All about Alzheimer’s Disease

As we age, our brains naturally shrink a little and our thought processes slow down. However, in Alzheimer’s disease, changes that occur in the brain are different to the changes seen in normal ageing.

The overall number of people developing dementia (prevalence) is increasing. As more people live longer life spans, the number of people with dementia is rising. Through improved public awareness and reduced social stigma, more people are seeking help when symptoms of dementia appear.

In the UK, there are more than 850,000 people living with dementia and this number is set to rise to over one million by 2025. Although it is often thought of as a disease of older people, around 5% of people with Alzheimer’s in the UK are under 65; this is known as young-onset Alzheimer’s disease.

What is Alzheimer’s disease?

Alzheimer’s disease is a physical illness which damages a person’s brain. It starts many years before symptoms start to show. As time passes, more and more brain cells are damaged, leading to worsening symptoms.

It is possible to have more than one type of dementia at the same time. Alzheimer’s disease is sometimes seen with vascular dementia or dementia with Lewy bodies. This can be called “mixed dementia”.

What is the difference between Alzheimer’s and dementia?

The word dementia is used to describe a group of symptoms; these include:

• Memory loss.
• Confusion.
• Mood changes.
• Communication difficulties.

Dementia is not a disease in itself, but it is caused by different diseases that affect the brain. These diseases damage brain cells over time causing symptoms of dementia. Alzheimer’s disease is the most common cause of dementia. About two out of three people living with dementia in the UK have Alzheimer’s disease, which is sometimes called “Alzheimer’s”.

How does Alzheimer’s disease affect the brain?

Changes in the brain may begin a decade or more before symptoms appear. During this very early stage of Alzheimer’s, toxic changes are taking place in the brain, including abnormal build-ups of proteins that form amyloid plaques and tau tangles.

Previously healthy neurons stop functioning, lose connections with other neurons, and die. Many other complex brain changes are thought to play a role in Alzheimer’s as well.

The damage initially appears to take place in the hippocampus and the entorhinal cortex, which are parts of the brain that are essential in forming memories. As more neurons die, additional parts of the brain are affected and begin to shrink. By the final stage of Alzheimer’s, damage is widespread and brain tissue has shrunk significantly.

Scientists are learning how age-related changes in the brain may harm neurons and affect other types of brain cells to contribute to Alzheimer’s damage. These age-related changes include atrophy (shrinking) of certain parts of the brain, inflammation, blood vessel damage, production of unstable molecules called free radicals, and mitochondrial dysfunction, which is a breakdown of energy production within a cell.

Who is at risk of Alzheimer’s?

Age is the biggest risk factor for developing Alzheimer’s disease. It affects one in 14 people over the age of 65, and one in six people over the age of 80. However, it can also affect people under the age of 65; this is known as young-onset dementia.

Other risk factors include but are not limited to:

• Smoking.
• Obesity.
• Diabetes.
• Vascular conditions, such as heart disease, stroke, and high blood pressure.
• High cholesterol levels.
• Hearing loss.
• Untreated depression.
• A sedentary lifestyle.
• Loneliness and social isolation.
• An inactive lifestyle.
• A previous severe head injury.
• A learning disability – Most people with Down syndrome develop Alzheimer’s. This may be because people with Down syndrome have an extra copy of chromosome 21, which contains the gene that generates harmful amyloids.

People who have had a severe head injury may be at higher risk of developing Alzheimer’s disease, but much research is still needed in this area. A small study in early 2017 was among the first to show a greater risk of dementia in professional footballers.

Researchers studied the brains of former footballers with memory problems. They found that most had signs of a form of dementia called chronic traumatic encephalopathy (CTE), and all had signs of Alzheimer’s disease.

As a result of this study, the Football Association has released new guidelines advising that children aged 11 and under should no longer be taught to head footballs in training.

What causes Alzheimer’s disease?

The causes of Alzheimer’s disease are very complex. In people with early-onset Alzheimer’s, a genetic mutation may be the cause. Late-onset Alzheimer’s arises from a complex series of brain changes that may occur over decades. The causes probably include a combination of genetic, environmental and lifestyle factors.

Very rarely, Alzheimer’s disease is caused by a genetic fault that runs in families, but this accounts for fewer than 1% of all people diagnosed with the condition.

In 2019 £122 million was put towards dementia research from the government and charities combined. The government contributed £82.9m and dementia charities £39.7m. This is essential for researching the causes, improving diagnosis and developing new treatments to help prevent it.

Symptoms of Alzheimer’s 

Alzheimer’s disease often develops slowly over several years, so symptoms are not always obvious at first. Early symptoms of Alzheimer’s are mild and don’t prevent someone from doing everyday activities by themselves. This is called mild cognitive impairment (MCI). For most people, the first signs of Alzheimer’s are problems with their memory, thinking, language or perception.

Early symptoms of Alzheimer’s may include:

• Memory – Regularly forgetting recent events, names and faces.
• Repetition – Becoming increasingly repetitive, e.g. repeating the same question over and over or repeating behaviours and routines.
• Misplacing things – Regularly misplacing items or putting them in odd places.
• Confusion – Not being sure of the date or time of day.
• Disorientation – People may be unsure of their whereabouts or get lost, particularly in unfamiliar places.
• Language and speaking – Problems finding the right words.
• Mood and behaviour – Some people become low in mood, anxious or irritable. Others may lose self-confidence, show less interest in what is happening around them or just start to do a lot less.

As Alzheimer’s progresses, symptoms may include:

• Memory and thinking skills – People will find that their ability to remember, think and make decisions gets worse.
• Communication – Speaking and understanding people becomes more difficult.
• Recognition – People may have difficulty recognising household objects or familiar faces.
• Day-to-day tasks – Such as using a TV remote control, phone or using the kettle become harder.
• Sleeping – Changes to sleep patterns often occur, such as waking frequently during the night.
• Behaviour – Some people become sad, depressed or frustrated about the challenges they face. Anxiety is also common, and people may become fearful or suspicious.
• Physical changes – People may have problems walking, be unsteady on their feet, find swallowing food more difficult or have seizures.
• Hallucinations and delusions – People may experience hallucinations, where they see or hear things that aren’t there. Others may believe things to be true that haven’t actually happened, known as having delusions.
• Care – People gradually require more help with daily activities like dressing, eating and using the toilet.
• Sundowning – People with Alzheimer’s can experience increased confusion and anxiety during the evening and at night. This is called sundowning.

It is a progressive disease, which means symptoms will get worse over time. The stages of Alzheimer’s and common symptoms that often correspond to each stage are described below.

What are the stages of Alzheimer’s?

Although each person with Alzheimer’s is different, most progress through a series of stages, each of which is characterised by more serious Alzheimer’s symptoms.

The following seven stages were developed by researchers and physicians to describe how a person with dementia could change over time; however, not everyone advances through the stages similarly. Sometimes sufferers seem to be in two or more stages at once, and the rate at which people advance through the stages is highly individual.

Stage 1 (Absence of Impairment) – There are no problems with memory, orientation, judgement, communication or daily activities. You or your loved one is a normally functioning adult.

Stage 2 (Minimal Impairment) – You or your loved one might be experiencing some lapses in memory or other cognitive problems, but neither family nor friends are able to detect any changes. A medical exam would not reveal any problems either.

Stage 3 (Noticeable Cognitive Decline) – Family members and friends recognise mild changes in memory, communication patterns or behaviour. A visit to the doctor might result in a diagnosis of early-stage or mild Alzheimer’s disease, but not always.

Common symptoms in this stage include:

• Problems producing people’s names or the right words for objects.
• Noticeable difficulty functioning in employment or social settings.
• Forgetting material that has just been read.
• Misplacing important objects with increasing frequency.
• Decrease in planning or organisational skills.

Stage 4 (Early-Stage/Mild Alzheimer’s) – Cognitive decline is more evident. You or your loved one may become more forgetful of recent events or personal details. Other problems include impaired mathematical ability, for instance difficulty counting backwards from 100 by 9s, a diminished ability to carry out complex tasks like throwing a party or managing finances, moodiness, and social withdrawal.

Stage 5 (Middle-Stage/Moderate Alzheimer’s) – Some assistance with daily tasks is required.

Problems with memory and thinking are quite noticeable, including symptoms such as:

• An inability to recall one’s own contact information or key details about one’s history.
• Disorientation to time and/or place.
• Decreased judgement and skills in regard to personal care.

Even though symptoms are worsening, people in this stage usually still know their own name and the names of key family members and can eat and use the bathroom without assistance.

Stage 6 (Middle-Stage/Moderate to Late-Stage/Severe Alzheimer’s) – This is often the most difficult stage for caregivers because it’s characterised by personality and behaviour changes. In addition, memory continues to decline, and assistance is required for most daily activities.

The most common symptoms associated with this stage include:

• Reduced awareness of one’s surroundings and of recent events.
• Problems recognising one’s spouse and other close family members, although faces are still distinguished between familiar and unfamiliar.
• Sundowning, which is increased restlessness and agitation in the late afternoon and evening.
• Difficulty using the bathroom independently.
• Bowel and bladder incontinence.
• Suspicion.
• Repetitive behaviour (verbal and/or nonverbal).
• Wandering.

Stage 7 (Late-Stage/Severe Alzheimer’s) – In the final stage, it is usually no longer possible to respond to the surrounding environment. You or your loved one may be able to speak words or short phrases, but communication is extremely limited. Basic functions begin to shut down, such as motor coordination and the ability to swallow. Total care is required around the clock.

Can Alzheimer’s be prevented?

Although research is still evolving, evidence is strong that people can reduce their risk of developing Alzheimer’s disease by making key lifestyle changes, including participating in regular activity and maintaining good heart health. According to Alzheimer’s Research UK, 1 in 3 cases of dementia could be avoided by leading a healthier lifestyle.

Regular physical exercise may be a beneficial strategy to lower the risk of Alzheimer’s and vascular dementia. Exercise may directly benefit brain cells by increasing blood and oxygen flow in the brain. Because of its known cardiovascular benefits, a medically approved exercise programme is a valuable part of any overall wellness plan.

A number of studies indicate that maintaining strong social connections and keeping mentally active as we age might lower the risk of cognitive decline and Alzheimer’s. Experts are not certain about the reason for this association. It may be due to direct mechanisms through which social and mental stimulation strengthen connections between nerve cells in the brain.

There appears to be a strong link between future risk of cognitive decline and serious head trauma, especially when injury involves loss of consciousness.

You can help reduce your risk of Alzheimer’s and protect your head by:

• Wearing a seat belt.
• Using a helmet when participating in sports, cycling and motorcycling.
• “Fall-proofing” your home by minimising clutter, loose rugs and poor lighting.

The Alzheimer’s Association offers 10 Ways to Love Your Brain, a collection of tips that can reduce the risk of cognitive decline.

How is Alzheimer’s diagnosed?

If you notice signs or symptoms of Alzheimer’s disease in yourself or a family member, it is important to arrange an appointment with your GP.

Your GP will in the first instance try to rule out any underlying physical or mental causes of the symptoms, many of which can be treated.

Such as:

• Depression.
• Anxiety.
• Vitamin deficiency.
• Diabetes.
• Hormonal conditions.
• Menopause.

It is a good idea to keep a record of symptoms for a few weeks to show your GP, as they will ask about the symptoms, when they started, how they affect daily life, and family medical history. It is also helpful for a family member or friend to go to the appointment with the person so they can talk about any changes they have seen.

Your GP is likely to carry out a short memory and concentration test.

This may include:

• Stating the day, date and year.
• Naming pictures of common objects, for example keys, pen, apple, chair etc.
• Remembering and repeating a list of items.
• Completing a simple drawing, for example putting numbers on a clock face.

Your GP should also arrange blood tests, an ECG – a check of heart rhythm – and a head scan. If other causes of the person’s symptoms are ruled out, your GP should refer them to a specialist memory clinic for more detailed assessments and further scans such as an MRI or CT scan to look for changes in the brain.

It may take several appointments and tests over a number of months to get a diagnosis of Alzheimer’s disease. Receiving a diagnosis of Alzheimer’s disease can be a relief for some people, as they have an explanation for what is happening to them and can access the support they need. For others, it can be upsetting and overwhelming.

Diagnosing dementia, and which type of dementia someone has, is important. It ensures people can get the right support and treatments plan for the future, and develop strategies to live well with dementia.

How is Alzheimer’s treated?

There is currently no cure for Alzheimer’s disease. However, treatments may temporarily ease some symptoms or slow down their progression in some people.

Medication is not suitable for all people with Alzheimer’s disease, for example, people with heart problems may not be able to take it. For those people that medication is suitable, donepezil, rivastigmine and galantamine are the main medications for Alzheimer’s disease, but they are only effective in the early to middle stages. These medications are Acetylcholinesterase (AChE) inhibitors – they increase levels of acetylcholine, a substance in the brain that helps nerve cells communicate with each other.

Memantine may be prescribed for moderate to severe Alzheimer’s disease, or if the person cannot tolerate the other treatments. This medicine is not an AChE inhibitor. It works by blocking the effects of an excessive amount of a chemical in the brain called glutamate.

In the later stages of dementia, a significant number of people will develop what’s known as behavioural and psychological symptoms of dementia (BPSD). A consultant psychiatrist can prescribe risperidone or haloperidol (antipsychotic medicines) for those showing persistent aggression or extreme distress. These are the only medicines licensed for people with moderate to severe Alzheimer’s disease where there’s a risk of harm to themselves or others.

Other treatments, activities and support are important in helping people live well with dementia.

These include:

• Cognitive stimulation therapy (CST) – This involves taking part in group activities and exercises designed to improve memory and problem-solving skills.
• Cognitive rehabilitation – This technique involves working with a trained professional, such as an occupational therapist, and a relative or friend to achieve a personal goal, such as learning to use a mobile phone or other everyday tasks. Cognitive rehabilitation works by getting you to use the parts of your brain that are working to help the parts that are not.
• Reminiscence work – This involves talking about things and events from your past. It usually involves using props such as photos, favourite possessions or music.
• Life story work – This involves a compilation of photos, notes and keepsakes from your childhood to the present day. It can be either a physical book or a digital version. These approaches are sometimes combined. Evidence shows they can improve mood and wellbeing.

Interventions such as “brain training” computer games have been shown to improve cognition over a short period, but research has not yet demonstrated whether this can help prevent dementia.

Final thoughts

Alzheimer’s has a huge impact on someone’s life; you may need to think about legal and financial matters and seek advice on the best approach for you. If you wish, you can arrange for a loved one to make financial, legal and health decisions on your behalf, which is called Lasting Power of Attorney (LPA).

For anyone to make a Will, you must have “testamentary capacity”. This legal term means there are specific things that you must be able to understand. For anyone with Alzheimer’s, then for their Will to be valid, their dementia must not affect their ability to make decisions about the Will. Get advice from a solicitor or ask an expert at the Alzheimer’s Society for more information.

If you drive and are diagnosed with Alzheimer’s you must notify the Driver and Vehicle Licensing Authority (DVLA) and your insurance company. You may not have to stop driving straight away, and you can discuss this further with your doctor.

Try to keep to a daily routine to provide familiarity and stability, and remain socially connected by continuing current activities or trying new ones.

Look into assistive products that make daily living easier, such as medication organisers, dementia clocks and personal fall alarms.

Useful sources of advice, information and support include:

• Alzheimer’s Research UK 0300 111 5555
• Alzheimer’s Society 0333 150 3456
• Age UK 0800 678 1602
• Dementia UK 0800 888 6678