by Henrylito D. Tacio
FOUR months after my grandmother, Modesta Tacio, turned 66, she started acting strange. She kept forgetting simple things: where she put her keys, if she had eaten lunch already, or if she had paid the electric and water bills. “Don’t worry. Forgetfulness happens once in a while,” my aunt Lydia assured her.
But as months progressed, her forgetfulness became worse. She could no longer remember the names of her grandchildren. “What’s your name again?” she would often inquire. At one time, my grandmother went alone to the public market (about one kilometer away from home), like she used to do.
But on her way back, she became disoriented and was completely lost. We went frantic when my aunt Lydia told us that my grandmother never came home. We searched for her all over the town but failed to find her. It was not until two days later that we finally located her in a village sleeping under a mango tree.
“I could no longer remember the road,” she said crying as she embraced my dad. When my aunt Aida Day – who lived in the United States for almost twenty years – came to visit us two years ago, their reunion was heartbreaking. Having been away for so long, my aunt hugged her so tight.
My grandmother failed to recognize her. “Why are you crying?” my grandma asked her. “You know, one of these days, my daughter Aida will visit me.”
My grandmother is having what the late American actress Rita Hayworth and Oscar-winning actor Charlton Heston are afflicted with—Alzheimer’s disease, the most common cause of dementia, an umbrella term for several symptoms related to a decline in thinking skills.
Currently, about 18 million people around the globe (projected to double by 2025 to 34 million) are suffering from Alzheimer’s. In Malaysia, about 50,000 people have the disease. In Hong Kong, some 70,000 patients suffer from it. Asians reportedly have lower risk of developing Alzheimer’s compared to those living in Western countries based on studies done in China and Taiwan.
But when Asians move to Western countries, they are most likely to develop Alzheimer’s. For instance, Alzheimer’s is more common among Japanese living in Hawaii than those living in Japan. “About 5 percent of men and 6 percent of women over 60 years of age are affected with Alzheimer’s,” says Dr Wang Xiangdong, adviser of the mental health and control substance abuse program of the regional office of World Health Organisation (WHO) in Manila. “With the ageing of populations, this figure is projected to increase rapidly over the next 20 years.”
Alzheimer’s has a gradual onset. Usually, it starts with subtle changes in memory function. “What comes first gets out last with the most recent memory getting lost first,” explains Dr Simeon Marasigan, associate professor at the department of neurology and psychiatry of the University of Santo Tomas in Manila.
In some instances, the sufferer may exhibit abnormal behavior. Jonathan Teo (not his real name) of Singapore was 70 when the doctors diagnosed him of suffering from Alzheimer’s. His family was very supportive by hiring a maid to take care of him. But recently, Teo has become delusional and complained that his maid is torturing him, which was untrue.
“People suffering from Alzheimer’s may be unreasonable,” explains Dr Victor Chong, a neurologist with special interest in dementia from the University Malaya Medical Centre in Kuala Lumpur. “For example, a husband with Alzheimer disease may often accuse the wife of infidelity.”
But as the disease progresses, language skills diminish, along with the ability to perform calculations or planning activities. A person who used to be very good at giving his opinions on certain topics, solving problems, and painting, may not be capable of doing them now. Doctors are able to diagnose the disease with 90% accuracy, even though proof can only be obtained by examining the brain after death.
Many other disease processes can mimic Alzheimer’s such as thyroid imbalances, vitamin B12 deficiency, brain injuries, tumors, and depression.
While there is still no cure for Alzheimer’s, the current “treatment” is still making the remaining years of someone with Alzheimer’s comfortable. But unlike in industrialized countries, nursing homes or hospital facilities are not available in most parts of Asia. As such, the basic responsibility for management of the patient rests with the family.
“Alzheimer’s is a long-term illness that requires a lot of care and love from family members,” says Dr Paul Pasco, a neurologist working with the Philippine General Hospital. Actually, Alzheimer’s has two victims: the patient and the caregiver.
In most cases, Alzheimer’s is more agonizing for the caregiver than for the patient. It is not only physically demanding but also emotionally draining. In most instances, a caregiver experience stress which usually manifest through denial, anger, social withdrawal, anxiety, depression, exhaustion, sleeplessness, irritability and lack of concentration.
“The family seeks help usually when the caregiver is under stress looking after the elderly,” suggests Professor Kua Ee Heok, a consultant psychiatrist from the National University of Singapore. Studies done in the United States found that caregivers of Alzheimer’s patients – compared to other people their age – have 70 percent more physician visits, are 50 percent more likely to suffer depression, and use 40 percent more medications.
Every now and then, family members should give appreciation to the caregiver to ease the agony. Listen to the words of Miyuki Tanaka, a Japanese daughter-in-law, who has been taking care of her husband’s mother having Alzheimer’s in Osaka: “The most painful thing for me now is that in spite of what I have done, no one is grateful to me. My husband is busy with his work and could not even say thank you. He has a younger sister who comes to visit her mother once in a while. Before leaving and without saying thanks, she usually say, ‘Please be kind to mother.’ I am not asking for much. I only want a word of gratitude.” The caregiver should not neglect his health.
“The Alzheimer’s patient can’t change the course of his disease, but the caregiver must learn to take care of himself,” advises Dr Pasco of the Philippines.
For instance, Prof Heok suggests that caregivers should be given a break by taking over caregiving responsibilities for a few days. “We sometimes advise the caregivers to bring those with Alzheimer’s to a day care centre where trained nurses could take care of them,” he says.
Families may also benefit by joining self-help groups or support groups. If there is no support group in the area, families may wish to start a new group. “Psychosocial interventions – including education, support, counseling and respite care – are extremely important in Alzheimer’s, both for patients and family caregivers,” reminds WHO’s Dr Xiangdong.
Since the disease has been described by Dr Lois Alzheimer in 1907, it continues to be a medical mystery. Until now, the cause of Alzheimer’s disease remains uncertain. “Alzheimer’s is one of the hottest areas of scientific research,” declares Dr Marasigan.
Science, however, has discovered that the gradual loss of brain function that characterizes Alzheimer’s is due to two proteins, beta-amyloid and tau. “These two are the possible culprits,” says Professor Edmund Chiu, a psychiatrist at St George’s Hospital in Melbourne University.
Beta-amyloid protein accumulates in the brains of patients with Alzheimer’s disease, activating immune cells that try unsuccessfully to remove it. That triggers the release of poisons that ultimately kill nerve cells, leaving behind a trail of plaques and tangles – the remains of nerve cells and fibers, clogged up with beta-amyloid.
Many of the nerve cells that are destined to die show abnormal deposits of a protein called tau, which is assumed to be toxic to nerves. Tau formation is related to the severity of disease. “The more severe the disease, the more tau is found within the brain,” informs Dr Adrian Tan, a neurologist who works at the Paragon Medical Centre and the Mount Elizabeth Medical Centre in Singapore.
Alzheimer’s has also been connected to a reduction of acetylcholine in the brain. Acetylcholine is a substance in the body that allows messages to travel from one nerve to another. For example, a person who decides to pick up a pen can act on the thought only when the hand receives the message from the brain.
Studies have shown that Alzheimer’s patients have a severe drop, sometimes 90 percent, of acetylcholine. Scientists still do not know exactly what causes Alzheimer’s but the biggest risk is simply age. Although it can occur at any age, even as young as 40 years, it is more common among the elderly.
Alzheimer’s occurs very rarely among those 40-50 years old, increases between 60 and 65 years, and is very common over 80 years,” says Dr Marasigan. Aside from increasing age, genes almost certainly play a role in the disease.
Take the case of Ronald Reagan, whose mother and brother died from the disease. “Usually, Alzheimer’s is not transmitted from family member to family member, although there is a higher risk if two or more family members are affected,” explains Dr Tan. Diet may also play a role.
Scientists from Rush-Presbyterian-St. Luke’s Medical Center in Chicago – who examined 815 people aged 65 and older over a four year period – found that the risk of developing Alzheimer’s was highest (2.3 times more likely) among those who consumed the highest levels of saturated fat. Conversely, people whose diet contained high levels of unsaturated fat were up to 80% less likely to develop Alzheimer’s disease.
Still another: “In a minority of cases, trauma may be a contributing factor,” says Dr Marasigan.
Studies conducted in the United States showed that about 15 percent of Alzheimer’s sufferers have a history of head injury.
Whatever the underlying cause or causes, Alzheimer’s disease is the result of the destruction of nerve cells in the brain. “These nerve cells cannot be replaced, so the person with Alzheimer’s disease gets progressively worse as more cells are destroyed,” points out Prof Chiu. However, there is no single cause of death associated with Alzheimer’s.
Many sufferers die from problems related to the decrease in brain function. “When Alzheimer’s is the cause of death, patients often die because of the complications related to the disease like as pneumonia, urinary tract infection, and skin infection from pressure sores,” says Dr Chong of Malaysia.
Alzheimer’s can run its course from insidious onset to death in just a few years, or play itself out over a period as long as 20 years. “Most people with Alzheimer’s live for seven to 10 years after diagnosis, spending five years under vigilant care,” says Dr Socorro Martinez, head of the memory center of St. Luke’s Medical Center in Manila.
Despite steadily increasing knowledge about the disease, “there is still no cure for Alzheimer’s or even an effective treatment at present,” says Dr Pasco. “Current available drugs have only minimal benefits.”
For some people in the early or middle stages of Alzheimer’s, medications such as tacrine may alleviate some cognitive symptoms. Donepezil, rivastigmine, and galantamine may keep some symptoms from becoming worse for a limited time.
There are also drugs available that may help control behavioral symptoms such as agitation (haloperidol and thioridazine), depression (sertraline), and insomnia (zolpidem and diphenhydramine). Various types of therapy are used to try to stimulate Alzheimer’s patients. These include: art therapy, music therapy, playing with toys.
Some health professionals encourage patients to reminisce about past memories as a way to reduce depression without the use of drugs. Meanwhile, new approaches to treatment currently under development include finding drugs that either alleviate some of the symptoms or slow down the process of nerve degeneration.
Another, as with heart disease and stroke, the search is on for measures that might prevent the disease from developing.
“The reality may seem bleak but there is hope,” says WHO’s Dr Xiangdong. “Recent researches have been discovering new facets of the disease. Better understanding of risk factors may lead the way to postpone the onset and reduce incidence. And with the dedication of some scientists, physicians, and epidemiologists, we will witness more promising new therapies.” — ###