Doctor, am I going to have Alzheimer disease?

I cannot recall how often I was asked “Doctor, do I have Alzheimer disease?” or “Doctor, am I going to have Alzheimer disease?”  I sometimes responded, “If you’re still asking you do not have it;” at least not yet.  My answer is based on the fact that Alzheimer patients have no or reduced insight, and not knowing their own limits or deficits.  The comic strip shows Calvin has insight for his behavior when he says, “Golly, I’d hate to have a kid like me”, although this may be too simplistic to assess whether Alzheimer patients have insight or not.

It is safe to say that memory is the first thing to go for Alzheimer patients.  But, memory is just part of the cognitive impairment that we call dementia (“senile” dementia is an obsolete term).  Our memory will not be as sharp as it used to be as we age (graciously or not).  Some years ago when James Watson’s entire genome was being sequenced, he asked the researchers to tell him any defect genes if he had (as he can take it) with only one exception of Alzheimer gene (ApoE4).  He said were he told that he had it, then he might begin to wonder whether he is falling victim of AD whenever his memory lapsed, which is almost unavoidable as he aged.

In addition to memory impairment, AD patients are gradually losing many other functions, such as executive function (planning, organizing, decision-making and strategizing), complex attention (paying the bill, balancing the checkbook, keeping the doctor’s appointment), language and learning skills, social cognition (losing ability to interact with others may lead to inappropriate behavior), reasoning, abstraction concept, judgment, everything so precious and so dear to us and to our loved ones.  Losing insight though they may be, the AD patients are frustrated, struggling, leading to emotional instability and personality change.

In evaluating the patient one needs to keep in mind that it is not any specific skill one lacks, it is the specific skill that one used to master and now lose.

Alzheimer patients shouldn’t drive.  But AD doesn’t occur overnight and driving can pose problems at the very early stage.  With the long term memory intact, they do not lose the driving skill and may be relatively safe on the road initially.  Some years ago I had a patient (who was apparently in the stage of so called “mild cognitive impairment” or MCI) who was planning to go to a local supermarket, and ended up in Virginia (5-hour drive away). The family didn’t know until they got a call from Virginia policeman.  She apparently forgot where she was going (a short term memory), and didn’t get out of any exit and kept driving and driving.

normal → mild cognitive impairment → Alzheimer disease

Mild cognitive impairment (MCI) is reserved for those who have dementia symptoms similar to that of AD, albeit much milder.  They are still able to function and to live independently, the Alzheimer patient cannot.  MCI patients may go on to have full blown AD if they live long enough, but the data is incomplete as of now.  The three beta-amyloid PET/CT scans show the progression of accumulation of beta-amyloid plaques from normal to MCI and to AD.

If memory lapse is the only problem you have, treat it as a nuisance, an inconvenience in life (and accept the fact that the old age is upon you, like it or not); rest assured that you’re not one of the 5 or 6 millions of unfortunate Alzheimer patients that this country has.