the Chinese for thousands of years to overcome loss of memory in the old, has been shown to be totally ineffective. All the fuss over fish oil as a key brain food may be unjustified. A two-year study found there is no evidence that the supplements offer benefits for brain function in older people, contradicting previous surveys on the wonders of omega-3 fatty acids. But physical fitness contributed to more than 3 per cent of the differences in cognitive ability in old age after accounting for a participant’s test scores at age 11.
About half of all lifetime cases of mental illness begin by age 14 but the chance of developing a mental disability increases as we age. The most common and serious one is dementia, an overall impairment in cognitive functioning sufficient to affect everyday activities, and there may be depression, hallucinations and delusions. The term dementia was introduced by Philippe Pinel in Paris in 1801; he also introduced the idea that people suffering from it should be treated with kindness—many patients at that time had actually been kept in chains—and he called this new principle ‘the moral treatment of insanity’. One of Pinel’s students, Dominique Esquirol, gave a very detailed and still valid description of dementia, pointing out, for example, that sufferers entertain perfect indifference to objects that were once most dear, and this includes relatives. They also often have a ridiculous passion. He carried out autopsies and noted abnormal convolutions in the brains of patients, but microscopic examinations of such brains had to wait for work on Alzheimer’s.
While dementia is rare before 60, it increases with age and is present in 5 per cent of the over 65s and in 20 per cent of the over 80s. Dementia isn’t a specific disease, rather it describes a group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning. Different types of dementia exist, depending on the cause. Low education and diabetes can contribute, and mental and physical activity help prevent it. Alzheimer’s disease is the most common form of this disease, and is the cause in two thirds of cases of dementia. It increases the risk of dying by two to five times, and for those over 85 accounts for one third of deaths, though this is rarely on the death certificate. Staff who look after Alzheimer’s patients need to recognise it can be a terminal illness.
Dementia and normal ageing may be on a continuum. Memory loss generally occurs in dementia, but memory loss alone doesn’t mean there is dementia. It can be difficult to distinguish between onset of Alzheimer’s and ordinary ageing relapses of memory and cognition. Dementia has many causes and some dementias, such as Alzheimer’s disease, occur on their own, not as a result of another disease. Some dementias, such as those caused by a reaction to medications or an infection, are reversible with treatment. Recent research shows that up to 80 per cent of people diagnosed with mild mental or cognitive impairment go on to develop much more debilitating dementia within just six years. As well as the personal devastation caused by cognitive decline, it is also the single biggest reason why older people lose independence and require 24-hour care.
There are some 820,000 people in Britain with dementia, about half of whom suffer from Alzheimer’s disease. Generally Alzheimer’s is diagnosed in people over 65 years of age, although the less-prevalent early-onset Alzheimer’s can occur much earlier. The disease in those in the 30 to 40 age group is rare, and even rarer are cases due to a genetic defect that results in it occurring in those as young as 16. There are estimates that there are over 20,000 younger people with dementia in the UK. The Alzheimer’s Society estimates that the disease costs Britain
Dementia causes problems with at least two brain functions, memory loss along with impaired judgement and language. Dementia can make an individual not just confused and unable to remember people and names, but also experience changes in personality and social behaviour. Some causes of dementia are treatable and even reversible, but early diagnosis is important so that treatment can begin before symptoms worsen. If the diagnosis is a dementia that will progressively deteriorate over time, such as Alzheimer’s disease, early diagnosis also gives a person time to plan for the future while he or she can still participate in making decisions. A quite simple test has been developed for detecting early stages of Alzheimer’s that would require further investigation. It is a two-page questionnaire, and has ten tests that include remembering a phrase, doing sums, identifying parts of a man’s suit, and drawing the time on a blank clock face. A quite different early diagnosis may be based on examining the fluid in the spine for the proteins that are responsible for the disease.
The disease is named after Alois Alzheimer, who was born in 1864 in Germany and studied medicine. He then worked at the Municipal Mental Asylum in Frankfurt, and later moved with Emil Kraepelin to the Max Planck Institute in Munich. He died in 1915. His first patient with the disease that was eventually to carry his name was Auguste D., a 51-year-old woman. She presented with jealousy of her husband, paranoia, memory impairment and, towards the end of her life, loud screaming. On 3 November 1906 Alzheimer presented the results obtained from studying the structure of the cellular organisation of her brain which included several fibrils—amyloid protein—and numerous small abnormal foci due to cell death. It was his mentor Emil Kraepelin who gave the disease his name in the eighth edition of his textbook in 1910.
At the early stages of Alzheimer’s disease the most commonly recognised symptom is memory loss, such as difficulty in remembering recently learned facts. Typically there is misplacing and losing objects and repeatedly asking the same questions. The sufferer has difficulty in finding words to complete a sentence and comprehension is poor, as is doing complex motor tasks. There are also non-cognitive symptoms—delusions, depression and anxiety, and verbal and physical aggression. Patients can be very difficult. One patient hit his wife, and did not understand the difference between night and day—he could go to bed and get up thirty times in a night. Median survival is about five years. Apathy can be observed at an early stage, and remains a most persistent symptom. Despite the loss of verbal language abilities, patients can often understand and return emotional signals. A remarkable finding is that facial asymmetry in men results in an increased mental decline in the years before death.
Although it may not be easy, people with Alzheimer’s disease can live quite full and productive lives. Taking time to prepare for the challenges that come as the disease progresses will ease the difficult transitions. Well- known personalities such as Bernard Levin and Iris Murdoch had Alzheimer’s, and Terry Pratchett has a special form. He has problems recognising visual signals and can take minutes to tie a tie, but his talking is fluent, though his reading can be confused. Watching him and others with Alzheimer’s on a BBC TV programme, there was nothing in the way they talked or behaved which gave any indication of abnormality. But they could not remember what had happened recently, and one could not copy a geometrical design. Pratchett has said he ‘would eat a dead mole’s arse’ if it would cure him. He wants to be able to choose when to die. The TV journalist John Suchet has described the dementia of his wife, which started when she was 61. She now will pile dirty plates on top of clean ones, and repeatedly flush the toilet when not using it. Her memory is poor. Husbands and wives are six times more likely to get dementia if their spouse has it. This could be related to the stress of caring or living with someone in that condition.
Andrea Gilleas describes in her book
Some cases of early-onset Alzheimer’s may be caused by a number of different gene mutations. These mutations cause the formation of abnormal amyloid, fibrous protein aggregates in the brain. One of the ways proteins can have severe negative effects is by becoming an amyloid. Many different proteins can do this, developing sticky elements which enable them to stick together and form sometimes deadly fibres. The amyloid appears to bind to the neurones with a prion protein that is associated with BSE and Creutzfeldt-Jacob disease. The amyloid accumulation interacts with a tau protein which gets into nerve cells and causes the formation of aggregates of particles, leading to the tangles which cause the death of nerve cells. Recent studies correlated levels of the tau and amyloid proteins in the cerebrospinal fluid with changes in cognition over time, and found that changes in these two protein levels may signal the onset of mild Alzheimer’s. This is a significant step forward in developing a test to help diagnose the early stages of Alzheimer’s disease.
One predisposing genetic risk factor is related to the APOE genes that code for proteins that help carry cholesterol in the bloodstream. APOE comes in several different forms; APOE4 occurs in about 40 per cent of all people who develop late-onset Alzheimer’s and is present in about 25 to 30 per cent of the population. People with
