Alzheimer Dementia

Dylan Wint, MD, Director, Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV

Diagnosing Alzheimer dementia presents clinicians with significant challenges, both in recognizing Alzheimer symptoms and in managing the disease itself. In this lecture, recorded exclusively for AudioDigest and available for Psychiatry CME credit, Dr. Dylan Wint discusses ways to improve the diagnosis and management of Alzheimer disease and dementia.

Director of the Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas, Nevada, Dr. Wint describes how to recognize symptoms of Alzheimer disease, appropriate imaging modalities to detect physiologic abnormalities indicative of the disease, and appropriate pharmacologic and nonpharmacologic treatments for managing Alzheimer disease.

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The Path Toward Dementia

In his lecture, Dr. Wint states that while dementia can be caused by any number of factors, Alzheimer disease is by far the most common cause of the disorder.

“When people develop symptomatic Alzheimer disease, they are going to progress to Alzheimer dementia, which is actually the end stage of a long process that probably starts 10 or 20 years before dementia sets in,” he says.

Recognizing Alzheimer Symptoms

Behavioral symptoms often provide the first evidence of the disease, Dr. Wint says. Studies show that more than 90% of people with Alzheimer disease will have behavioral symptoms at some point in their illness, often before cognitive symptoms are recognized.

Behavioral symptoms can include irritability, disinhibition, aberrant motor behavior, apathy, elation, depression, agitation, anxiety, delusions, and hallucinations. Those symptoms tend to become more prevalent as Alzheimer disease progresses, Dr. Wint says, and they’re often the most disruptive.

Pathology of Cognitive Symptoms

Cogitative symptoms include rapid and complete forgetting, where the patient is totally unable to remember information only hours – or even minutes – after it’s been given to them.

That’s because the disease attacks the hippocampus and other regions of the medial temporal lobes, Dr. Wint explains, which are responsible for recording new information. If the hippocampus and the regions around it are not working, not only will the patient be unable to recall the information when they need it, the information is actually not in their brain at all.

Other common symptoms, such as spatial disorientation, arise from the parietal lobes of the brain, he says. Sometimes the first clue is that the patient gets lost going to a familiar place or makes a wrong turn on a familiar route. Misplacing items can also indicate spatial disorientation.

Diagnostic Imaging Modalities

Although Alzheimer disease is not easily recognized on an MRI scan, there are some signs on an MRI that can help diagnose it, Dr. Wint says, such as atrophy in the medial temporal lobes and in the pre-cuneus region of the parietal lobe.

PET scans in Alzheimer disease will typically show bilateral parietal hypermetabolism, which often extends also into the temporal lobes. There are also specific PET scans that seek out and detect the type of amyloid that's present in Alzheimer disease

Spinal fluid analysis can show decreased beta amyloid in the spinal fluid, Dr. Wint says, due to the accumulation of insoluble beta amyloid as plaques in the brain. Increased phospho‐tau can also be seen in the spinal fluid, and specific ratios of amyloid to tau can indicate the presence of Alzheimer disease.

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Neuropsychiatric Indicators of Alzheimer disease

Dr. Wint goes on to explain the pathology behind the psychiatric symptoms that can help in diagnosing Alzheimer dementia.

“In people who had Alzheimer disease and psychosis, there were more neurofibrillary tangles than in those without psychosis,” he says. “Similar pathology is seen for those with agitation compared to those without agitation. Neuroimaging studies show worse atrophy in the cingulate region in people with apathy, and in people with delusions, there's a lower frontal lobe metabolism on PET scanning.”

In pathology studies, Alzheimer patients with depression had higher densities of plaques and tangles throughout the cortex of their brains, Dr. Wint says.

Nonpharmacologic Treatment

The goal of dementia treatment is not to eliminate psychotic symptoms, but to ensure the patient doesn’t act upon them. Eliminating psychotic symptoms requires antipsychotics, which can be dangerous to elderly patients, particularly those with dementia, Dr. Wint says. For that reason, he does not advocate the use of antipsychotics when treating elderly patients’ dementia, but to start with non-pharmacologic treatments.

If the patient is early enough in their dementia, or has mild cognitive impairment, psychotherapy can be used. Increased levels of activity, particularly physical exercise, can also be helpful in the patient’s treatment. Electroconvulsive therapy (ECT) has a long history of effective use in patients with severe depression and dementia, Dr. Wint says, and although it should be used with caution, it is quite safe, even for fragile individuals.

Patients displaying signs of apathy can become more active when held to a structured schedule, he suggests, or by incorporating beneficial behaviors into the patient’s routine, such as requiring them to engage in an active, health-related activity before they watch TV (“Which seems to be the default activity for folks of apathy,” Dr. Wint observes).

Pharmacologic Symptom Management

In cases where pharmacologic treatment is deemed safe and appropriate, Olanzapine and Risperidone are both effective, usually in lower doses than those prescribed for schizophrenia, Dr. Wint says. Aripiprazole and Quetiapine can help reduce agitation in dementia patients, and irritability can be treated with serotonergic antidepressants, such as Citalopram or Prazosin.

Dr. Wint recommends informing patients or decision-makers of the potential risks of medication and weighing those risks against the degree to which the psychotic symptoms are interfering with the patient’s quality of life.

The Importance of Early Recognition

Because Alzheimer disease is the most common cause of dementia, Dr. Wint says, it’s important that clinicians, especially psychiatrists, recognize the symptoms of the disease and understand its role as an early indicator of major neurocognitive disorder.

“Psychiatrists and geriatric psychiatrists are going to see these patients in very high numbers because of how common behavioral and psychiatric syndromes are among these patients,” he says. “And it's us as psychiatrists who actually have the ability to detect that someone is undergoing a cognitive decline that may be Alzheimer disease.”



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