Diagnosing Alzheimer's Disease and Comparing Early Symptoms to Normal Aging

BY STEPHEN A. WILSON

Alzheimer’s disease (AD) is a scary thing. In a recent survey, it was the disease most feared by more than 50% of British adults. Not all dementia is AD; for example, vascular dementia, which can be the end result of chronic diseases, most commonly stroke, that result in decreased blood flow to parts of the brain. However, AD is the most common and well-known type and will be our focus.

From the U.S. National Institute of Health, Alzheimer’s disease is a degenerative brain disorder characterized by progressive loss of memory and cognitive abilities. It is marked by the accumulation of amyloid plaque and neurofibrillary tangles in the brain, which can disrupt normal brain function. AD typically begins in the mid-60s. Over time, it leads to severe impairment that affects activities of daily living (ADLs).

ADLs is a specific medical term that refers to five essential self-care tasks and abilities that people perform independently daily to maintain their health and well-being.

• Eating: Feed oneself

• Bathing: Wash oneself

•Dressing: Put on and take off clothing

• Toileting: Use the bathroom

• Mobility: Move around safely

People with AD experience insidious onset of progressively losing their memories, their ability to learn, and their capacity to perform ADLs.

Diagnosing AD requires a comprehensive clinical evaluation combining medical history, cognitive assessment, and corroboration from family members or close contacts. Clinical evaluation begins with assessing cognitive decline across multiple domains, including memory, language, attention, visuospatial thinking and awareness, executive function (working memory, flexible thinking, selfcontrol), and mood. Initial assessment involves one or more brief screening questionnaires (e.g., Montreal Cognitive Assessment – MoCA, Mini Mental Status Exam – MMSE, AD8, IQCODE, Mini-COG, and SLUMS are some common ones). If the diagnosis remains uncertain, neuropsychological testing becomes necessary.

Doctors will also order blood tests looking for possible non-AD causes of the symptoms, for example syphilis, B12 deficiency, or liver, kidney, electrolyte or thyroid abnormalities. They will also often order some form of brain imaging, usually an MRI, to check for vascular, structural issues (e.g., cancer, old stroke(s), abnormal fluid, or bleeding), amyloid plaques, or neurofibrillary tangles.

In a future column, the focus will be treatment. The remainder of our time will be about warning signs and the difference between normal and abnormal aging.

10 Early Warning Signs of Alzheimer’s Disease vs. Normal Aging

1. Memory loss that disrupts daily life

The hallmark sign. Forgetting recently learned information, important dates, or events, and increasing reliance on notes or family members for things they used to manage independently. This is not just forgetting where you put your keys. Everyone does that. The key difference is frequency and impact.

• Forgetting recent conversations

• Repeating the same questions

• Missing appointments even with reminders

Normal Aging:

• Occasionally forgetting names or appointments but remembering them later

• Misplacing items once in a while

• Needing reminders for new information

2. Difficulty planning or solving problems

Tasks that involve numbers or multi-step processes

– following a recipe or paying monthly bills – become harder and take longer.

Normal Aging:

• Taking a bit longer to solve a problem

• Occasionally making a small mistake when managing finances

3. Challenges completing familiar tasks

Losing fluency in things that used to be second nature. Getting confused driving to a familiar location, organizing a grocery list, or remembering the rules of a favorite game.

Normal Aging:

• Sometimes needing help with new technology

• Occasionally forgetting why you walked into a room

4. Confusion with time or place

Losing track of dates, seasons, or the passage of time.

Forgetting where they are or how they got there.

Normal Aging:

• Momentarily forgetting the day of the week

• Occasionally losing track of time when busy

5. Trouble understanding visual images or spatial relationships

Difficulty reading, judging distances, or recognizing contrast, which can affect driving.

6. New problems with words

Struggling to follow or join conversations, repeat themselves, or have trouble finding the right word for everyday objects.

Normal Aging:

• Sometimes struggling to find the right word

• Occasionally losing a train of thought

7. Misplacing items and losing the ability to retrace steps

Objects end up in unusual places (keys in the fridge, wallet in a sink, jewelry in a shoe) and they cannot retrace their steps to find them.

8. Decreased or poor judgment

Examples: giving away lots of money, easily scammed, or neglecting personal hygiene.

Normal Aging: Making a questionable decision once in a while

9. Withdrawal from work or social activities

Avoiding hobbies, social events, or work tasks they once enjoyed because they feel overwhelmed or embarrassed.

10. Changes in mood or personality

Becoming anxious, suspicious, easily upset, or confused, especially in unfamiliar situations.

Normal Aging: Becoming irritable when tired or stressed

AD is a sad and scary disease that insidiously robs people of who they are and slowly steals them from their loved ones.

Dr. Stephen A. Wilson, MD, MPH, FAAFP, is Chair of Family Medicine at Boston University Chobanian and Avedisian School of Medicine and Chief of Family Medicine for Boston Medical Center.