Alzheimer’s disease is often referred to as the “disease of the century” and is found to afflict approximately 4 million Americans, mostly those over the age of 65. It is the harshest of all incurable diseases because it hits its victim twice. First, the mind dies, slowly and irrevocably, until even the simplest tasks become insurmountable. Then, after many years, the body dies. Alzheimer’s disease is even more devastating for the families and caregivers of its victims. It is identified as “dementia of the Alzheimer’s type” in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (Handy et al, 1998). The disease is the outcome of mental deterioration occurring especially in later life and is an irreversible condition. Major characteristics include short- and long-term memory loss, impaired judgment, slovenly appearance, and poor hygiene. When a person is afflicted by Alzheimer’s disease, it is not only that person, who suffers, but also the family, neighbors, friends, relatives, and society by and large. It is estimated that about four million Americans are currently diagnosed with AD. The prevalence rate is about 10% for individuals aged 65 or more (LA Health, 2008) and almost 50% among those over the age of 85 (LA Health, 2008). The onset of Alzheimer’s disease is linked to aging and hence the study of this chronic disease in the context of life span development is interesting. Other risk factors for AD include familial association, Down syndrome, and the apolipoprotein E4 allele. The onset of Alzheimer’s disease in old age, when studied in the context of lifespan development, shows three major factors: dementia and depression accompanying the disease, the lifestyle changes that are forced upon the victims of Alzheimer’s disease, and the impact of Alzheimer’s disease on the caregivers.
Background
Forgetfulness can happen at any age and any stage in lifespan development. But when memory loss becomes severe and other cognitive functions such as reasoning, concentration, and judgment fail, it is a sure sign that the patient is suffering from some form of dementia, a classification that includes Alzheimer’s disease. Alzheimer’s disease was named for Alois Alzheimer, a German physician credited with the first description of the disorder. In 1906, he presented the case of a 51-year-old patient who suffered from progressive memory loss and disorientation, depression and hallucinations, and severe dementia and eventually died (Hecht, 1985). On examination of the dead patient’s brain, it was found that there was severe atrophy (shrinkage) and an unusual clumping and distortion of fibers in the nerve cells of the cerebral cortex, or outer layer of the brain. Since the symptoms first appeared in middle age, Alzheimer’s disease was considered to develop before age 65 and when it did, it was known under the name of presenile dementia. Dementia that accompanied aging after 65, called senile dementia, was supposed to be caused by the hardening of the arteries and a natural outcome of old age (Hecht, 1985). Further research has shown that the lesions that found in Alzheimer’s patient were also found in older patients with senile dementia. Only a small number of cases showed any changes in blood vessels that could be attributed to the aging factor. The term “senile dementia of the Alzheimer’s type” then came into use to refer to the late-onset form of the disease. Today it is widely accepted that Alzheimer’s disease can come at any age though older people are more susceptible to it.
Alzheimer’s disease is the most common cause of dementia and statistics show that it now afflicts nearly 4 million Americans. These numbers are expected to increase with an increasing average age of the U.S. population. By the year 2050, it is predicted that approximately 14.5 million people will suffer from Alzheimer’s disease. Alzheimer’s disease is not part of the normal aging process, although it affects predominantly elderly people. Whereas only 10% of those 65 years of age and older are affected by this disease, the percentage may be as high as 48% in those 85 years of age and older. Studies have shown that while the general population over age 65 runs a 2 percent or 3 percent chance of developing Alzheimer’s disease, the likelihood increases to about 7 percent or 8 percent if a parent or brother, or sister is afflicted.
Macroscopic and microscopic Pathology
Alzheimer’s disease early cases of earlier onset show symmetrical and diffuse atrophy of cerebral gyri. The atrophy extends to the temporal (most often), frontal, parietal, or occipital lobes. Sections through the cerebral hemispheres reveal thinning of the cortical ribbon and symmetrical enlargement of the ventricular system (hydrocephalus ex-vacuo). Senile plaques, neurofibrillary tangles, and vascular deposition of amyloid are among the most conspicuous abnormalities observed very early in the study of AD (Stein and Baum, 1995). The hippocampal formation, subiculum, amygdala, and neocortical association areas are also affected by the disease. It is presently believed that the dementia characteristic of AD is due to the marked neuronal and/or synaptic loss observed in the affected brain regions (Stein and Baum, 1995).
Onset Symptoms and Later Symptoms
Alzheimer’s disease sets in gradually starting with short-term memory loss and what makes the loss in memory striking is that the entire event is forgotten without a trace. As the memory loss gets more serious, the Alzheimer’s victim becomes unable to even remember the previous sentence in a conversation or identify familiar people, objects, and names. Other early behavioral changes include an inability to concentrate, anxiety, irritability, agitation, withdrawal, and petulance. Later, the patient may have trouble with figures and understanding what is being read and may become disoriented as to time and place. However, symptoms vary from person to person and some may lose their sense of direction, while others may exhibit temper tantrums and obsessive behavior. Depression and delusions are also sometimes present along with AD. Some people get powerful visions that alter their perceptions. Death generally comes in three to 10 years after the onset of the disease, usually from pneumonia or some other infection that afflicts bedridden patients.
Alzheimer’s disease affects the cognitive functions the most and this includes “severe memory loss and impairment of language skills, learning ability, and the ability to think abstractly and make reasonable judgments about events in one’s surroundings” (Clark, 2002, p. 175). Other symptoms include “fearfulness, delusions, excessive irritability, and unusually aggressive behavior” (Clark, 2002, p. 175). Though these traits may be attributed to aging when they seriously affect the daily lifestyle of an individual, a tentative diagnosis of Alzheimer’s disease is made (Clark, 2002). In the absence of a biological marker for degenerative dementias, the diagnosis must be based on elicited information and analysis of a combination of factors, such as clinical presentation, cognitive profile, complaints and informant reports, neuroimaging techniques, and risk factors. The only way to conclusively diagnose Alzheimer’s disease is after death. An autopsy will show the brain lesions with neurofibrillary tangles–twisted nerve fibers inside nerve cells–and neurotic plaques – degenerating bits of nerve cells surrounding a core of fibrous material called amyloid (Hecht, 1985). In addition to the tangles and plaques, there also is a loss of nerve cells in regions of the brain essential for memory and thought processes, and in certain more primitive regions at the base of the brain. Though there are many drugs in the market for the treatment of Alzheimer’s disease, such as lecithin and piracetam, naloxone, corticotrophin, and vasopressin, the reality is that nothing much can be done to stop and cure the disease (Hecht, 1985). Symptomatic treatment may be offered when serious psychological disorders such as depression and delusions are present.
Lifestyle Changes
According to the Alzheimer’s Association, there are ten major signs that indicate the onset of Alzheimer’s disease in old age: memory loss; difficulty performing familiar tasks; problems with language such as aphasia, forgetting simple words or substituting unusual words, etc.; disorientation to time and place; poor or decreased judgment; problems with abstract thinking; misplacing things; rapid swings in mood or behavior; personality transformations and acute loss of initiative when it comes to housework, business activities or social obligations (Thies, 2004).
The clinical course of AD is frequently divided into three relatively distinct phases: the forgetfulness phase, the confusional phase, and the dementia phase (Ramanathan, 1997). A slow progressive degeneration begins that impairs the victim’s mental abilities. At first, the person with AD shows forgetfulness and the tendency to keep repeating words. It is possible that other cognitive skills such as perception and judgment may be affected along with memory and judgment may also be affected. Due to the loss of memory, old people who are afflicted with AD find it difficult to focus on tasks, learn new things or acquire skills. Their work skills also deteriorate and as a result, these patients are likely to experience anxiety and depression. As the disease progresses, memory loss becomes severe and there are dramatic changes in personality. They tend to lose track of current events, judgment is impaired, and patients are no longer able to do mathematical tasks or work that needs more of their intellectual faculties. As the disease progresses still further, victims become bedridden and unable to live a normal life (Ramanathan, 1997). This situation creates problems not only for themselves but also for their caregivers and friends. Their sleep patterns are also disrupted. Eventually, when the patients reach a stage when caregiving becomes almost impossible, they are sent to a healthcare facility where they are likely to spend their last years. Sometimes, it may be arranged to provide them 24-hour home care.
Depression in old age due to Alzheimer’s disease
Depression and Alzheimer’s share symptoms, and some symptoms of depression may actually represent early signs of AD (Gruetzner, 2001). Studies show that major depression afflicts 17-31% of patients with dementia and depressive symptoms occur in 50% of patients with dementia. The prevalence rates for depression in Alzheimer’s disease (17-29%) and vascular dementia (19-27%) are about equal (Fisher et al., 1990). Patients with dementia who develop concurrent depression tend to have a genetic vulnerability to depression. Depression is often characterized by self-pity, rejection sensitivity, and anhedonia. A depressed mood has been associated with a subsequent threefold increase in dementia risk (Devanand et al., 1996). Identifying depression with AD is more difficult because depressive symptoms are often transitory, or less severe and pervasive, than those seen in major depressive disorders. People who are aware of dementia symptoms and understand what it means to have Alzheimer’s disease might have a greater risk of becoming depressed at an early stage of dementia. This psychological reaction to loss does not, however, explain the fact that depression occurs in people who not only have little awareness of dementia symptoms but who have more severely advanced dementia (Devanand et al, 1996). When suffering from depression, people with Alzheimer’s disease are known to be more distressed and agitated and to have greater problems with functioning and performing activities of daily living. Family members experience more stress and burden because of the increased dysfunction and mood-related disturbances experienced by their loved ones. Identifying depression with AD is more difficult because depressive symptoms are often transitory, or less severe and pervasive, than those seen in major depressive disorders.
Caregiving and Alzheimer’s Disease
Research shows that there are six illness qualities of Alzheimer’s disease that affects the role of the caregivers: the disease changes the ill member so dramatically that it creates a discontinuity of the self; the disease is constant and pervasive; the disease introduces repetition into the caregiver’s daily life; the disease is unpredictable in its overall course; the situation is perceived by the family members to be out of control, and finally, the disease always ends in death (Martinson and Muwaswes, 1993). Studies involving family members of people afflicted with Alzheimer’s disease have noted that the disease results in a discontinuity and eventual loss of the self. Due to the loss of memory, the person is unable to hold his past, present, and future together and hence there is a discontinuity in the context of time, space, and relationships. The disease, therefore, represents a profound loss to the loved ones of the victim. A woman who is well known for her excellent grasp of languages may no longer be able to speak coherently and a soft-spoken man known for his gentleness may become one who curses all the time. The “person” has lost his identity and hence, to the caregivers, is no longer present. Caregivers who hold this stance describe the illness as a “living death”. According to Martinson and Muwaswes (1993), Alzheimer’s disease may be conceptualized as a developmental reversal of a child becoming an adult. Contrary to the infant who acquires increasingly complex skills and capacities over time, the person with Alzheimer’s disease loses skills and capacities. Though the victim is like a child, families note that unlike the case of child care, where the demand for care decreases over time, as Alzheimer’s disease progresses, the demand for care increases. The person with Alzheimer’s disease is dependent on his caregiver for even simple acts of daily living such as dressing and eating to social and cognitive functions. Research shows that caregivers looking after patients with AD have problems in three areas: monitoring the person’s safety and well-being, communicating in ways that don’t upset the ill member, and providing the basic necessities of living to an adult who has largely forgotten how to manage his or her self. According to a study titled “The MetLife Study of Alzheimer’s Disease: The Caregiving experience” which studied more than 400 people whose care recipients were over the age of 65, it was found that Alzheimer’s caregivers suffer more stress, higher costs, and a greater commitment of time compared to caregivers of other diseases (MetLife, 2006). Research shows that caregivers of old people with AD suffer stress, a sense of burden, and also feelings of grief and loss (Sanders and Adams, 2005). Alzheimer’s caregivers reported high levels of emotional and physical stress and were found to be more at risk for physical and mental health complications. It has also been found that one in eight will become ill or injured as a direct result of caregiving, and one in three uses medication for caregiving-related difficulties. Depression among caregivers is three times the norm for people in their age group (Thies, 2004). This shows that Alzheimer’s disease impacts the lifespan tasks of their caregivers as well.
Conclusion
The onset of Alzheimer’s disease in old age is one that reverses the life developmental process and hence has serious outcomes for both the victim and his close family. Three issues regarding Alzheimer’s disease are significant – dementia and depression accompanying the disease, the lifestyle changes that are forced upon the victims of Alzheimer’s disease and their caregivers, and the management of the disease in old age. It can be seen easily that dementia and depression both aggravate each other and hence symptomatic treatment of depression is very important in the case of Alzheimer’s disease. Moreover, as a result of dementia and depression, the victims of AD become more and more dependent on their caregivers for their daily activities and they also lose their original selves in the process. The caregivers play a crucial role when there is an onset of AD in old age. It is important that they are very patient with the victims and understand that it is an incurable disease. The tragedy of the onset of AD in old age is well shown by the fact that caregivers find that death is a sort of release for old people with Alzheimer’s disease.
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