People with Alzheimer’s experience difficulties communicating, learning, thinking and reasoning — problems severe enough to have an impact on an individual's work, social activities and family life.

The Alzheimer's Association has developed a checklist of common symptoms to help you recognize the difference between normal age-related memory changes and possible warning signs of Alzheimer’s disease.

There’s no clear-cut line between normal changes and warning signs. It’s always a good idea to check with a doctor if a person’s level of function seems to be changing. The Alzheimer’s Association believes that it is critical for people diagnosed with dementia and their families to receive information, care and support as early as possible.

10 warning signs of Alzheimer's:
 

1. Memory loss. Forgetting recently learned information is one of the most common early signs of dementia. A person begins to forget more often and is unable to recall the information later.

What's normal? Forgetting names or appointments occasionally.

2. Difficulty performing familiar tasks. People with dementia often find it hard to plan or complete everyday tasks. Individuals may lose track of the steps involved in preparing a meal, placing a telephone call or playing a game.

What's normal? Occasionally forgetting why you came into a room or what you planned to say.

3. Problems with language. People with Alzheimer’s disease often forget simple words or substitute unusual words, making their speech or writing hard to understand. They may be unable to find the toothbrush, for example, and instead ask for "that thing for my mouth.”

What's normal? Sometimes having trouble finding the right word.

4. Disorientation to time and place. People with Alzheimer’s disease can become lost in their own neighborhood, forget where they are and how they got there, and not know how to get back home.

What's normal? Forgetting the day of the week or where you were going.

5. Poor or decreased judgment. Those with Alzheimer’s may dress inappropriately, wearing several layers on a warm day or little clothing in the cold. They may show poor judgment, like giving away large sums of money to telemarketers.

What's normal? Making a questionable or debatable decision from time to time.

Introduction

The primary symptoms of Alzheimer’s disease include memory loss, disorientation, confusion, and problems with reasoning and thinking. These symptoms worsen as brain cells die and the connections between cells are lost. Although current drugs cannot alter the progressive loss of cells, they may help minimize or stabilize symptoms. These medications may also delay the need for nursing home care.

Cholinesterase Inhibitors

The U.S. Food and Drug Administration (FDA) has approved two classes of drugs to treat cognitive symptoms of Alzheimer’s disease. The first Alzheimer medications to be approved were cholinesterase (KOH luh NES ter ays) inhibitors. Three of these drugs are commonly prescribed—donepezil (Aricept®), approved in 1996; rivastigmine (Exelon®), approved in 2000; and galantamine (approved in 2001 under the trade name Reminyl® and renamed Razadyne® in 2005). Tacrine (Cognex®), the first cholinesterase inhibitor, was approved in 1993 but is rarely prescribed today because of associated side effects, including possible liver damage.

All of these drugs are designed to prevent the breakdown of acetylcholine (pronounced a SEA til KOH lean), a chemical messenger in the brain that is important for memory and other thinking skills. The drugs work to keep levels of the chemical messenger high, even while the cells that produce the messenger continue to become damaged or die. About half of the people who take cholinesterase inhibitors experience a modest improvement in cognitive symptoms.

For more information, see the Cholineterase Inhibitors fact sheet.

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Definition

When Alzheimer’s disrupts memory, language, thinking and reasoning, these effects are referred to as “cognitive symptoms” of the disease. The term “behavioral and psychiatric symptoms” describes a large group of additional symptoms that occur to at least some degree in many individuals with Alzheimer’s. In early stages of the disease, people may experience personality changes such as irritability, anxiety or depression. In later stages, other symptoms may occur, including sleep disturbances; agitation (physical or verbal aggression, general emotional distress, restlessness, pacing, shredding paper or tissues, yelling); delusions (firmly held belief in things that are not real); or hallucinations (seeing, hearing or feeling things that are not there).

Many individuals with Alzheimer’s and their families find behavioral and psychiatric symptoms to be the most challenging and distressing effects of the disease. These symptoms are often a determining factor in a family’s decision to place a loved one in residential care. They also often have an enormous impact on care and quality of life for individuals living in long-term care facilities.

Medical evaluation

A person exhibiting behavioral and psychiatric symptoms should receive a thorough medical evaluation, especially when symptoms come on suddenly. Treatment depends on a careful diagnosis, determination of the possible causes, and the types of behavior the person is experiencing. With proper treatment and intervention, significant reduction or stabilization of the symptoms can often be achieved.

Symptoms often reflect an underlying infection or medical illness. For example, the pain or discomfort caused by pneumonia or a urinary tract infection can result in agitation. An untreated ear or sinus infection can cause dizziness and pain that affect behaviors. Side effects of prescription medication are another common contributing factor to behavioral symptoms. Side effects are especially likely to occur when individuals are taking multiple medications for several health conditions, creating a potential for drug interactions.

Non-drug interventions

There are two distinct types of treatments for agitation: non-drug interventions and prescription medications. Non-drug interventions should be tried first. In general, steps to managing agitation include (1) identifying the behavior, (2) understanding its cause, and (3) adapting the caregiving environment to remedy the situation.

Correctly identifying what has triggered symptoms can often help in selecting the best behavioral intervention. Often the trigger is some sort of change in the person’s environment:

• change in caregiver
• change in living arrangements
• travel
• hospitalization
• presence of houseguests
• bathing
• being asked to change clothing

A key principle of intervention is redirecting the affected individual’s attention, rather than arguing, disagreeing, or being confrontational with the person. Additional intervention strategies include the following:

• simplify the environment
• simplify tasks and routines
• allow adequate rest between stimulating events
• use labels to cue or remind the person
• equip doors and gates with safety locks
• remove guns
• use lighting to reduce confusion and restlessness at night

Medications to treat agitation

Medications can be effective in some situations, but they must be used carefully and are most effective when combined with non-drug approaches. Medications should target specific symptoms so their effect can be monitored. In general, it is best to start with a low dose of a single drug. People with dementia are susceptible to serious side effects, including a slightly increased risk of death from antipsychotic medications. Risk and potential benefits of a drug should be carefully analyzed for any individual. Examples of medications commonly used to treat behavioral and psychiatric symptoms include the following:

Antidepressant medications for low mood and irritability

• citalopram (Celexa®)
• fluoxetine (Prozac®)
• paroxetine (Paxil®)
• sertraline (Zoloft®)

Anxiolytics for anxiety, restlessness, verbally disruptive behavior and resistance

• lorazepam (Ativan®)
• oxazepam (Serax®)

Antipsychotic medications for hallucinations, delusions, aggression, hostility and uncooperativeness

• aripiprazole (Abilify®)
• clozapine (Clozaril®)
• olanzapine (Zyprexa®)
• quetiapine (Seroquel®)
• risperidone (Risperdal®)
• ziprasidone (Geodon®)

Although antipsychotics are among the most frequently used medications for treating agitation, some physicians may prescribe an anticonvulsant/mood stabilizer, such as carbamazepine (Tegretol®) or divalproex (Depakote®) for hostility or aggression.

Sedative medications, which are used to treat insomnia or sleep problems, may cause incontinence, instability, falls or increased agitation. These drugs must be used with caution, and caregivers need to be aware of these possible side effects.

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Introduction

Several herbal remedies and other dietary supplements are promoted as effective treatments for Alzheimer’s disease and related disorders. Claims about the safety and effectiveness of these products, however, are based largely on testimonials, tradition, and a rather small body of scientific research. The rigorous scientific research required by the U.S. Food and Drug Administration for the approval of a prescription drug is not required by law for the marketing of dietary supplements.

Concerns about alternative therapies

Although many of these remedies may be valid candidates for treatments, there are legitimate concerns about using these drugs as an alternative or in addition to physician-prescribed therapy:

• Effectiveness and safety are unknown. The maker of a dietary supplement is not required to provide the U.S. Food and Drug Administration (FDA) with the evidence on which it bases its claims for safety and effectiveness.
• Purity is unknown. The FDA has no authority over supplement production. It is a manufacturer’s responsibility to develop and enforce its own guidelines for ensuring that its products are safe and contain the ingredients listed on the label in the specified amounts.
• Bad reactions are not routinely monitored. Manufacturers are not required to report to the FDA any problems that consumers experience after taking their products. The agency does provide voluntary reporting channels for manufacturers, health care professionals, and consumers, and will issue warnings about products when there is cause for concern.
• Dietary supplements can have serious interactions with prescribed medications. No supplement should be taken without first consulting a physician.

Coenzyme Q10

Coenzyme Q10, or ubiquinone, is an antioxidant that occurs naturally in the body and is needed for normal cell reactions to occur. This compound has not been studied for its effectiveness in treating Alzheimer’s.

A synthetic version of this compound, called idebenone, was tested for Alzheimer’s disease but did not show favorable results. Little is known about what dosage of coenzyme Q10 is considered safe, and there could be harmful effects if too much is taken.

Ginkgo biloba

Ginkgo biloba is a plant extract containing several compounds that may have positive effects on cells within the brain and the body. Ginkgo biloba is thought to have both antioxidant and anti-inflammatory properties, to protect cell membranes, and to regulate neurotransmitter function. Ginkgo has been used for centuries in traditional Chinese medicine and currently is being used in Europe to alleviate cognitive symptoms associated with a number of neurological conditions.

In a study published in the Journal of the American Medical Association (October 22/29, 1997), Pierre L. Le Bars, MD, PhD, of the New York Institute for Medical Research, and his colleagues observed in some participants a modest improvement in cognition, activities of daily living (such as eating and dressing), and social behavior. The researchers found no measurable difference in overall impairment.

Results from this study show that ginkgo may help some individuals with Alzheimer’s disease, but further research is needed to determine the exact mechanisms by which Ginkgo works in the body. Also, results from this study are considered preliminary because of the low number of participants, about 200 people.

Few side effects are associated with the use of Ginkgo, but it is known to reduce the ability of blood to clot, potentially leading to more serious conditions, such as internal bleeding. This risk may increase if Ginkgo biloba is taken in combination with other blood-thinning drugs, such as aspirin and warfarin.

Currently, multicenter trial with about 3,000 participants is investigating whether Ginkgo may help prevent or delay the onset of Alzheimer’s disease or vascular dementia.

Huperzine A

Huperzine A (pronounced HOOP-ur-zeen) is a moss extract that has been used in traditional Chinese medicine for centuries. Because it has properties similar to those of FDA-approved Alzheimer medications, it is promoted as a  treatment for Alzheimer’s disease.

Evidence from small studies shows that the effectiveness of huperzine A may be comparable to that of the approved drugs. Large-scale trials are needed to better understand the effectiveness of this supplement.

In Spring 2004, the National Institute on Aging (NIA) launched the first U.S. clinical trial of huperzine A as a treatment for mild to moderate Alzheimer’s disease.

Because huperzine A is a dietary supplement, it is unregulated and manufactured with no uniform standards. If used in combination with FDA-approved Alzheimer drugs, an individual could increase the risks of serious side effects.

Phosphatidylserine

Phosphatidylserine (pronounced FOS-fuh-TIE-dil-sair-een) is a kind of lipid, or fat, that is the primary component of cell membranes of neurons. In Alzheimer’s disease and similar disorders, neurons degenerate for reasons that are not yet understood. The strategy behind the possible treatment with phosphatidylserine is to shore up the cell membrane and possibly protect cells from degenerating.

The first clinical trials with phosphatidylserine were conducted with a form derived from the brain cells of cows. Some of these trials had promising results. However, most trials were with small samples of participants.

This line of investigation came to an end in the 1990s over concerns about mad cow disease. There have been some animals studies since then to see whether phosphatidylserine derived from soy may be a potential treatment. A report was published in 2000 about a clinical trial with 18 participants with age-associated memory impairment who were treated with phosphatidylserine. The authors concluded that the results were encouraging but that there would need to be large carefully controlled trials to determine if this could be a viable treatment.

Coral calcium

“Coral” calcium supplements have been heavily marketed as a cure for Alzheimer’s disease, cancer, and other serious illnesses. Coral calcium is a form of calcium carbonate claimed to be derived from the shells of formerly living organisms that once made up coral reefs.

In June 2003, the Federal Trade Commission (FTC) and the Food and Drug Administration (FDA) filed a formal complaint against the promoters and distributors of coral calcium. The agencies state that they are aware of no competent and reliable scientific evidence supporting the exaggerated health claims and that such unsupported claims are unlawful.

Coral calcium differs from ordinary calcium supplements only in that it contains traces of some additional minerals incorporated into the shells by the metabolic processes of the animals that formed them. It offers no extraordinary health benefits. Most experts recommend that individuals who need to take a calcium supplement for bone health take a purified preparation marketed by a reputable manufacturer.

See also the FDA/FTC press release on the coral calcium complaint