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ARTICLES
Arthritis and anti-inflammatory agents as possible protective factors for Alzheimer's disease
A review of 17 epidemiologic studies

1. 2. 3.

Patrick L. McGeer, PhD, FRCP(C), MD, Michael Schulzer, PhD and Edith G. McGeer, PhD +Author Affiliations 1. From the Kinsmen Laboratory of Neurological Research, Department of Psychiatry (Drs McGeer and E.G. McGeer) and the Departments of Medicine and Statistics (Dr. Schulzer), University of British Columbia, Vancouver, BC, Canada. 2. Supported by grants from the Alzheimer Society of B.C. and the Jack Brown and Family A.D. Research Fund, as well as donations from individual British Columbians. 3. Received November 3, 1995. Accepted in final form January 19, 1996. 4. Address correspondence and reprint requests to Dr. Patrick L. McGeer, Kinsmen Laboratory of Neurological Research, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.

ABSTRACT
Alzheimer's disease (AD) lesions are characterized by the presence of numerous inflammatory proteins.This has led to the hypothesis that brain inflammation is a cause of neuronal injury in AD and that anti-inflammatory drugs may act as protective agents. Seventeen epidemiologic studies from nine different countries have now been published in which arthritis, a major indication for the use of anti-inflammatory drugs, or anti-inflammatory drugs themselves have been considered as risk factors for AD. Both factors appear to be associated with a reduced prevalence of AD. The small size of most studies has limited their individual statistical significance, but similarities in design have made it possible to evaluate combined results. We have used established methods of statistical meta-analysis to estimate the overall chance of individuals exposed to arthritis or anti-inflammatory drugs developing AD as compared with the general population. Seven case-control studies with arthritis as the risk factor yielded an overall odds ratio of 0.556 (p < 0.0001), while four case-control studies with steroids yielded odds ratios of 0.656 (p = 0.049) and three case-control studies with nonsteroidal anti-inflammatory drugs (NSAIDs) yielded an odds ratio of 0.496 (p = 0.0002). When NSAIDs and steroids were combined into a single category of anti-inflammatory drugs, the odds ratio was 0.556 (p < 0.0001). Population-based studies were less similar in design than case-control studies, complicating the process of applying statistical meta-analytical techniques. Nevertheless, population-based studies with rheumatoid arthritis and NSAID use as risk factors strongly supported the results of case-control studies. These data suggest anti-inflammatory drugs may have a protective effect against AD. Controlled clinical trials will be necessary to test this possibility. NEUROLOGY 1996;47: 425-432 y Copyright 1996 by Advanstar Communications Inc. Scientists have identified factors that increase the risk of Alzheimers. The most important risk factorsage, family history and hereditycan't be changed, but emerging evidence suggests there may be other factors we can influence.

Age Family history

Genetics What you can do now



AGE The greatest known risk factor for Alzheimers is advancing age. Most individuals with the disease are age 65 or older. The likelihood of developing Alzheimers doubles about every five years after age 65. After age 85, the risk reaches nearly 50 percent. One of the greatest mysteries of Alzheimer's disease is why risk rises so dramatically as we grow older.

Family history
Another strong risk factor is family history. Those who have a parent, brother, sister or child with Alzheimers are more likely to develop the disease. The risk increases if more than one family member has the illness. When diseases tend to run in families, either heredity (genetics) or environmental factors, or both, may play a role.

Aluminum not a cause

During the 1960s and 1970s, aluminum emerged as a possible suspect in causing Alzheimers disease. This suspicion led to concerns about everyday exposure to aluminum through sources such as cooking pots, foil, beverage cans, antacids and antiperspirants. Since then, studies have failed to confirm any role for aluminum in causing Alzheimers. Almost all scientists today focus on other areas of research, and few experts believe that everyday sources of aluminum pose any threat.

Genetics (heredity)
Scientists know genes are involved in Alzheimers. There are two types of genes that can play a role in affecting whether a person develops a diseaserisk genes and deterministic genes. Alzheimer's genes have been found in both categories.

Genetic testing
Genetic tests are available for both APOEe4 and the rare genes that directly cause Alzheimers. However, health professionals do not currently recommend routine genetic testing for Alzheimers disease. Testing for APOE-e4 is sometimes included as a part of research studies. Learn more: Genetic Testing Topic Sheet 1. Risk genes increase the likelihood of developing a disease, but do not guarantee it will happen. Scientists have so far identified several risk genes implicated in Alzheimer's disease. The risk gene with the strongest influence is called

apolipoprotein E-e4 (APOE-e4). Scientists estimate that APOE-e4 may be a factor in 20 to 25 percent of Alzheimer's cases. APOE-e4 is one of three common forms of the APOE gene; the others are APOE-e2 and APOE-e3. Everyone inherits a copy of some form of APOE from each parent. Those who inherit APOE-e4 from one parent have an increased risk of Alzheimers. Those who inherit APOE-e4 from both parents have an even higher risk, but not a certainty. Scientists are not yet certain how APOE-e4 increases risk. In addition to raising risk, APOE-e4 may tend to make Alzheimer's symptoms appear at a younger age than usual. 2. Deterministic genes directly cause a disease, guaranteeing that anyone who inherits them will develop the disorder. Scientists have discovered variations that directly cause Alzheimers disease in the genes coding three proteins: amyloid precursor protein (APP), presenilin-1 (PS-1) and presenilin-2 (PS-2). When Alzheimers disease is caused by these deterministic variations, it is called autosomal dominant Alzheimers disease (ADAD) or familial Alzheimers disease, and many family members in multiple generations are affected. Symptoms nearly always develop before age 60, and may appear as early as a person's 30s or 40s. Deterministic Alzheimer's variations have been found in only a few hundred extended families worldwide. True familial Alzheimers accounts for less than 5 percent of cases.

A closer look: Genes linked to Alzheimer's

The 23 human chromosome pairs contain all of the 30,000 genes that code the biological blueprint for a human being. This interactive illustration highlights the chromosomes containing each of the three genes that cause familial Alzheimer's and the gene with the greatest impact on Alzheimer's risk.

23 chromosome pairs

Amyloid precursor protein (APP), discovered in 1987, is the first gene with mutations found to cause an inherited form of Alzheimer's. Presenilin-1 (PS-1), identified in 1992, is the second gene with mutations found to cause earlyonset of Alzheimer's. Variations in this gene are the most common cause of early-onset Alzheimer's. Presenilin-2 (PS-2), 1993, is the third gene with mutations found to cause early-onset Alzheimer's. Apolipoprotein E-e4 (APOE4), 1993, is the first gene variation found to increase risk of Alzheimer's and remains the risk gene with the greatest known impact. Having this mutation, however, does not mean that a person will develop the disease.

What you can do now: Factors you may be able to influence

Most experts believe that the majority of Alzheimer's disease occurs as a result of complex interactions among genes and other risk factors. Age, family history and heredity are all risk factors we cant change. Now, research is beginning to reveal clues about other risk factors we may be able to influence through general lifestyle and wellness choices and effective management of other health conditions. Head trauma: There may be a strong link between serious head injury and future risk of Alzheimers, especially when trauma occurs repeatedly or involves loss of consciousness. Protect your brain by buckling your seat belt, wearing your helmet when participating in sports, and fall-proofing your home. Heart-head connection: Growing evidence links brain health to heart health. Your brain is nourished by one of your bodys richest networks of blood vessels. Every heartbeat pumps about 20 to 25 percent of your blood to your head, where brain cells use at least 20 percent of the food and oxygen your blood carries. The risk of developing Alzheimers or vascular dementia appears to be increased by many conditions that damage the heart or blood vessels. These include high blood pressure, heart disease, stroke, diabetes and high cholesterol. Work with your doctor to monitor your heart health and treat any problems that arise. Studies of donated brain tissue provide additional evidence for the heart-head connection. These studies suggest that plaques and tangles are more likely to cause Alzheimer's symptoms if strokes or damage to the brains blood vessels are also present.

Latinos and African-Americans at risk

Because Latinos and African-Americans in the United States have higher rates of vascular disease, they also may be at greater risk for developing Alzheimers. According to a growing body of evidence, risk factors for vascular disease including diabetes, high blood pressureand high cholesterol may also be risk factors for Alzheimers and stroke-related dementia. Learn more: Be Heart Smart and Adopt a Brain Healthy Diet. General healthy aging: Other lines of evidence suggest that strategies for overall healthy aging may help keep your brain as well as your body fit. These strategies may even offer some protection against developing Alzheimers or related disorders. Try to keep your weight within recommended guidelines, avoid tobacco and excess alcohol, stay socially connected, and exercise both your body and mind.

Potential Contributing Factors

y Cardiovascular disease: Risk factors associated with heart disease and stroke, such as

high blood pressure and high cholesterol, may also increase one's risk of developing Alzheimer's disease. High blood pressure may damage blood vessels in the brain, disrupting regions that are important in decision-making, memory and verbal skills. This

could contribute to the progression of the disease. High cholesterol may inhibit the ability of the blood to clear protein from the brain.
y Type 2 Diabetes: There is growing evidence of a link between Alzheimer's disease and type

2 diabetes. In Type 2 diabetes insulin does not work effectively to convert blood sugar into energy. This inefficiency results in production of higher levels of insulin and blood sugar which may harm the brain and contribute to the progression of Alzheimer's.
y Oxidative Damage: Free radicals are unstable molecules that sometimes result from

chemical reactions within cells. These molecules seek stability by attacking other molecules, which can harm cells and tissue and may contribute to the neuronal brain cell damage caused by Alzheimer's.
y Inflammation: Inflammation is a natural, but sometimes harmful, healing bodily function in

which immune cells rid themselves of dead cells and other waste products. As protein plaques develop, inflammation results, but it is not known whether this process is damaging and a cause of Alzheimer's, or part of an immune response attempting to contain the disease.
y Other Possible Risk Factors: Some studies have implicated prior traumatic head injury,

lower education level and female gender as possible risk factors. Alzheimer's disease may also be associated with an immune system reaction or a virus.

Heredity
Familial Alzheimers disease (FAD) or early-onset Alzheimers is an inherited and rare. It affects less than 10 percent of Alzheimers disease patients. Familial Alzheimer's disease develops before age 65, in people as young as 35. It is caused by gene mutations on chromosomes 1, 14 and 21. If even one of these mutated genes is inherited from a parent, the person will almost always develop Familial Alzheimer's disease. All offspring in the same generation have a 50/50 chance of developing this type of Alzheimer's if one parent has it. The majority of Alzheimers disease cases are late-onset, usually developing after age 65. Lateonset Alzheimers disease has no known cause and shows no obvious inheritance pattern. However, in some families, clusters of cases are seen. Although a specific gene has not been identified as the cause of late-onset Alzheimers disease, genetic factors do appear to play a role in the development of this form of the disease. A gene called Apolipoprotein E (ApoE) appears to be a risk factor for the late-onset form of Alzheimer's disease. There are three forms of this gene: ApoE2, ApoE3 and ApoE4. Roughly one in four Americans has ApoE4 and one in twenty has ApoE2. While inheritance of ApoE4 increases the risk of developing Alzheimer's disease, ApoE2 substantially protects against it.

Scientists believe that several other genes may influence the development of Alzheimers disease. Two of these genes, UBQLN1 and SORL1, are located on chromosomes 9 and 11. Researchers have also identified three genes on chromosome 10, one of which produces an insulin degrading enzyme that may contribute to the disease. A gene, called TOMM40, appears to significantly increase ones susceptibility to developing Alzheimers when other risk factors are present, such as having the ApoE-4 gene. Several recently discovered genes that influence Alzheimers disease risk are CLU (also called APOJ) on chromosome 8, which produces a protein called clusterin, PICALM on chromosome 11 and CR1 on chromosome 1. Genetic risk factors alone are not enough to cause the late-onset form of Alzheimers disease, so researchers are actively exploring education, diet and environment to learn what role they might play in the development of this disease.

Prevention
Alzheimer's disease is a complex disorder, for which there is currently no known prevention or cure. Some research has generated hope that one day it might be possible to slow the progression of Alzheimers disease, delay its symptoms or even prevent it from occurring at all. Although there is preliminary data to support the benefit of some interventions, such as physical activity and cardiovascular risk reduction, nothing at this time has definitively been shown to prevent Alzheimer's disease or other dementias. The scientific advisors of the American Health Assistance Foundation (AHAF) do not currently recommend or endorse any commercial nutritional supplement, exercise program, or cognitive training exercises for the purposes of preventing Alzheimers disease. In spite of this, AHAF encourages people to evaluate the role of these interventions on the overall health and spirits of both the patient and caregivers

Diet
A number of preliminary studies suggest that how we eat may raise or lower our risk of developing Alzheimers disease. Eating a diet that is high in whole grains, fruits, vegetables and that is low in sugar and fat can reduce the incidence of many chronic diseases, and researchers are continuing to study whether these dietary modifications are also applicable to Alzheimers disease. However, the strongest research supporting these modifications has been performed in animal studies, and remains to be rigorously established in randomized and controlled clinical trials. There are, however, some exciting reports, that though currently preliminary, may one day be shown to protect against Alzheimers disease. Many of these modifications have also been shown to be part of overall healthy lifestyles that are likely to protect against other diseases as

well. For example, researchers found that clinical trial participants who adhered to a Mediterranean diet have a slower decline on the mini-mental state examination (MMSE) cognitive decline. The Mediterranean diet may be protective against other diseases as well, including age-related macular degeneration. Also, vitamin D3 has been shown to have neuroprotective effects that may preserve cognitive function. This vitamin is produced naturally by the body from exposure to the sun, and is also being studied by AHAF supported scientists for its potential protective effects against glaucoma. Some studies conducted in animals have shown that including blueberries, strawberries, and cranberries in the diet can lead to improved cognitive function, both in animals that age normally and in those that have been bred to develop Alzheimers disease. Scientists are beginning to study what chemicals within these berries might be responsible for their beneficial effects. Curcumin is a spice typically found in turmeric which is used to enhance the flavor of curries and meats in Indian cuisine. Currently researchers are studying the effects of curcumin on the human brain. Recent research implies that curcumin might actually reduce the amount of betaamyloid plaques associated with Alzheimers disease. The problem with curcumin is that, in its natural state it is very difficult for a human body to absorb curcumin consumed as food. Once in the blood stream, it is also quite difficult for curcumin pass from the blood to the brain. AHAF funded scientists are studying whether special preparations of curcumin might overcome these limitations. Similarly, a study conducted on green tea and Alzheimers disease indicates that an antioxidant found in green tea, called epigallocatechin gallate (EGCG), has powerful antiplaque ability and may actually prevent or delay Alzheimers disease. Switching from animal based oils and vegetable oil to extra virgin olive oil may also be a good habit to adopt. According to recent research, not only is extra virgin olive oil a generally healthy food, but it may prevent Alzheimers disease as well. Studies suggest that oleocanthal, a naturally-occurring compound found in extra-virgin olive oil, changes the structure of Amyloid beta-Derived Diffusible Ligands (ADDLs). ADDLs are proteins that are toxic to nerve cells and may contribute to the symptoms of Alzheimer's disease. By structurally changing ADDLs, oleocanthal may be stopping the proteins' ability to damage nerve cells within the brain.

Exercise
Exercise is an important activity to add to a healthy lifestyle. AHAF encourages people to discuss exercise plans with their health care provider, so that an appropriate exercise program can be tailored for your specific needs. Studies conducted on those with mild cognitive impairment (MCI) indicate that aerobic exercise may improve cognitive agility. In one study, investigators looked at the relationship between physical activity and ones risk of developing Alzheimers disease. 1,700 adults aged 65 years and older were observed over a 6-year period in this study. Results showed that the risk of Alzheimers disease was 35 to 40 percent lower in

those who exercised for at least 15 minutes 3 or more times a week than in those who exercised fewer than 3 times a week. While it is not proven that exercise could prevent Alzheimers disease or slow its progression, animal studies and preliminary human studies have produced significant interest amongst scientists. Larger, and more rigorous, randomized controlled trials will be necessary before a definitive statement on the role of exercise in the prevention of Alzheimers disease can be made. In spite of this, developing an exercise program as part of an Alzheimers disease patients routine may also be helpful with maintaining muscle strength, decreasing frailty, and elevating mood.

Building Brain Reserves & Social Engagement

Many people born between 1945 and 1964 or baby boomers are beginning to worry about Alzheimers disease. Millions are already caring for their parents and watching them fade away, and they realize they may be next in line. Although there is currently no cure, scientists believe there are ways to lower the risk of developing Alzheimers disease by continually exercising our brains. Some research suggests that shoring up mental reserves as we age may protect against the onslaught of Alzheimer's. This approach may also delay onset of the disease or possibly help retain cognitive function longer if it does strike. Building cognitive reserves is a lifelong process that begins in childhood as we expand reading skills. According to classic neurological theory, during the early developmental stages of life, the human brain forms an enormous number of neurons, or nerve cells, but many of these cells also die. The neurons that survive do so by connecting with other neurons during the rapidgrowth stage of the nervous system that occurs in childhood and adolescence. Reading progressively more challenging books, learning a musical instrument, creating art, playing chess and engaging in any mental activity all help form these vital neural connections that can last a lifetime, and appear to buffer people from cognitive decline later on. Fortunately, according to the theory of "neuroplasticity," brain reserves can be expanded throughout life, even into advanced old age. A team of researchers led by Dr. David Bennett, M.D., director of the Rush Alzheimers Research Center, has studied neuroplasticity in adults. These scientists found that those who continue to learn, to embrace new activities, learn new skills in essence, to exercise their brains -- continue to build up connections that in turn lower their risk of Alzheimer's disease. Perhaps they have begun to develop the disease, but they show no symptoms because they have brain cells to spare. Another study led by Dr. Robert Friedland, of Case Western Reserve University School of Medicine, compared mental, physical and social activity levels in adults with rates of developing Alzheimer's disease. The researchers discovered that the more active adults, those who played

a musical instrument, gardened, and played mentally engaging board games, for example, were significantly less likely to develop Alzheimer's disease. The benefit extended to those who were active between the ages of 40 and 60, so its never too late to start building intellectual muscle, and stimulating hobbies have a pay-off regardless of the age they are started. Each of these studies, though hopeful and promising, require replication before their impact on risk of Alzheimers disease can be confirmed. But what does it hurt? While AHAF does not recommend any commercial products that advertise Alzheimers disease prevention, learning new skills or enriching your life in study of a favorite topic is an act of empowerment that AHAF recommends for all people at any age. It is never too late to start new and creative activities. Continue to enjoy favorite pastimes, but challenge yourself by learning something new. Try a foreign language, read books and newspapers, solve puzzles and brain teasers, sing, dance, play board and video games, correspond by mail and email and engage in conversation. The combination of social, mental and physical stimulation is really the best medicine we have for a healthy life.

NSAIDS
Over the past couple of years, reports have been surfacing that NSAIDs like Ibuprofen, Naproxen and COX-2 inhibitors might actually prevent Alzheimers disease. Researchers have been rigorously studying the relationship between NSAID use and Alzheimers disease and no benefit has been demonstrated. Despite these results, scientists continue to look for ways to test how other anti-inflammatory drugs might affect the development or progression of Alzheimers disease.

Estrogen
Over the past several years, estrogen has been recognized as having a protective role in the brain. However, its potential role in the development of Alzheimers disease has yet to be determined. In fact, clinical trials have shown that estrogen does not slow the progression of already-diagnosed Alzheimers disease and is not effective in treating or preventing AD if treatment is begun in later life. One large trial found that women older than 65 who began taking estrogen in the form of Premarin or PremPro were actually at an increased risk of developing Alzheimers disease and dementia. Although results from such studies were disappointing, many questions remain. For instance, would starting estrogen therapy closer to menopause be more effective in preventing Alzheimers disease? These questions and other concerns related to estrogens relationship with Alzheimers disease are currently being studied in clinical trials.

Diabetes and Alzheimer's linked

Diabetes may increase your risk of Alzheimer's. Reduce this risk by controlling your blood sugar. Diet and exercise can help.
By Mayo Clinic staff Diabetes and Alzheimer's disease are connected in ways that still aren't completely understood. While not all research confirms the connection, many studies indicate that people with diabetes especially type 2 diabetes are at higher risk of eventually developing Alzheimer's disease. Taking steps to prevent or control diabetes may help reduce your risk of Alzheimer's disease.

Understanding the connection

Because diabetes damages blood vessels, it has long been recognized as a risk factor for vascular dementia a type of cognitive decline caused by damaged blood vessels in the brain. Many people with cognitive decline have brain changes that are hallmarks of both Alzheimer's disease and vascular dementia. Some researchers think that each condition helps fuel the damage caused by the other. Ongoing research focuses on confirming the link between Alzheimer's and diabetes and understanding why it exists. The link between type 2 diabetes and Alzheimer's may be especially strong as a result of the complex ways that type 2 diabetes affects the ability of the brain and other body tissues to use sugar (glucose) and respond to insulin. Diabetes may also increase the risk of developing mild cognitive impairment (MCI), a transition stage between the cognitive changes of normal aging and the more serious problems caused by Alzheimer's disease and other types of dementia. Greater insight into how diabetes and Alzheimer's disease are connected may eventually reveal new strategies to avoid Alzheimer's as a complication of diabetes. These insights may also suggest new Alzheimer's treatments.

Reducing your risk of Alzheimer's

Based on today's knowledge, working with your health care team to prevent diabetes or manage your diabetes effectively is your best strategy to avoid complications including those that may affect your brain. Preventing diabetes or managing it successfully will also help you avoid other complications, including heart disease and damage to your eyes, kidneys and nerves in your feet. Steps you can take to prevent or manage diabetes include: Follow your health care team's recommendations about the best plan for monitoring your blood glucose, cholesterol level and blood pressure.

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Eat healthy foods, including fruits and vegetables, lean meats, whole grains, and low-fat milk and cheese. Exercise at least 30 minutes most days of the week. If your doctor prescribes medication, take it on schedule. Small steps can make a big difference. In a large study funded by the National Institute of Diabetes and Digestive and Kidney Diseases, participants with blood sugar levels slightly above normal (prediabetes) cut their risk of developing type 2 diabetes in half by losing as little as 5 to 7 percent of their body weight and exercising for 30 minutes five days a week. That weight loss translates to 10 to 14 pounds (4.5 to 6.4 kilograms) for a 200-pound (90.7-kilogram) person.

Can a head injury cause or hasten Alzheimer's disease or other types of dementia?
Answer
from Glenn Smith, Ph.D.
The immediate effects of a head injury can include dementia symptoms, such as confusion, memory loss, and changes in speech, vision and personality. Depending on the severity of your injury, these symptoms may clear up quickly, last a long time or never go away completely. However, such symptoms that begin soon after your injury generally don't get worse over time as happens with Alzheimer's disease. Certain types of head injuries, however, may increase your risk of developing Alzheimer's disease or other dementias later in life. The greatest increase in future dementia risk seems to occur after a severe head injury that knocks you out for more than 24 hours. A moderately serious head injury that causes unconsciousness for more than 30 minutes, but less than 24 hours, also seems to increase risk to a smaller extent. There's no evidence that a single mild head injury that doesn't knock you out, or that knocks you out for less than 30 minutes, increases your risk of dementia. However, repeated mild injuries may increase risk of future problems with thinking and reasoning. You're likely at greatest risk of developing dementia or Alzheimer's later in life, post-head injury, if you also have other risk factors. For example, carrying one form of the apolipoprotein E (APOE) gene increases the risk of Alzheimer's in any individual. A head injury in such a person would increase his or her risk further. It's important to note that many people who sustain a severe head injury never develop Alzheimer's disease or later dementia. More research is needed to understand the link.

Oophorectomy (ovary removal): A risk factor for dementia?

If I have my ovaries removed before I'm 50, will I be more likely to have dementia when I get older?
Answer
from Mary M. Gallenberg, M.D.
You might, but more research is needed to know for sure. Ovary removal (oophorectomy), often done in conjunction with hysterectomy, has a dramatic effect on your body before menopause. This abrupt loss of your ovaries is also called surgical menopause, because it triggers all the changes of menopause. Your ovaries produce most of your body's estrogen, a reproductive hormone that has many functions beyond regulating your menstrual cycle. Estrogen may protect your brain from age-related changes leading to cognitive impairment and dementia. Some studies have suggested that early oophorectomy may increase your risk of dementia or other cognitive function deficits. Some research suggests that you may help offset this risk by taking hormone therapy (HT) until you reach a natural age of menopause. More research will be needed before doctors can know for sure whether oophorectomy will increase your risk of dementia and whether HT is necessary. That's why it's important to talk with your doctor before deciding to have an oophorectomy. Ask your doctor: What condition the surgery is treating What other treatment options there are Whether you're close to menopause Whether you'll be a candidate for HT For some women, oophorectomy is worth the long-term risks. If you carry one of the genetic mutations that make you likely to develop breast and ovarian cancers, for example, this surgery may save your life even if you don't take HT.

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What is Alzheimer's disease?

Alzheimer's disease is the most common of a large group of disorders known as "dementias." It is an irreversible disease of the brain in which the progressive degeneration of brain cells causes thinking ability and memory to deteriorate. Alzheimer's disease also affects behaviour, mood and emotions, and the ability to perform daily living activities.

There is currently no cure for Alzheimer's disease, but there are treatment options and lifestyle choices that can slow its progression and, within the next five years, treatments are expected that may well stop the disease in its tracks! Also, the pursuit of new research strategies should one day help restore some lost function and memory. Alzheimer's disease progresses through early, middle and late stages before reaching the final end of life stage. However, identifying the transition from one stage to another is often difficult. Not only does the disease usually progress slowly, but the symptoms related to each stage tend to overlap and the order in which they appear and how long they last varies from person to person. The duration following diagnosis is usually seven to ten years. However, when the diagnosis is delayed, as it may be if the affected person fails to see a doctor early on, the disease duration is shorter than this. Conversely, as the ability to diagnose Alzheimer's disease improves and people become more willing to be assessed, survival times following diagnosis are lengthening.

What are risk factors?

Many diseases have specific causes, for example a virus causes measles. However, the causes of many chronic diseases or conditions are unknown or uncertain. In their search for answers, scientists look for factors that appear to be linked to the development of a disease. These are "risk factors" if they are present, there is an increased chance, but not a certainty, that the disease will develop. Risk factors are characteristics of the person, their lifestyle, environment, and genetic background, which contribute to the likelihood of getting a disease. Some risk factors can be modified (e.g. lowering blood pressure); other risk factors cannot be modified (such as a person's genetic makeup). It is important to note that risk factors are not on their own causes of a disease. In general, scientists believe that Alzheimer's disease is caused when the combined effects of the various risk factors cross a certain threshold and overwhelm the natural self-repair mechanisms in the brain, thus reducing the brain's ability to maintain healthy nerve cells. Identification of risk factors for Alzheimer's disease is important because they can indicate lifestyle choices that can help reduce a person's chance of developing the disease. Some factors are beyond individual control, while other important risk factors can be reduced through appropriate lifestyle.

How are risk factors determined?

Two types of studies are used to determine risk factors. One approach is to study people who already have the disease (in this case Alzheimer's disease) and compare them with people who are similar in age, gender and other characteristics, but who do not have the disease. This is known as a case-control study. Information is gathered on their personal and family characteristics, as well as on past exposures that may have occurred through lifestyle and work. Risk factors are identified as occurring more frequently in those with the disease than in those without. It is important to note that risk factors are still seen in the group who do not have Alzheimer's disease, but not as often. This method was used in the first analysis of risk factors for Alzheimer's disease from the Canadian Study of Health and Aging (CSHA).1

The second approach is to monitor a group of healthy people over a long period of time. This is known as a cohort study. From this group, people with particular characteristics (such as a tendency towards high blood pressure) or similar lifestyles (such as vegetarianism) are compared to people without those characteristics or lifestyles to detect any difference in the rate at which the two groups develop a disease. Factors that are known to be associated with a specific disease, such as obesity in the case of Alzheimer's disease, are of particular interest in cohort studies. Using these approaches, characteristics and exposures that are associated with the occurrence of the disease can be identified. This approach was used in the second analysis of risk factors for Alzheimer's disease from the Canadian Study of Health and Aging.2

What are the risk factors associated with Alzheimer's disease?

Age Age is the most important risk factor. As we age, our body's ability to repair itself becomes less efficient. The extent by which the self-repair of our brains diminishes varies from person to person and these differences contribute to an individual's susceptibility to Alzheimer's disease as they age. As well, many of the other known risk factors for the disease tend to increase with age (such as elevated cholesterol and being overweight). However, risk factors do not cause Alzheimer's disease on their own. The brain has to reach a certain critical age for the disease to occur. The older you become the higher the risk 1 in 20 Canadians over age 65 and 1 in 4 of those over age 85 are affected by Alzheimer's disease. Family history and Genetics A very small percentage of people with Alzheimer's disease (5-7%) has Familial Alzheimer's disease or FAD (formerly known as "early onset Alzheimer's disease"). At some point in their family history certain genes mutated and developed the abnormal characteristics that cause FAD. These inherited genes have a powerful influence: if one parent has FAD, each child has a 50 % chance of inheriting the disease, and with two parents with FAD, 75% of their children will go on to develop Alzheimer's disease in adulthood. These inherited genes differentiate FAD from the more common sporadic form of Alzheimer's disease, but the disease itself is identical. The sporadic form of Alzheimer's disease (which used to be called "late onset Alzheimer's disease"), was formerly assumed to have no family linkages. However, it's now known that a person with a direct relative (parent or sibling) with Alzheimer's disease has a three times greater chance of developing the disease than someone who does not.* The risk increases further if both parents have the disease. So aside from the FAD-related genes there are Alzheimer's disease-related genetic factors shared by family members. New research is revealing more and more genetic risk factors for the sporadic form of Alzheimer's disease. That means that these genes are found to a greater extent among those with the disease, though they are also found in people without Alzheimer's disease. People with these genetic risk factors are not in the same high-risk category as people who have the mutated genes responsible for FAD. In fact, the risk associated with any one of these newly discovered genetic risk factors is lower than the risk associated with having a

parent with the sporadic form of the disease (with the exception of the apoE4 gene discussed below). *Here is a useful way of looking at the relative risk: of 100 people with no defined genetic risk factor, 5 will get Alzheimer's disease at age 65 (and 95 will not). Of 100 people, each with a parent with Alzheimer's disease, 15 will get Alzheimer's disease at age 65 (and 85 will not). ApoE4 Gene This gene is the most important genetic risk factor for the sporadic form of Alzheimer's disease. ApoE genes regulate the production of a protein that helps carry cholesterol and other fats in the blood to the cells of the body. Of the three variants of the apoE gene (apoE2, apoE3 and apoE4), the apoE4 variant is associated with an increased risk of Alzheimer's disease. In our cells (except ova and sperm) all genes are paired, one being contributed by the father and one by the mother. If a person's pair of apoE genes includes one apoE4 gene, their risk of developing Alzheimer's disease is increased. However, approximately half of all people with two apoE4 genes will develop Alzheimer's disease at age 65. People with no apoE4 genes can still get Alzheimer's disease and people with two apoE4 genes will not necessarily get the disease. Female Gender Twice as many women get Alzheimer's disease than men. Many believe that it is in a large part a result of the changes to women's hormones at menopause, in particular the decline of the important hormone estrogen. In the past estrogen was often prescribed to relieve symptoms of menopause and to reduce the risk of developing Alzheimer's disease. However, a fairly recent large-scale clinical study recommended discontinuation of Hormone Replacement Therapy (HRT) because of potentially dangerous side effects. A number of clinical researchers regard HRT as worthy of further study especially in the context of Alzheimer's disease. Any decision regarding the use of HRT should be made in consultation with a physician. However, hormonal changes are not the only factor contributing to the increased incidence of Alzheimer's disease in women. On average, women live longer than men and age is a risk factor. Women are also more prone to diabetes, which is also a risk factor (see below), and recently, a gene was identified that occurs only in women, and appears to somewhat increase the risk for Alzheimer's disease. Cardiovascular Disease All the risk factors for cardiovascular disease (such as high blood pressure and high cholesterol levels) are also risk factors for both Alzheimer's disease and Vascular Dementia. Strokes and mini-strokes (the latter detected largely through later testing), are also wellaccepted risk factors for Alzheimer's disease and for Vascular Dementia. Diabetes

It has been known for some time that type 2 ("Adult") diabetes is a risk factor for Alzheimer's disease. It has been generally assumed that the two are linked by cardiovascular disorders, which are associated with diabetes and are risk factors for Alzheimer's disease. It has also been known that the utilization of glucose in the brains of people with Alzheimer's disease is impaired, somewhat resembling the situation in the bodies of people with type 2 diabetes. An even more recent finding suggests that the Alzheimer's brain has a diabetes-like condition that some are calling type 3 diabetes. Researchers have found that in people with Alzheimer's disease the production of insulin in the brain is reduced and the nerve cells are less sensitive to it. (Production of insulin in the brain is independent of insulin production in the pancreas, the major insulin-producing organ). Anti-diabetic drugs that target the brain are now being tested in people with Alzheimer's disease. Recently evidence was also presented that children with type 1 ("Juvenile") diabetes are at risk for developing Alzheimer's disease in later life. Down Syndrome Almost all individuals with Down syndrome who live into their forties and beyond will develop the abnormal changes in the brain (the plaques and tangles) that characterize Alzheimer's disease. It is important to note, however that not all people with Down syndrome who develop these brain changes will go on to develop dementia. It seems likely that these people may not yet have developed other age-induced changes that occur in most people with Alzheimer's disease. Mild Cognitive Impairment (MCI) In MCI, there is a level of cognitive and/or memory impairment beyond that expected for normal aging but not sufficiently advanced to be called "dementia" or "Alzheimer's disease." It is estimated that up to 85% of people with MCI, who are often in their early forties or fifties, will develop Alzheimer's disease within ten years, making MCI an important risk factor for the disease. Researchers now know that the abnormal changes in the brain characteristic of Alzheimer's disease can begin to appear in people diagnosed with MCI twenty or more years before there are signs of dementia. Brain imaging may make it possible to detect the most at-risk individuals with MCI, and research to this end is ongoing. Head injury Brain injuries at any age, especially repeated concussions, are accepted by most clinicians as risk factors for the later development of Alzheimer's disease. Low Levels of Formal Education Several studies have shown that people who have less than six years of formal education appear to have a higher risk of developing Alzheimer's disease. It has been assumed that the brain stimulation associated with learning provides a protective effect for the brain; therefore more education provides greater protection. However, new studies challenge this conclusion, and it may be that factors often associated with low educational background, such as unhealthy lifestyle, account for the risk rather than low educational level itself.

Other Risk Factors In addition to the risk factors described above, all of the following have been documented as risk factors for Alzheimer's disease: inflammatory conditions (possibly reflecting immune system malfunction), a history of episodes of clinical depression, stress, and inadequate exercising of the brain. Risk factors that are less firmly established include smoking, excessive alcohol consumption and drug abuse. Aluminum Most researchers no longer regard aluminium as a risk factor for Alzheimer's disease. However, some researchers are still examining whether some people are at risk because their bodies have difficulties in handling foods containing the metals copper, iron, and aluminium.

Remember
Risk factors do not on their own cause Alzheimer's disease. They suggest an increased chance but not a certainty that the disease will develop. Similarly, having little or no exposure to known risk factors does not necessarily protect a person from developing Alzheimer's disease. Further research will help deepen our understanding of the role of risk factors in developing Alzheimer's disease.

Reducing the risk

In studies of identical twins (who share the same genes) it was found that about 60% of the overall risk for sporadic Alzheimer's disease comes from lifestyles and not from genes. Living a healthy lifestyle may help to reduce one's overall risk of developing Alzheimer's disease. A healthy lifestyle includes healthy eating, maintaining a healthy weight, taking part in regular physical activity (which can be quite modest), maintaining normal blood pressure and cholesterol levels and participating in activities that involve socializing and stimulating brain activity. 10 WARNING SIGNS Alzheimer's disease is a progressive, degenerative disease. Symptoms include loss of memory, difficulty with day-to-day tasks, and changes in mood and behaviour. People may think these symptoms are part of normal aging but they aren't. It is important to see a doctor when you notice any of these symptoms as they may be due to other conditions such as depression, drug interactions or an infection. If the diagnosis is Alzheimer's disease, your local Alzheimer Society can help. To help you know what warning signs to look for, the Alzheimer Society has developed the following list:

1.

Memory loss that affects day-to-day function It's normal to occasionally forget appointments, colleagues' names or a friend's phone number and remember them later. A person with Alzheimer's disease may forget things more often and not remember them later, especially things that have happened more recently. 2. Difficulty performing familiar tasks Busy people can be so distracted from time to time that they may leave the carrots on the stove and only remember to serve them at the end of a meal. A person with Alzheimer's disease may have trouble with tasks that have been familiar to them all their lives, such as preparing a meal. 3. Problems with language Everyone has trouble finding the right word sometimes, but a person with Alzheimer's disease may forget simple words or substitute words, making her sentences difficult to understand. 4. Disorientation of time and place It's normal to forget the day of the week or your destination -- for a moment. But a person with Alzheimer's disease can become lost on their own street, not knowing how they got there or how to get home. 5. Poor or decreased judgment People may sometimes put off going to a doctor if they have an infection, but eventually seek medical attention. A person with Alzheimer's disease may have decreased judgment, for example not recognizing a medical problem that needs attention or wearing heavy clothing on a hot day. 6. Problems with abstract thinking From time to time, people may have difficulty with tasks that require abstract thinking, such as balancing a cheque book. Someone with Alzheimer's disease may have significant difficulties with such tasks, for example not recognizing what the numbers in the cheque book mean. 7. Misplacing things Anyone can temporarily misplace a wallet or keys. A person with Alzheimer's disease may put things in inappropriate places: an iron in the freezer or a wristwatch in the sugar bowl. 8. Changes in mood and behaviour Everyone becomes sad or moody from time to time. Someone with Alzheimer's disease can exhibit varied mood swings -- from calm to tears to anger -- for no apparent reason. 9. Changes in personality People's personalities can change somewhat with age. But a person with Alzheimer's disease can become confused, suspicious or withdrawn. Changes may also include apathy, fearfulness or acting out of character. 10. Loss of initiative It's normal to tire of housework, business activities or social obligations, but most people regain their initiative. A person with Alzheimer's disease may become very passive, and require cues and prompting to become involved.

Symptoms & Stages of Alzheimers Disease

Some common early symptoms of Alzheimers disease include confusion, disturbances in shortterm memory, problems with attention and spatial orientation, changes in personality, language

difficulties and unexplained mood swings. Normally, these symptoms are very mild, and presence of the disease may not be apparent to the person experiencing the symptoms, loved ones or even health professionals. The three stages listed below represent the general progression of the disease. Although these symptoms will likely vary in severity and chronology, overlap and fluctuate, the overall progress of the disease is fairly predictable. On average, people live for 8 to 10 years after diagnosis, but this terminal disease can last for as long as 20 years. Alzheimers generally leads to impairment of cognitive and memory function, communication problems, personality changes, erratic behavior, dependence and loss of control over bodily functions. Alzheimers disease doesnt affect every person the same way, but symptoms normally progress in these stages. Stage 1 (Mild): This stage can last from 2 to 4 years. Early in the illness, those with Alzheimers tend to be less energetic and spontaneous. They exhibit minor memory loss and mood swings, and are slow to learn and react. They may become withdrawn, avoid people and new places and prefer the familiar. Individuals become confused, have difficulty organizing and planning, get lost easily and exercise poor judgment. They may have difficulty performing routine tasks, and have trouble communicating and understanding written material. If the person is employed, memory loss may begin to affect job performance. They can become angry and frustrated. Some specific examples of behaviors that people exhibit in this mild stage include:
y Getting lost y Difficulty managing money and paying bills y Repetitive questions and conversations y Taking longer than usual to finish routine daily tasks y Poor judgment y Losing things or misplacing them in odd places y Noticeable changes in personality or mood

Stage 2 (Moderate): This is generally the longest stage and can last 2 to 10 years. In this stage, the person with Alzheimers is clearly becoming disabled. Individuals can still perform simple tasks independently, but may need assistance with more complicated activities. They forget recent events and their personal history, and become more disoriented and disconnected from reality. Memories of the distant past may be confused with the present, and affect the persons ability to comprehend the current situation, date and time. They may have trouble recognizing familiar people. Speech problems arise and understanding, reading and writing are more difficult, and the individual may invent words. They may no longer be safe alone and can wander. As Alzheimers patients become aware of this loss of control, they may become

depressed, irritable and restless or apathetic and withdrawn. They may experience sleep disturbances and have more trouble eating, grooming and dressing. Stage 3 (Severe): This stage may last 1 to 3 years. During this final stage, people may lose the ability to feed themselves, speak, recognize people and control bodily functions, such as swallowing or bowel and bladder control. Their memory worsens and may become almost nonexistent. They will sleep often and grunting or moaning can be common. Constant care is typically necessary. In a weakened physical state, patients may become vulnerable to other illnesses, skin infections, and respiratory problems, particularly when they are unable to move around. Back to top

Memory Problems: Is It Alzheimers?

Mild forgetfulness and memory delays are often part of the normal aging process. Older individuals simply need more time to learn a new fact or to remember an old one. We all have occasional difficulty remembering a word or someone's name; however, those with Alzheimer's disease will find these symptoms progressing in frequency and severity. Everyone, from time to time will forget where they placed their car keys; an individual with Alzheimers disease may not remember the purpose of the keys. There has been recent interest in a condition called mild cognitive impairment (MCI). Individuals with amnesic MCI, the most common form, have memory impairment (for example, difficulty remembering names and following conversations and pronounced forgetfulness), but are able to perform routine daily activities without assistance. These MCI patients generally have normal judgment, perception and reasoning skills. Many people with MCI are at risk for further cognitive decline, usually caused by Alzheimers disease. However, while all patients who develop some form of dementia go through a period of MCI, not all patients exhibiting MCI will develop Alzheimers disease. Symptoms of MCI may include:
y Memory problems that are noticed by others y Poor performance on cognitive tests y Depression y Irritability, anxiety and sometimes aggressive or apathetic behavior

Many conditions can contribute to the development of memory problems and dementia; Alzheimers disease is just one of them. A decline in intellectual functioning that significantly interferes with normal social relationships and daily activities is characteristic of dementia, which is most commonly caused by Alzheimers disease. Alzheimers disease and multi-infarct dementia (a series of small strokes in the brain) cause the vast majority of dementias in the

elderly. Other possible causes of dementia-like symptoms include infections, drug interactions, a metabolic or nutritional disorder, brain tumors, depression or another progressive disorder like Parkinson's disease. If memory loss increases in frequency or severity, makes an impression on friends and family, begins to interfere with daily activities (for example, employment tasks, social interactions and family chores), seek qualified professional advice and evaluation by a physician with extensive knowledge, experience and interest in dementia and memory problems.

Visit Your Doctor

Visit your physician if you, your family and friends, notice worsening memory loss that begins to affect normal daily tasks, employment and social interactions. Other signs that may point to Alzheimer's disease include changes in personality, language difficulties, problems with simple mathematical tasks, impairment in gait or movement, and problems with attention and orientation. A physician with extensive knowledge and experience in dementia and memory problems can perform a thorough evaluation to determine whether someone has dementia, and if so, its potential causes. Other specialists may be called upon for a better diagnosis. Proper medication may be able to slow the progression of the disease and delay cognitive decline. These drugs are generally more effective the earlier they are administered.

What are the symptoms of Alzheimer's disease?

The onset of Alzheimer's disease is usually gradual, and it is slowly progressive. Memory problems that family members initially dismiss as "a normal part of aging" are in retrospect noted by the family to be the first stages of Alzheimer's disease. When memory and other problems with thinking start to consistently affect the usual level of functioning; families begin to suspect that something more than "normal aging" is going on. Problems of memory, particularly for recent events (short-term memory) are common early in the course of Alzheimer's disease. For example, the individual may, on repeated occasions, forget to turn off an iron or fail to recall which of the morning's medicines were taken. Mild personality changes, such as less spontaneity, apathy, and a tendency to withdraw from social interactions, may occur early in the illness. As the disease progresses, problems in abstract thinking and in other intellectual functions develop. The person may begin to have trouble with figures when working on bills, with understanding what is being read, or with organizing the day's work. Further disturbances in behavior and appearance may also be seen at this point, such as agitation, irritability, quarrelsomeness, and a diminishing ability to dress appropriately.

Later in the course of the disorder, affected individuals may become confused or disoriented about what month or year it is, be unable to describe accurately where they live, or be unable to name a place being visited. Eventually, patients may wander, be unable to engage in conversation, erratic in mood, uncooperative, and lose bladder and bowel control. In late stages of the disease, persons may become totally incapable of caring for themselves. Death can then follow, perhaps from pneumonia or some other problem that occurs in severely deteriorated states of health. Those who develop the disorder later in life more often die from other illnesses (such as heart disease) rather than as a consequence of Alzheimer's disease.
Alzheimers disease is difficult to diagnose, and it's best when a team of professionals -- including a neurologist, neuropsychologist, geriatrician, and possibly others -- works together to arrive at an accurate diagnosis. A total diagnostic workup includes a medical history, imaging procedures, and neuropsychological testing, as well as other procedures depending on the individual's presentation. When a neuropsychologist or other professional in the field of psychology or psychiatry sees a person exhibiting symptoms of Alzheimer's, a set of criteria is often used to help make an accurate diagnosis. The Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), also known as the DSM-IV, outlines a detailed set of criteria for the diagnosis of Alzheimers. First, multiple cognitive deficits must be present, one of which must be memory impairment. In addition to problems with memory, one or more of the following must be displayed: y Aphasia -- a deterioration of language abilities, which can manifest in several ways y Apraxia -- difficulty executing motor activities, even though movement, senses, and the ability to understand what is being asked are still intact y Agnosia -- an impaired ability to recognize or identify objects, even though sensory abilities are intact y Problems with executive functioning, such as planning tasks, organizing projects, or carrying out goals in the proper sequence In order to meet the criteria for Alzheimers disease, the deficits must affect ones ability to hold a job or volunteer position, fulfill domestic responsibilities, and/or maintain social relationships. The deficits must also represent a significant decline from the persons previous level of functioning. Alzheimers disease involves a gradual onset and progressive worsening of symptoms. In order to receive a diagnosis of Alzheimers, the deficits can't be due to another medical condition, such as Parkinsons disease, thyroid problems, or alcoholism. Similarly, the symptoms can't occur exclusively during an episode of delirium, or be better explained by a psychological disorder such as depression or schizophrenia.

Source:

There is no singular test that can definitively diagnoseAlzheimer's disease, although imaging technology designed to detect Alzheimer's plaques and tangles is rapidly becoming more powerful and precise. Still, a comprehensive, competent diagnostic workup by a skilled physician can pinpoint the cause of Alzheimer's-like symptoms with over 90% accuracy. Diagnosis of Alzheimer's disease should include the following: y Medical history -- This should include questions about past illnesses, prior injuries and surgeries, and current chronic conditions in order to identify other possible causes for Alzheimer's-like symptoms. For instance, if you suffered a serioushead injury any time in your past, it could account for the problems with memory or concentration that you're currently experiencing. If your loved one has heart disease, that could be reducing blood flow to the brain and causing forgetfulness. y Medication history -- This should includeallergies, experienced side effects from past medications, and a list of current medications and dosages. Not only will this inform any future prescription decisions; it also might reveal a medication interaction or overdosage that accounts for your or your loved one's confusion and other symptoms. y Mood evaluation -- The evaluation should include an assessment for anxiety or depression, which can create Alzheimer'slike symptoms in older people as well as occur concurrently with Alzheimer's or another dementia. Depression, in particular, can result in a set of symptoms collectively known as pseudodementia. If a mood disorder is detected, it can be treated alongside other disorders, such as Alzheimer's. y Mental status exam -- To assess memory, concentration, and other cognitive skills. The mental status exam is a researchbased set of questions that results in a score that indicates a general level of impairment. If you or your loved one scores high on a mental status exam, there is less of a chance that Alzheimer's is the culprit; another (possibly treatable) condition may be responsible for the symptoms. However, highly educated individuals have scored high on mental status exams even though they do have Alzheimer's disease.

Complete physical exam -- To assess hearing, vision, blood pressure, pulse, and other basic indicators of health and disease. A current physical exam can detect acute medical conditions such as an infection that might be causing Alzheimer's-like symptoms. y Appropriate laboratory tests -- These will vary according to your or your loved one's medical history and current symptoms. Blood tests are the most common laboratory tests ordered. For example, if you are exhibiting prediabetic symptoms, a blood glucose test would be ordered. Aside from blood tests, if your loved one's symptoms came on suddenly and include severe confusion, a urinalysis would probably be conducted to rule out a urinary tract infection. y Neurological exam -- This should include an examination of the motor system (movement), reflexes, gait (walking), sensory functioning, and coordination in order to detect problems with the nervous system that may be causing problems with thinking and behavior. y Imaging procedures -- Detailed pictures of the brain, such as a CT scan (computed tomography), an MRI (magnetic resonance imaging), or a PET scan (positron emission tomography) to identify changes in brain structure or size indicative of Alzheimer's, or to look for brain tumors, blood clots, strokes, normal pressure hydrocephalus (NPH), or other abnormalities that might account for Alzheimer's-like symptoms. There is no particular kind of physician that specializes in Alzheimers disease. Many people first seek help from their primary care physician, who may oversee the total diagnostic process or refer the individual to any of the following specialists: y Neurologist -- Specializes in diseases of the nervous system, including Alzheimers,Parkinsons, epilepsy, and stroke. y Psychiatrist -- Specializes in mental, emotional, and behavioral disorders. y Neuropsychologist -- Specializes in the brain-behavior relationship and can conductneuropsychological testing to determine the type and level of impairment due to Alzheimer's, head injury, stroke, or other conditions. The goal of a diagnostic workup is to explore every possible cause for the person's symptoms and to address any reversible condition or treatable problem. If a cause is not reversible or treatable, then the goal is to help the individual manage the symptoms through medical treatments or behavior management.

Sources:

Alzheimer's diagnosis. Fisher Center for Alzheimer's Research Foundation. 2007.http://www.alzinfo.org/alzheimersdiagnosis.asp Basics of Alzheimers disease: What it is and what you can do. Alzheimer's Association. 2005. http://www.alz.org/national/documents/brochure_basic