Signs and Symptoms

The early symptoms of Alzheimer disease can be missed because people may think they are due to "natural aging." The following are common signs and symptoms of Alzheimer disease:

Psychological Symptoms

• Memory loss that gets worse, starting with forgetting recent events and new information, progressing to not recognizing friends and family members
• Difficulty concentrating
• Difficulty understanding words, completing sentences, or finding the right words
• Getting lost in familiar places
• Restlessness
• Depression
• Aggression, agitation, anxiety, restlessness
• Distrusting others
• Withdrawal, disinterest, hostility, or loss of inhibitions

Physical Symptoms

• Problems with movement or coordination
• Muscle stiffness, shuffling or dragging feet while walking
• Insomnia or change in sleep patterns
• Weight loss
• Incontinence
• Muscle twitching or seizures

Causes

Researchers are not sure what causes Alzheimer disease. Genetics and the environmental factors may both contribute. Recent research indicates that free radicals (molecules that damage cells and DNA) may play a role.

The brains of people with Alzheimer disease have a buildup of two types of proteins. Clumps of abnormal cells called plaques, are made of beta-amyloid protein. These plaques build up between neurons and may stop them from communicating with each other. Inside nerve cells are tangles, made of twisted tau protein. The brain needs tau protein to function, but in people with Alzheimer disease the protein gets twisted, which may damage brain cells.

People with the APOE-e4 gene are more likely to develop Alzheimer disease, it is known as a "risk gene" for the condition. But scientists think other genes may be involved. And even people without inherited genes for the disease can get Alzheimer disease.

Risk Factors

The causes and risk factors linked to Alzheimer disease are not entirely clear but include:

• Family history of Alzheimer disease
• Older age. The risk of getting Alzheimer disease doubles every 5 years after age 65.
• Long-term high blood pressure
• Heart disease
• History of head trauma. One or more serious blows to the head may put a person at increased risk.
• Downs syndrome
• Education level. People with higher levels of education are less likely to develop Alzheimer disease.

Diagnosis

There is no single test for Alzheimer disease. A true diagnosis can be made only after a person dies and an autopsy is done on the brain.

However, Alzheimer disease usually has a pattern of symptoms. A doctor will start by ruling out other possible causes. The doctor will ask questions about medical history and symptoms and do a physical exam, including a neurological exam.

The following tests may also be used:

• Mental status evaluation. To test memory and attention span. It can also show any problems in problem-solving, social, and language skills.
• Genetic test. Using a blood test for the APOE-e4 gene. Having the gene may suggest Alzheimer disease, but it does not always mean someone has the disease.
• Imaging tests such as CT, MRI, or PET scans.

In the early stages, brain scans may be normal. In later stages, an MRI may show certain brain areas have gotten smaller. While the scans do not confirm the diagnosis of Alzheimer disease, they rule out other causes of dementia, such as stroke and tumor.

Preventive Care

No one knows exactly how to prevent Alzheimer disease, but eating a healthy diet and exercising regularly help.

• Eating more fatty, cold-water fish, such as tuna and salmon, may lower your risk of dementia. Fish have high levels of omega-3 fatty acids, which are good for the heart and the brain. Eating fish at least 2 to 3 times per week provides a healthy amount of omega-3 fatty acids.
• Antioxidants, such as vitamins A, E, and C (found in darkly colored fruits and vegetables), may help prevent damage caused by free radicals.
• Keeping blood pressure levels normal may reduce the risk for Alzheimer disease.
• Keeping mentally and socially active may help delay the start or slow the progression of Alzheimer disease.

Treatment

The goals in treating Alzheimer disease are to:

• Slow progression of the disease
• Manage behavior problems, confusion, and agitation
• Provide a safe living environment
• Support family members and other caregivers

There is no cure for Alzheimer disease. The most promising treatments include lifestyle changes and medications.

Lifestyle

Studies show the following lifestyle changes may help improve behavior in people with Alzheimer disease:

• A regular walk with a caregiver or trusted companion may improve communication skills and reduce the chance of wandering.
• Bright light therapy may reduce insomnia and wandering.
• Calming music may reduce wandering and restlessness, boost brain chemicals, and improve behavior.
• Pets can sometimes help people improve behavior.
• Relaxation training and other exercises that require focused attention may help boost social interaction and make it easier to do tasks.
• The Safe Return Program, started by the Alzheimer's Association, encourages identification bracelets, wallet cards, and clothing labels for people with Alzheimer disease. Information is stored in a national database and given to authorities when a person is reported missing.

Medicines

Several drugs are available to help slow the progression of Alzheimer disease and possibly improve mental function.

Cholinesterase inhibitors: increase the amount of acetylcholine in the brain. Side effects can include nausea, fatigue, and diarrhea. This class of drugs includes:

• Donepezil (Aricept)
• Rivastigmine (Exelon)
• Galantamine (Razadyne, formerly called Reminyl)

Memantine (Namenda): This drug works by regulating a chemical messenger called glutamate, which is involved in information storage and retrieval in the brain. Side effects may include headache, constipation, confusion, and dizziness. It is the only drug approved for treatment of moderate-to-severe Alzheimer disease.

The following medications may also ease the symptoms related to Alzheimer disease:

• Selective serotonin reuptake inhibitors (SSRIs) are antidepressants that boost a brain chemical called serotonin. They are used to treat depression that often happens in the early stages of Alzheimer disease.
• Methylphenidate (Concerta) is a stimulant that is often prescribed for attention deficit hyperactivity disorder. It is sometimes used to treat withdrawal and apathy in people with Alzheimer disease.
• Carbamazepine is an anti-seizure drug that stabilizes sodium levels in the brain. It is sometimes used to treat agitation in people with Alzheimer disease.

Nutrition and Dietary Supplements

People with Alzheimer disease may need help with their diet. They often forget to eat and drink and can get dehydrated.

Follow these tips for a healthy diet:

• Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes) and vegetables (such as squash and bell peppers).
• Eat foods high in B-vitamins and calcium, such as almonds, beans, whole grains, dark leafy greens (such as spinach and kale), and sea vegetables such as kelp and dulse.
• Eat more high-fiber foods, including beans, oats, and root vegetables (such as potatoes and yams).
• Avoid refined foods such as white breads, pastas, and especially sugar.
• Eat fewer red meats and more lean meats and cold-water fish.
• Use healthy oils in foods, such as olive oil
• Reduce or eliminate trans-fats, found in commercially-baked goods, such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
• DO NOT smoke.
• Drink 6 to 8 glasses of filtered water daily.
• Exercise at least 30 minutes daily, 5 days a week.

Always tell you doctor about any herb or dietary supplement you are taking, because some could interact with other medicines. These supplements may help with some symptoms of Alzheimer disease, although more research is needed:

• Phosphatidylserine shows promise in several studies. Phosphatidylserine is a substance that is found in the brain. It may raise levels of brain chemicals involved with memory, according to several studies. It may work best in people with mild symptoms, and may stop working after about 16 weeks. DO NOT take phosphatidylserine if you are taking blood thinners such as warfarin (Coumadin), clopidogrel (Plavix), or aspirin. Use caution if taking it with ginkgo. In both cases, your risk of bleeding may increase. Phosphatidylserine may cause sleeplessness in some people. It may interact with other medicines for Alzheimer disease and glaucoma. Ask your doctor before taking it.
• Antioxidants may protect against developing dementia. They may even slow the progression of dementia. In some, but not all, studies, vitamin E combined with Aricept seemed to slow mental decline in people with Alzheimer disease. Another antioxidant, coenzyme Q10, may help the brain get more oxygen. It may also help blood clot, so blood-thinners may not work as well as they should. The skins of dark berries also provide valuable antioxidants. Try eating half a cup of frozen blueberries daily, freezing them helps your body better absorb the antioxidants.
• Vitamins:biotin (300 mcg); B1 (50 to 100 mg), B2 (50 mg), B6 (50 to 100 mg), B12 (100 to 1,000 mcg), folic acid (400 to 1,000 mcg). No scientific evidence shows a direct benefit, but B12 and folic acid lower the levels of an amino acid in the blood that is often high in people with Alzheimer disease. Shots of B12 may work better than pills.
• Zinc (30 to 50 mg per day) is often low in elderly people, and may help improve memory. Zinc can sometimes displace copper in the body, and at higher than 45 mg, can potentially weaken the immune system over time.

Herbs

Herbs may strengthen and tone the body's systems. As with any therapy, you should work with your health care provider before starting treatment. You may use herbs as dried extracts (capsules, powders, or teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups per day.

• Ginkgo (Ginkgo biloba) shows some evidence for treating early Alzheimer disease and vascular dementia. However, one large randomized, double-blind, placebo-controlled study found that ginkgo did not prevent Alzheimer disease or dementia. If you are taking blood-thinning medication, such as warfarin (Coumadin), clopidogrel (Plavix), or aspirin, DO NOT use ginkgo without your doctor's supervision.
• Huperzine A, a chemical made from the plant Huperzia serrata, may improve memory in both vascular and Alzheimer dementia, according to several studies in China. More research is needed. Huperzine A may slow your heart rate and can interact with many medications. DO NOT take huperzine A if you have liver disease, or if you are about to have anesthesia. Huperzine A may be associated with gastrointestinal blockage. There is also concern that Huperzine A may worsen emphysema. Talk to your doctor before taking huperzine A if you already take medicine to treat Alzheimer disease.
• American ginseng ((Panax quinquefolium) improves blood flow to the brain. Use with caution if you have high blood pressure, diabetes, or a history of hormone-sensitive conditions, and talk to your doctor before combining ginseng with gingko.
• One study found that lemon balm (Melissa officinalis) helped improve mental function in people with mild-to-moderate Alzheimer disease. Lemon balm may act like a mild sedative.
• Bacopa (Bacopa monnieri) leaf extract, called Brahmi, is used in Ayurvedic or Indian medicine to improve brain function and learning. However, no scientific studies have looked at bacopa to see whether it might work for dementia. One study found that 300 mg per day for 12 weeks seemed to improve brain function in healthy people. Bacopa may slow your heart rate. People with stomach ulcers, intestinal problems, or emphysema should not tale bacopa.
• Vinpocetine (isolated from Vinca minor) may increase blood flow to the brain and help the brain use oxygen better. More research is needed. Vinpocetine may interact with blood-thinning medicines such as warfarin (Coumadin), clopidogrel (Plavix), and aspirin.

Acupuncture

Small studies have shown that transcutaneous electrical nerve stimulation (TENS), a technique used in physical therapy and certain types of acupuncture, may improve memory and daily living skills in people with Alzheimer disease. More studies are needed.

Massage and Physical Therapy

People with Alzheimer disease become frustrated and anxious because they cannot communicate well with language. Using touch, or massage, as nonverbal communication may help. In one study, people with Alzheimer disease who got hand massages and were spoken to in a calming manner had lower pulse rates and did not engage in as much inappropriate behavior. Health care professionals think that massage may help not only because it is relaxing, but because it provides a form of social interaction.

Mind-Body Medicine

Music Therapy

Music therapy, using music to calm and heal, cannot slow or reverse dementia. But it may improve quality of life for both a person with Alzheimer disease and their caregiver. Clinical reports suggest that music therapy may reduce wandering and restlessness and increase chemicals in the brain that promote sleep and ease anxiety. Studies also show that listening to music improves mood.

Aromatherapy

Preliminary studies suggest aromatherapy, including lavendar may help alleviate agitation among people who have dementia.

Support for the Caregiver

Studies suggest that caregivers who receive emotional support have better quality of life, which also benefits the people they care for.

Other Considerations

Alzheimer disease can lead to many complications, including:

• Falls
• "Sundowning", withdrawal or agitation in the evening
• Malnutrition and dehydration
• Infection, from urinary tract infections or pneumonia
• Asphyxiation, stopped breathing
• Harmful or violent behavior toward self or others
• Suicide
• Poor health and support due to caregiver burnout
• Physical and emotional abuse, including neglect
• Heart disease

Alzheimer disease gets worse over time, however, people with the disease may live for many years. Those with a long-standing history of high blood pressure are more likely to get worse faster.

Supporting Research

Aboukhatwa M, Dosanjh L, Luo Y. Antidepressants are a rational complementary therapy for the treatment of Alzheimer's disease. Mol Neurodegener. 2010;5:10.

Akhondzadeh S, Abbasi SH. Herbal medicine in the treatment of Alzheimer's disease. Am J Alzheimers Dis Other Demen. 2006;21(2):113-8.

Begum AN, Jones MR, Lim GP, Morihara T, Kim P, Heath DD, et al. Curcumin structure-function, bioavailability, and efficacy in models of neuroinflammation and Alzheimer's disease. J Pharmacol Exp Ther. 2008 Jul;326(1):196-208.

Bell DR, Gochenaur K. Direct vasoactive and vasoprotective properties of anthocyanin-rich extracts. J Appl Physiol. 2006;100(4):1164-70.

Christen Y. Oxidative stress and Alzheimer disease. Am J Clin Nutr. 2000;71(suppl):621S-629S.

Crawford TJ, Higham S, Mayes J, Dale M, Shaunak S, Lekwuwa G. The role of working memory and attentioonal disengagement on inhibitory control: effects of aging and Alzheimer's disease. Age (Dordr). 2013;35(5):1637-50.

DeKosky ST, et al; Ginkgo Evaluation of Memory (GEM) Study Investigators. Ginkgo biloba for prevention of dementia: a randomized controlled trial. JAMA. 2008 Nov 19;300(19):2253-62.

Diamond BJ, Shiflett SC, Feiwel N, et al. Ginkgo biloba extract: mechanisms and clinical indications. Arch Phys Med Rehabil. 2000;81:669-78.

Ferri: Ferri's Clinical Advisor 2015. Philadelphia, PA: Elsevier Mosby; 2014.

Fukui H, Arai A, Toyoshima K. Efficacy of music therapy in treatment for the patients with Alzheimer's disease. Int J Alzheimers Dis. 2012;2012:531646. doi: 10.1155/2012/531646.

Harris CS, Cuerrier A, Lamont E, et al. Investigating wild berries as a dietary approach to reducing the formation of advanced glycation endproducts; chemical correlates of in vitro antiglycation activity. Plant Foods Hum Nutr. 2014;69(1):71-7.

Heo JH, Lee ST, Chu K, Oh MJ, Park HJ, Shim JY, Kim M. An open-label trial of Korean red ginseng as an adjuvant treatment for cognitive impairment in patients with Alzheimer's disease. Eur J Neurol. 2008 Aug;15(8):865-8.

Howes MJ, Houghton PJ. Ethnobotanical treatment strategies against Alzheimer's disease. Curr Alzheimer Res. 2012 Jan;9(1):67-85. Review.

Ihl R, Tribanek M, Bachinskaya N; GOTADAY Study Group. Efficacy and tolerability of a once daily formulation of Ginkgo biloba extract EGb 761 in Alzheimer's disease and vascular dementia: results from a randomised controlled trial. Pharmacopsychiatry. 2012 Mar;45(2):41-6. doi: 10.1055/s-0031-1291217. Epub 2011 Nov 15.

Jiang H, Luo X, Bai D. Progress in clinical, pharmacological, chemical and structural biological studies of huperzine A: a drug of traditional Chinese medicine origin for the treatment of Alzheimer's disease. Curr Med Chem. 2003;10(21):2231-52.

Kelley BJ, Knopman DS. Alternative medicine and Alzheimer disease. Neurologist. 2008 Sep;14(5):299-306.

Kidd PM. Alzheimer's disease, amnestic mild cognitive impairment, and age-associated memory impairment: current understanding and progress toward integrative prevention. Altern Med Rev. 2008 Jun;13(2):85-115.

Koger SM, Brotons M. Music therapy for dementia symptoms (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

Le Bars PL, Kieser M, Itil KZ. A 26-week analysis of a double-blind, placebo-controlled trial of the Ginkgo biloba extract EGb761 in dementia. Dement Geriatr Cogn Disord. 2000;11:230-7.

Lee ST, Chu K, Sim JY, Heo JH, Kim M. Panax ginseng enhances cognitive performance in Alzheimer disease. Alzheimer Dis Assoc Disord. 2008 Jul-Sep;22(3):222-6.

Lim YY, Maruff P, Pietrzak RH, et al. Effect of amyloid on memory and non-memory decline from preclinical to clinical Alzheimer's disease. Brain. 2014;137(Pt1):221-31.

Limpeanchob N, Jaipan S, Rattanakaruna S, Phrompittayarat W, Ingkaninan K.Neuroprotective effect of Bacopa monnieri on beta-amyloid-induced cell death in primary cortical culture.J Ethnopharmacol. 2008 Aug 5. (Epub ahead of print)

Lin PW, Chan WC, Ng BF, Lam LC. Efficacy of aromatherapy (Lavandula angustifolia) as an intervention for agitated behaviours in Chinese older persons with dementia: a cross-over randomized trial. Int J Geriatr Psychiatry. 2007;2(5):405-10.

Little JT, Walsh S, Aisen PS. An update on huperzine A as a treatment for Alzheimer's disease. Expert Opin Investig Drugs. 2008 Feb;17(2):209-15.

McDaniel MA, Maier SF, Einstein GO. "Brain-specific" nutrients: a memory cure? Nutrition. 2003;19(11-12):957-75.

Mantle D, Pickering AT, Perry AK. Medicinal plant extracts for the treatment of dementia: a review of their pharmacology, efficacy and tolerability. CNS Drugs. 2000;13:201-13.

Masaki KH, Losonczy KG, Izmirlian G. Association of vitamin E and C supplement use with cognitive function and dementia in elderly men. Neurology. 2000;54:1265-72.

Olazaran J, Reisberg B, Clare L, et al. Nonpharmacological therapies in Alzheimer's disease: a systematic review of efficacy. Dement Geratr Cogn Disord. 2010; 30(2):161-78.

Orr SK, Bazinet RP. The emerging role of docosahexaenoic acid in neuroinflammation. Curr Opin Investig Drugs. 2008 Jul;9(7):735-43.

Pettegrew JW, Levine J, McClure RJ. Acetyl-L-carnitine physical-chemical, metabolic, and therapeutic properties: relevance for its mode of action in Alzheimer's disease and geriatric depression. Mol Psychiatry. 2000;5:616-32.

Ringman JM, Frautschy SA, Teng E, Begum AN, et al. Oral curcumin for Alzheimer's disease: tolerability and efficacy in a 24-week randomized, double blind, placebo-controlled study. Alzheimers Res Ther. 2012 Oct 29;4(5):43.

Scherder EJ, Van Someren EJ, Bouma A, vd Berg M. Effects of transcutaneous electrical nerve stimulation (TENS) on cognition and behavior in aging. Behav Brain Res. 2000;111(1-2):223-5.

Simopoulos AP. Omega-3 fatty acids in inflammation and autoimmune diseases. J Am Coll Nutr. 2002;21(6):495-505.

Singh M, Arseneault M, Sanderson T, Murthy V, Ramassamy C. Challenges for research on polyphenols from foods in Alzheimer's disease: bioavailability, metabolism, and cellular and molecular mechanisms. J Agric Food Chem. 2008 Jul 9;56(13):4855-73. Review.

Snowdon DA, Tully CL, Smith CD, Riley KR, Markesbery WR. Serum folate and the severity of atrophy of the neocortex in Alzheimer disease: findings from the Nun Study. Am J Clin Nutr. 2000;71:993-8.

Szatmari SZ, Whitehouse PJ. Vinpocetine for cognitive impairment and dementia. Cochrane Database Syst Rev. 2003;(1):CD003119.

Tabet N, Birks J, Grimley Evans J. Vitamin E for Alzheimer's disease (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

van Marum RJ. Current and future therapy in Alzheimer's disease. Fundam Clin Pharmacol. 2008 Jun;22(3):265-74. Review.

Vellas B, Coley N, Ousset PJ, Berrut G, Dartigues JF, Dubois B, Grandjean H, Pasquier F, Piette F, Robert P, Touchon J, Garnier P, Mathiex-Fortunet H, Andrieu S; GuidAge Study Group. Long-term use of standardised Ginkgo biloba extract for the prevention of Alzheimer's disease (GuidAge): a randomised placebo-controlled trial. Lancet Neurol. 2012 Oct;11(10):851-9. doi: 10.1016/S1474-4422(12)70206-5. Epub 2012 Sep 6. Review.

Wang J, Ho L, Zhao W, Ono K, Rosensweig C, Chen L, Humala N, et al. Grape-derived polyphenolics prevent Abeta oligomerization and attenuate cognitive deterioration in a mouse model of Alzheimer's disease. J Neurosci. 2008 Jun 18;28(25):6388-92.

Wettstein A. Cholinesterase inibitors and ginkgo extracts -- are they comparable in the treatment of dementia? Phytomed. 2000;6:393-401.

Yoon JH, Baek SJ. Molecular targets of dietary polyphenols with anti-inflammatory properties. Yonsei Med J. 2005;46(5):585-96.

Yue J, Dong BR, Lin X, Yang M, Wu HM, Wu T. Huperzine A for mild cognitive impairment. Cochrane Database Syst Rev. 2012 Dec 12;12:CD008827. doi: 10.1002/14651858.CD008827.pub2.

Zhang HY, Zheng CY, Yan H, Wang ZF, Tang LL, Gao X, Tang XC. Potential therapeutic targets of huperzine A for Alzheimer's disease and vascular dementia. Chem Biol Interact. 2008 Sep 25;175(1-3):396-402. (Epub 2008 May 13)

Zhao Y, Zhao B. Natural antioxidants in prevention and management of Alzheimer's disease. Front Biosci (Elite Ed). 2012 Jan 1;4:794-808. Review.