to the nervous system.
• Mental state exam – This exam assesses cognitive abilities, such as memory, attention, language, reasoning, and visual/spatial functioning. It also addresses psychological issues involving mood and behavior.
• Neuropsychological and neuropsychiatric assessment – Depending on the history and initial evaluation, patients may be referred to other team members within our Center for more comprehensive cognitive testing or detailed neuropsychiatric assessment.
• Brain imaging – Imaging studies, such as an MRI scan, can identify conditions like cerebrovascular disease (strokes) or tumor that may be contributing to memory impairment. It also can detect patterns of brain atrophy (shrinkage) that point to certain underlying neurodegenerative processes, such as Alzheimer's disease. Additionally, a PET scan, which evaluates functional activity in the brain, may be useful in distinguishing Alzheimer's disease from other neurodegenerative conditions.
• Blood tests – Depending on what blood tests have been performed prior to a patient's visit, additional blood tests may be done to help rule out causes of brain dysfunction due to metabolic and endocrine disorders or infectious diseases.
• Spinal fluid– Sometimes a lumbar puncture is recommended to measure abnormal proteins in the spinal fluid that are associated with Alzheimer's disease and to rule out inflammation or infection.

Once the clinical team has established a diagnosis, they will develop a detailed treatment plan tailored to the needs of each patient. Treatment will be based on the type of memory disorder involved, the stage of the disease, contributing conditions, and the goals of the patient and their family.

Medications
Although there currently are no established treatments that can modify or reverse Alzheimer’s disease itself, medications are available to optimize a patient’s condition. FDA-approved medications are prescribed to help enhance memory and attention. Other medications may be prescribed to address mood and behavioral disorders. Often, these kinds of symptoms are managed by one of our neuropsychiatrists or geriatric psychiatrists, who are experts in this area.

Education
Our clinical team works with patients and their families to educate them about the disease, which can help everyone affected to understand the illness and plan for the future. Our social workers assist families in preparing for each stage of the disease. This may include connecting families to community services, providing advice about modifications to the home environment, organizing safety assessments, or ensuring that financial interests are protected. Social workers and other team members also provide guidance and support to caregivers, who have to deal with the many challenges associated with a neurological disease in a loved one.

Treating other conditions
Patients with Alzheimer’s disease and related memory disorders often do not have the capacity to compensate for other medical conditions that may affect brain function. Our clinical team works to identify any other medical conditions that may negatively impact the brain, such as depression, sleep disorders, pain, or vascular/heart disease. The Alzheimer clinical team also carefully reviews medications that patients have been taking for other conditions, and assesses whether side-effects may be contributing to their impairments. If a patient has other medical conditions or medication side-effects that may be disrupting brain function, we work closely with the patient’s other physicians to address these issues and improve function.

Psychiatry Services
Living with Alzheimer’s disease does have an impact on mental health and often can lead to depression. At Brigham and Women’s Hospital, Alzheimer’s disease patients have access to the services they need to cope with the challenges they face on a day-today basis.

Specialists within the Department of Psychiatry at Brigham and Women’s Hospital provide a broad range of programs, including specialized services that address the unique needs of patients living with chronic conditions, such as Alzheimer’s disease.

In addition to standard of care treatments currently available, Brigham and Women’s Hospital offers patients with Alzheimer’s disease the opportunity to participate in clinical trials of investigational agents being tested to try to slow the progression of Alzheimer’s disease. There are trials for all stages of Alzheimer’s disease, including prevention trials, mild cognitive impairment, and Alzheimer’s dementia, sponsored by the National Institutes of Health and other organizations, ongoing at Center for Alzheimer’s Research and Treatment (CART).

No patient is obligated to participate, but many are interested in the opportunity to increase our understanding of Alzheimer’s disease and potentially help us to discover more effective treatments that could benefit them or other patients.

Brigham and Women’s Hospital provides a multidisciplinary approach to patient care, collaborating with colleagues in other medical specialties. If your neurologist or neurosurgeon discovers an underlying illness or concern, you will be referred to an appropriate Brigham and Women’s Hospital physician or allied health professional for an expert evaluation.

Neurology and Neurosurgery Advances Newsletter article: Clinical Trial Evaluates Novel Approach to Alzheimer’s Disease Prevention