Alzheimer's in the clinic

What happens when a person begins to notice that there might be something wrong with their memory? To understand the clinical side of things, Katie Haylor was joined in studio by Tim Rittman, a clinician from Cambridge University...

Tim - That's a really difficult question to answer, when people think about Alzheimer’s typically you think about the memory problems that people have. So certainly memory loss is a part of Alzheimer's disease but there are other things which can come along with it as well. So difficulty with coordination, difficulty with vision what we call visual spatial difficulties. So that might be judging distances or driving for example people might find it difficult to reverse their car. People often have anxiety as well particularly for social situations. So someone who is previously very outgoing might become a lot more nervous in those situations. I think it's very hard to say what a typical person with Alzheimer's looks like because you know, in my clinic I see people who can't read and write, and English is their Second Language and Alzheimer's disease is very different for someone else who's a professor from the University of Cambridge. So there's certainly a loss of function and problems with memory and other cognitive processes but it's very individual as to how that affects people's lives.

Katie - Can we generalise about the progression? Is there a pattern that you tend to see?

Tim - There is to some extent in most people the first thing that will be noticed will be the memory problems. And it's a particular type of memory problem where you'll forget things about events that have happened in the past or you might get lost. And usually these will be more noticeable to other people than to the person who's suffering memory problems or experiencing those memory problems. Over time they become more problematic and more noticeable and people begin to lose function so they begin to fine day to day things more and more difficult. So for example if you cook a roast dinner it might be that you've never had to think about doing that. But then those processes become more difficult. It takes you more time and then eventually that will be impossible to do because you just can't remember or put together all of the different parts of that particular process.

Katie - Now Alzheimer's isn't the only kind of dementia. So what other kinds are there and how is Alzheimer's different?

Tim - Yeah there's quite a few different types of dementia and the commonest that we see certainly is Alzheimer's disease. Close behind that is something called vascular dementia so that affects the blood vessels in the brain. From a clinical point of view that often comes with difficulty walking people's gait becomes very short they make sort of small strides and often comes with a sort of grumpiness as well and the slight change in behavior. There are other forms of dementia so frontotemporal dementia which is completely different from Alzheimer's disease and that  often the memory is quite good but there's a lot behavioral change. So people might become very inappropriate make rude comments or completely inappropriate comments but that can also affect language as well. So there is certainly a whole group of dementias where problems with grammar, or with syntax, or with remembering what words mean are that the first presentation.

Katie - Is Alzheimer’s a terminal illness? Can you die of having Alzheimer's disease or is it a bit more complicated than that?

Tim - It is a bit more complicated than that. I think there's no getting around the fact that Alzheimer’s is a progressive disease and if nothing else happens in your life then you'd expect that your life expectancy is shortened if you have Alzheimer's disease. Having said that if you look at the death certificates of people who've had Alzheimer's disease mostly it will say something like pneumonia because of the gradual loss of brain function eventually leads to a loss of those basic functions. So breathing, monitoring different bodily functions, and that can lead to a shutdown of the body. So yes Alzheimer's is certainly progressive and it does lead to a shortening of lifespan. I think increasingly as clinicians we're recognizing that and taking on board the more palliative aspects of Alzheimer's disease which is is really important along with all the other things that we have to address in the illness coming to the end of life and addressing those specific issues is increasingly important.

Katie - So Tim if somebody comes in to see you in your clinic what kinds of assessments would you get them to do to potentially diagnose Alzheimer’s? How does it work?

Tim - So first thing, the most important thing, is to take a history and talk through what's been going on. But we do get people to do some cognitive tests so this tests a range of things. So memory, visual spatial function, language function, what we call executive function so that’s planning an organisation of the brain and we look at patterns within those tests. So there is no one specific answer that you know if you fail on that you'll definitely have a diagnosis of Alzheimer's disease or dementia, it doesn’t quite work like that, it’s more fitting into a pattern along with the history and other bits and pieces.

Katie - And do you allow for the fact then that this is quite a nerve racking thing to do potentially? So people might not necessarily perform great on particularly one day or one time?

Tim - Absolutely yeah. There are a lot of things you have to take into account. Certainly nerves come into it and we recognize that the nurses who administer the testing clinic are really used to assessing people and when we discuss the cases afterwards we'll say, you know, how did the person perform on the test? Were they really making an effort for example or were they really struggling and nervous? And we take into account the levels of education as well we know, someone who’s got a very high level of education is naturally going to do a bit better on the cognitive tests and someone who isn't so educated and we take all of those things into account.

Katie - So these tests where someone is doing a particular task and giving you some information they play one part, but do you actually look at what's going on inside someone's brain?

Tim - We certainly do brain scans. Yeah. One of the reasons and probably the main reason for doing a brain scan is to make sure we're not missing something like you know brain tumour or a stroke or some other cause for memory problems. But we do look for certain patterns of change in the brain and shrinkage in the brain.

Katie - So is it fair to say then that people shouldn't panic perhaps if they forget something a couple of times, but it's a pattern that they should look out for. What would you suggest people are wary of?

Tim - Yeah I think we've all had the experience you know this morning I got up and went upstairs and couldn't remember what on earth I gone there for and that's entirely normal. Or that what we call a cocktail party anomia, you go to a party you can't remember someone's name five minutes later. These are all entirely normal and part of everyday life. Usually, it's when other people are worried about your memory other people start noticing it or you find that those memory problems are really stopping you doing things. That's when we start thinking about you know, could this be the early signs of dementia?

Katie - And briefly after you’ve diagnosed someone, what happens next to them?

Tim - We start thinking about some treatments sometimes. Particularly in Alzheimer's disease, we don't have any treatments which can stop the disease process or turn the clock back. But we do have some medications which can boost some of the chemicals in the brain to help with memory and attention.