37 Alzheimer’s Dementia

Name: Alice Howland

Source: Still Alice by Lisa Genova (book, 2007)

Background Information

Alice Howland is a Caucasian female who is 50 years old. She currently works as a cognitive psychology professor at Harvard University. Overall, Howland presents as a healthy 50-year-old woman. Howland is a petite woman, but not underweight. Howland remains active in her work and social life and other than leading a hectic life appears happy. Howland lives with her husband (John) and the two have three grown children, all of which live out of the home. Howland maintains many close friendships and is in a stable, long-term relationship. Howland does not have any reported drug or alcohol related history. Howland states that she may have a glass or two of wine with dinner, but the only medication she takes is a multivitamin. Howland has not had any head injuries or serious health issues. Howland’s mother and sister died in a car accident when she was 18 and her father died the previous year from Cirrhosis of the liver. Howland allowed that her father was an alcoholic and that they did not have much contact over the last several years before his death.

Description of the Problem

Howland frequently exhibits disorientation and gets lost when she is only a few blocks from her home. She recognizes the building and knows that she is supposed to know how to get home, but her mind is blank. Howland frequently misplaces items and is unable to find them. At times, she replaces items and later finds the lost item. She frequently loses her train of thought, or is unable to remember significant details of her life. As a professor, she often visited other universities as a guest speaker or would present at conferences, lately, she would lose track near the middle to end of her lecture and have to refer to her notes. This was not common for Howland as she used her speeches repeatedly only making small changes that were easy to remember. Howland reports forgetting words during a lecture, she states that it is not even on the tip of her tongue; the word is just completely gone from her memory. Howland recently missed a conference in Chicago, simply because she forgot about it. Howland also states that she has to write down a detailed schedule of what time and where her classes are or she will simply forget to go teach them.

Diagnosis

Dementia of the Alzheimer’s Type (294.1x)

Diagnostic criteria:

1. The development of multiple cognitive deficits manifested by both
   • (1) memory impairment (impaired ability to learn new information or to recall previously learned information)
   • (2) one (or more) of the following cognitive disturbances:
     1. aphasia (language disturbance)
     2. apraxia (impaired ability to carry out motor activities despite intact motor function)
     3. agnosia (failure to recognize or identify objects despite intact sensory function)
     4. disturbance in executive functioning (i.e. planning, organizing, sequencing, abstracting)
2. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
3. The course is characterized by gradual onset and continuing cognitive decline.
4. The cognitive deficits in Criteria A1 and A2 are not due to any of the following:
   • (1) other central nervous system conditions that cause progressive deficits in memory and cognition (e.g. cerebrovascular disease, Parkinson’s disease, Huntington’s disease, subdural hematoma, normal-pressure hydrocephalus, brain tumor)
   • (2) systemic conditions that are known to cause dementia (e.g. hypothyroidism, vitamin B12 or folic acid deficiency, niacin deficeincy, hypercalcemia, ceurosyphilis, HIV infection)
   • (3) substance-induced conditions
5. The deficits do not occur exclusively during the course of a delirium.
6. The disturbance is not better accounted for by another Axis I disorder (e.g. Major Depressive Disorder, Schizophrenia).

Howland displays impairment in recalling previous learned material and has disturbances in executive functioning. Howland is not suffering from any central nervous system conditions, systemic conditions, or substance-induced conditions. She is having difficulties at work due to her memory loss unlike her previous performance in her job. Her memory loss and confusion began gradually and steadily worsened.

• Code based on presence or absence of a clinically significant behavioral disturbance:
  • 294.10 Without Behavioral Disturbance: if the cognitive disturbance is not accompanied by any clinically significant behavioral disturbance.
  • 294.11 With Behavioral Disturbance: if the cognitive disturbance is accompanied by a clinically significant behavioral disturbance (e.g., wandering, agitation).

Howland does not present with any behavioral disturbances at this time.

• Specify subtype:
  • With Early Onset: if onset is at age 65 years or below
  • With Late Onset: if onset is after age 65 years
• Coding note: Also code 331.0 Alzheimer’s disease on Axis III. Indicate other prominent clinical features related to the Alzheimer’s disease on Axis I (e.g., 293.83 Mood Disorder Due to Alzheimer’s Disease, With Depressive Features, and 310.1 Personality Change Due to Alzheimer’s Disease, Aggressive Type).

Howland’s diagnosis falls under the Early Onset subtype as she is only 50 years old.

Epidemiology

The prevalence rates of Dementia of Alzheimer’s Type increases dramatically with increasing age, rising from .6% in males and .8% in females at age 65 to 11% in males and 14% in females by age 85. As age increases so do the prevalence rates; at age 90 the rates rise to 21% in males and 25% in females, and by age 95 the prevalence rates are as high as 36% in males and 41% in females. Unfortunately, 40%-60% are moderate to severe cases.

Howland was unaware of her extended families medical history because her mother passed at a young age and her father, to her knowledge, did not display any symptoms before his death.

Accuracy of Portrayal

Overall, the book accurately displays the course of Early Onset Alzheimer’s. The high and lows of mood as the disease progresses are genuine and show the true emotions that not only a person suffering from the disease deals with, but what family members and friends deal with. The book also shows how the disease progresses, somewhat slowly at first and then a continual decline in functioning, not only mentally but also physically. The rate at which each person declines is different, but overall the beginning is gradual and then the decline seems to speed up. It does seem as if the book may have sped up the disease a bit much. The confusion and slight memory loss that progresses into complete memory loss and description of living with strangers does seem to ring true. A person with this disease must frequently feel as if she is with strangers, even when she is with her own family. The book did not go into the very late stages of the disease, at which time those with Alzheimer’s physical decline is serious and require feeding tubes and most usually hospitalization or nursing home care, as they are no longer able to walk, feed themselves, or even speak.

Treatment

At this time, there are no medications available to cure Alzheimer’s, only medications that seem to slow the progression. For Alice Howland the best course of treatment would include cholinesterase inhibitors during the beginning stages and an N-methyl D-aspartate (NMDA) antagonist once symptoms become more severe in nature. These medications only slow the progression of the disease, although these medications have been effective in slowing the progression of Alzheimer’s in many patients. When the disease presents itself as a safety issue for Howland (forgetting that she is cooking, wandering off and getting lost or unable to take care of her personal daily needs) she needs either nursing home care or 24-hour home care. When Howland reaches the stage where she is no longer able to feed herself or walk, nursing home care is the best recourse for proper care. A healthy diet recommendation through all stages of the disease by limiting unhealthy food intake and eating healthy may help slow the progression of Alzheimer’s. However, this is in combination with proper medication. As long as she is able, exercise, reading, crossword puzzles, and other mentally and physically stimulating activities may help slow the progression of the disease, however, there is not adequate research into this area.

Name: Fiona Anderson

Source: Away From Her (movie, 2006)

Background Information

Fiona Anderson is a Caucasian female in her late 60’s/early 70’s. She is fit for her age, not overweight or underweight. Fiona’s family originates from Iceland, but she was raised in Canada. She is married to Grant Anderson (for 44 years) and they have no children. Fiona is currently unemployed; after Grant retired from his job as a professor, the couple moved to Brandt County, Ontario. The couple currently lives in the farmhouse that belonged to Fiona’s grandparents and have lived there for 20 years. Fiona lives an active lifestyle by going on cross country skiing trips around their property with her husband. The couple will occasionally see their other married friends, but most live far away. There is no known drug or alcohol problem. Fiona has the occasional drink at home with her husband, but in no way ever appears to have had too much. There is a subject matter that has remained unresolved between Fiona and her husband; while Grant was still teaching there was speculation and rumors that he had an affair with one of his students. Fiona, instead of enraged by Grant’s adultery was thankful that he did not leave her. In order to make a better life for themselves and they moved away from all the distractions. Fiona seems to have dealt with Grant’s unfaithfulness and her deteriorating memory with a great deal of acceptance and dignity.

Description of the Problem

Fiona exhibits the early signs of memory loss. When she is helping put away the dishes, she forgets, pauses, puts the frying pan in the freezer, and walks away. Her memory loss then progresses to where she has to put labels on all the cabinets and drawers of what belongs where. Fiona admits that at times she forgets what words mean, like the word yellow. Fiona forgets how to say “wine” while offering her guest another glass. During her evaluation she is asked a series of questions involving mail, she answers the majority of the questions correct but then forgets where a person would take the mail to send it. Fiona becomes even more disoriented as time goes by and loses her way home and wanders off. Her husband is constantly finding things that she has left undone or forgot about, such as when she put a pot of water on to boil, then left the house. The most recent development of Fiona’s memory degrading happened after she was admitted to Meadowlake, a care taking facility. After being separated from her husband for only 30 days she seemed to have lost all knowledge of their married life. She exhibited recognition of his face but not what they meant to each other or the life they shared. Fiona begins to form an attachment with a man who is in Meadowlake with her; when asked about him she states, “I like Aubrey because he doesn’t confuse me.”

Diagnosis

Dementia of the Alzheimer’s Type (294.1x)

Diagnostic criteria:

1. The development of multiple cognitive deficits manifested by both
   • (1) memory impairment (impaired ability to learn new information or to recall previously learned information)
   • (2) one (or more) of the following cognitive disturbances:
     1. aphasia (language disturbance)
     2. apraxia (impaired ability to carry out motor activities despite intact motor function)
     3. agnosia (failure to recognize or identify objects despite intact sensory function)
     4. disturbance in executive functioning (i.e. planning, organizing, sequencing, abstracting)
2. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
3. The course is characterized by gradual onset and continuing cognitive decline.
4. The cognitive deficits in Criteria A1 and A2 are not due to any of the following:
   • (1) other central nervous system conditions that cause progressive deficits in memory and cognition (e.g. cerebrovascular disease, Parkinson’s disease, Huntington’s disease, subdural hematoma, normal-pressure hydrocephalus, brain tumor)
   • (2) systemic conditions that are known to cause dementia (e.g. hypothyroidism, vitamin B12 or folic acid deficiency, niacin deficiency, hypercalcemia, ceurosyphilis, HIV infection)
   • (3) substance-induced conditions
5. The deficits do not occur exclusively during the course of a delirium.
6. The disturbance is not better accounted for by another Axis I disorder (e.g. Major Depressive Disorder, Schizophrenia).

Fiona meets criteria for A1 and A2; the cognitive disturbances that she exhibits are aphasia, agnosia, and possible impaired ability to carry out particular motor abilities. The impairments from criteria A1 and A2 have affected her relationship with her spouse, friends, and how she interacts with others, as well as her daily activities. Fiona does not have any recorded nervous system, substance-induced, or systemic conditions that could impair her memory. Fiona’s memory loss has had a continuous decline and started gradually. She is not recorded to have any other Axis I disorders.

Code based on presence or absence of a clinically significant behavioral disturbance:

• 294.10 Without Behavioral Disturbance: if the cognitive disturbance is not accompanied by any clinically significant behavioral disturbance.
• 294.11 With Behavioral Disturbance:if the cognitive disturbance is accompanied by a clinically significant behavioral disturbance (e.g., wandering, agitation).

Fiona has presented some behavioral disturbances, such as wandering the street and woods.

Accuracy of Portrayal

Overall, the movie provides an accurate portrayal of the disease and the effects it has on the person suffering from it. A person not knowing anything about Alzheimer’s would learn from the movie that with time that short-term or working memory starts to diminish first. A person suffering from Alzheimer’s will gradually lose more of their memory abilities, eventually impairing their long-term memory and recall. They will also learn that people with Alzheimer’s can know someone one day but not know them the next. They may also repeat the same questions or statements, having no recollection of already saying them. In the movie they say Fiona is young for already having Alzheimer’s, which is not entirely accurate, as she is beyond the age of 65. This puts her in the Late Onset category, which is more common than Early Onset.

Treatment

There is no current cure for Alzheimer’s, but there are medications shown to help slow the progression of the disease. The Food and Drug Administration has approved two types of drugs that could help Fiona: cholinesterase inhibitors and mematine. A good diet and exercise will also help in creating a good environment for the medication to work and help Fiona stay mentally alert. It would also be beneficial to keep the mind working by taking part in any sort of puzzles that help exercise the brain. In the movie they admitted Fiona into a caretaking facility not too long after she was diagnosed with the disease. In my opinion, they could have waited longer to admit her. Her memory seemed to deteriorate faster after she was in the care of the home.