My Doctor Online The Permanente Medical Group

Causes

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The actual cause of Alzheimer’s is unknown. However, we know that there is a build up of an abnormal protein, called beta-amyloid, which comes from cell membrane proteins in the brain. When beta-amyloid deposits accumulate, they form a substance called plaques. The plaques damage nerve function and may lead to brain cell death. Nerve cell damage causes the progressive loss of thinking and memory skills experienced by people with Alzheimer’s. Some of the most affected nerve cells are those that release acetylcholine, a chemical that is vital for transmitting nerve impulses that support memory, judgment, and other thought processes. 

Alzheimer’s can occur at any age from 45 or older, but the disease is increasingly common in older people. About 10 percent of people older than 65 have Alzheimer’s, but more strikingly, about 50 percent of people who are 85 years old have Alzheimer’s disease.

Depression is also common in elderly people without dementia. When the depression is severe, it can cause mental slowness, which can resemble dementia. Other causes of dementia can include:

• Brain tumors
• Injury to the brain
• Infection
• HIV/AIDS
• Heavy alcohol consumption
• Fronto-temporal dementia (also known as Pick’s disease)
• Parkinson’s Disease

Symptoms

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Normally as we grow older, we all experience senior moments or memory lapses. For most of us, these lapses usually involve temporarily forgetting a name or something we meant to do. These incidents may be annoying, but they do not prevent us from functioning normally.

Dementia affects memory much more significantly. For example, people with dementia usually are not aware how poor their memory has become and may not even realize that they forgot something. People with normal memory loss are usually aware that they have forgotten something.

The following list highlights the differences between memory symptoms experienced during normal aging and those caused by dementia. With normal forgetfulness, you may: 

• Forget details, not events
• Use notes or cues
• Recognize people or places
• Follow directions
• Know the date and time

With dementia, you:

• Forget recent events
• Cannot manage your daily affairs without help
• Gradually lose the ability to recognize yourself or others
• Eventually cannot follow directions
• Gradually become unaware of day or time

Progression of Dementia

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Because there are many different causes of dementia, it is difficult to predict its course. Dementia has been known to progress more rapidly in some people or to last as long as 25 years in others.

As a person’s thinking becomes more impaired, they have increased difficulty in performing activities of daily living. Below is a chart that roughly graphs the progression of the disease.

Screening and Diagnosis

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If you have symptoms that you are concerned about, such as memory loss or behavior changes, talk to us about your concerns. It is helpful to bring someone to the visit who knows you well, since they can add another perspective on how well you are functioning. We will also test your cognitive function. These tests can be simple screening tests – such as answering some questions to assess your memory and reasoning abilities – or we may recommend more in- depth and complicated testing, depending on the severity of your symptoms. 

There are a number of conditions that can mimic dementia, including depression, anxiety, and even medication side effects. Depending on the results of your initial visit, we may request some additional tests to evaluate the specific cause of your dementia, which will help us recommend the most appropriate treatment. Tests may include:

• A neurological examination
• Lab tests, including blood counts, liver tests, vitamin B12 level, thyroid tests, calcium level, electrolytes, and kidney tests
• CT scan or MRI of the brain

There is no definitive scan or laboratory test to confirm a diagnosis of Alzheimer’s, although there are some features of brain scans, such as significant atrophy (or shrinkage) of the brain, that can sometimes support the diagnosis.

Conditions That Mimic Dementia

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Certain medical conditions and some types of medication side effects may seem similar to dementia. They include:

• Depression. People with depression frequently complain of problems with mental function and memory. This condition has been termed pseudo-dementia and is the most frequently identified treatable cause of cognitive difficulties. Differentiating between pseudo-dementia and true dementia can be challenging because it is difficult to tell if the primary issue is major depression, or if someone is feeling depressed because they are having cognitive problems.
• Infection. People with lung or urinary tract infections can experience cognitive symptoms that mimic dementia. The symptoms appear suddenly, but gradually go away as the infection is treated.
• Anticholinergic drugs. These drugs are used to treat a variety of disorders including stomach cramps, ulcers, motion sickness, and bladder incontinence. They work by blocking the effects of acetylcholine, a chemical neurotransmitter that has influence throughout the brain and several other vital organs. These medications may change brain chemistry and cause impairment in memory, judgment, and other thought processes.  
• Sleeping pills and anti-anxiety medications. Medications such as Valium (diazepam), Ativan (lorazepam), and even Benadryl, can affect your cognitive capabilities as you get older and your body is less able to metabolize these drugs.

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Treatments

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Medications

There are several medications used to treat the symptoms of Alzheimer's. Unfortunately, no medication has yet been developed to stop the disease from progressing. All current approved medications work by improving cognitive and behavioral symptoms.

• Acetylcholinesterase inhibitors. These drugs inhibit an enzyme that breaks down acetylcholine – a chemical transmitter involved in memory, judgment and other thought processes. Brain cells that release acetylcholine are among the first to be affected by the disease. However, these drugs do not keep the nerve cells from dying and therefore cannot prevent the disease from progressing. There is some evidence that these medications, which include donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl), may also improve other cognitive functions besides memory. The most common side effects are upset stomach and diarrhea, although in unusual circumstances some agitation may also occur.
• NDMA Receptor Antagonist: Memantine (Namenda). This medication treats the symptoms of dementia and Alzheimer’s. It does not seem to be as effective as anticholinergic medications, but may be an option in later stages of the disease. The drug can improve mental function and memory, though it may not alter progression of the disease. Side effects include tiredness, dizziness, confusion, headache, sleepiness, constipation, vomiting, and pain.
• Antidepressants. Depression occurs in about 40 percent of people with Alzheimer’s and may worsen mental abilities. Antidepressants can relieve symptoms of depression and may improve quality of life.
• Complementary and alternative therapies. Hundreds of herbal remedies, vitamins, and other dietary supplements are marketed as treatments for Alzheimer’s disease and dementias. If you are considering any alternative therapies, please talk with us about them so that we can ensure they do not interfere with your medications.

Clinical Trials

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Unfortunately, there are no drugs yet available that can actually prevent or slow the progression of Alzheimer’s disease. At the moment, Alzheimer’s drugs temporarily treat the symptoms of the disease only. There may be clinical trials that would be appropriate for you or your friend or family member. The National Institutes of Health provides information on clinical research trials that are available on its web site called Clinical Trials.gov

Lifestyle Changes and Management

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Keep your brain active

Exercising your brain can help reduce symptoms of dementia. Try the following:

• Stay engaged in life by starting a new hobby, volunteering, taking a class, and challenging yourself.
• Simplify your life by avoiding unnecessary complications and preparing for the future.
• Join a group exercise class.
• Keep blood pressure under control.
• Understand your medications. Know why you are taking each medication and be educated on side effects.
• Complete an advanced directive and identify someone to make decisions on your behalf if you are unable to do so.
• Find a primary care doctor who understands you and your condition.

Driving and Dementia

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People with advanced dementia should not drive because it is unsafe. Even people who are in the very early stages of dementia may be in danger when driving. The best way to decide if you or a family member can drive safely is to ask the Department of Motor Vehicles to evaluate driving fitness. Clues that you or a family member may be having difficulty driving include:

• Driving at inappropriate speeds, too fast or too slow
• Scrapes or dents on car, garage, or mailbox
• Minor fender benders, near misses, or other accidents
• Getting lost in familiar places
• Trouble navigating turns
• Moving into a wrong lane 
• Delayed response to unexpected situations

The California Department of Motor Vehicles (DMV)  provides helpful information.

California Law (California Health and Safety Code Section 103900) requires physicians to report people with conditions that result in lapses of consciousness, episodes of confusion, or dementia.

The DMV has the sole authority to grant you driving privileges. We do not have the authority, nor are we able to hasten the review process. The DMV will send paperwork to you that has a section for us to complete. Please bring it with you to an appointment or mail it to us. Expect that it will take about a week for us to complete the paperwork. If you would like a copy, please indicate that on the forms. 

Advice for Caregivers

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Caring for a loved one with Alzheimer’s is very stressful and one person cannot do it alone. Our Health Education department has books, videos, and fact sheets that help you understand dementia and plan for the future.

Too much stress can be damaging to both a caregiver and the person with Alzheimer’s. If you are a caregiver and you feel overwhelmed and are neglecting your own physical, mental, and emotional well-being, you may be putting your health and yourself at risk.

If you are experiencing stress on a regular basis, discuss this with us or consult your doctor.

Managing Behavioral Problems Associated With Dementia

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Dementia causes a number of behavioral problems including agitation, combativeness, hallucinations, incontinence, sleeplessness, and sundowning, which is an increase in erratic and disruptive behavior in the evening and nighttime hours.

Because cognitive functioning is already impaired, people with dementia are more susceptible to side effects, such as confusion, caused by medications that affect behavior. For this reason, we will help you consider non-medication alternatives to behavioral problems before we prescribe medications. 

Legal Considerations

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There are legal considerations for people with dementia. If you are suffering from dementia, choose someone to make medical choices for you, in case you become unable to make those decisions yourself. We strongly encourage you and your family members to complete an advanced directive and a durable power of attorney for health care.

If you were chosen by a person with dementia to make medical decisions for them, talk to them about their health care wishes now. This discussion should include the kinds of medical treatment that they would want and would not want. This information will allow you to carry out their wishes.

Your Care with Me

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If you are having symptoms that concern you, your first contact will typically be with your personal physician, who will evaluate your health and symptoms.

If specialty care is needed, your personal physician will facilitate the process of scheduling an appointment in my department. If appropriate, she or he might call me or one of my colleagues while you are in the office so we can all discuss your care together. If we decide you need an appointment with me after that discussion, we can often schedule it the same day or soon thereafter.

During your office visit, we will discuss your medical and family history and I will assess your cognitive function―your ability to think, learn, and remember. I recommend that you bring along a friend or caregiver who can offer an objective opinion about how you are managing your daily activities.

I will explain the findings of your exam and answer any questions or concerns you may have. We will discuss treatment options, and together we will create a treatment plan that is right for you.

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If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

If you have urgent concerns or issues while my office is closed, or need general medical advice, you can call the Appointment and Advice line, available 24 hours a day, 7 days a week. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

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Coordinating Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

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Convenient Resources for You

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As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your preventive services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments, and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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