Dementia and Alzheimer's Disease: a Multifaceted View

    From an early age, I was taught that physical ailments took precedence over any emotional/ mental issues that could be occurring. For example, my parents always took us to our doctor’s appointments whenever we were sick and whenever we needed checkups. If there was a physical symptom present (coughing, runny nose, body aches, etc), it was an immediate onset of questions and concerns. Emotionally, stress was acknowledged and was taken care of by giving space or sustenance to help us cope with it. However, things that couldn’t necessarily be pinpointed were depression, anxiety, ADD/ ADHD, bipolar disorder, etc, which all run prevalently in my family. These were issues that were not in any way degraded: they were simply issues that were presented as “American” beliefs, or things that did not exist when my mom lived in Mexico on her little ranch or when my dad lived in the city a couple of hours away from her. My understanding of the brain was very limited until high school, when I was exposed to several different ideas about how the brain works and how it functions to monitor other parts of the body. The brain was and continues to be a fascinating entity that encompasses all aspects of who we are as people, what biological elements influence our stability, why we think the way we do and how all of these things come together to aid us in staying alive. In an ayurvedic perspective, the brain would be the root that spans into every crack and crevice of the human body. To better comprehend the fullest picture that we possibly can, we have to go past the biological and dive into the social and psychological scopes.

    Brain disorders/diseases in particular are typically categorized in 5 different groups. Neurological disorders, storage disorders, personality/ mood disorders, developmental disorders and prion diseases. The classification of these conditions dates back to Ancient Greece, where it is believed that Hippocrates had the first official ranking for mental illnesses, including melancholia, mania and phobias. Since then, the groupings and types of ailments linked to them have changed, and they continue to be updated periodically as more information and data are collected. Neurological disorders include, but are not limited to, Myasthenia, Gravis, Multiple Sclerosis, ALS, AD, Parkinson’s disease, Huntington’s disease and Dementia. These disorders often affect motor function, the psychological and/ or cognitive mind as well as the emotions. Storage disorders include Tay-Sachs or Gaucher. They are considered to be metabolic disorders that result in degradation of certain lysosomal enzymes meant to digest the larger and more harmful molecules inside cells. Personality/ mood disorders are disorders that include the more common ones we typically hear about, such as schizophrenia, paranoia, obsessive compulsive disorder, depression and bipolar disorder. These are mental disorders that are characteristic of unhealthy patterns of thinking, functioning and behaving. Developmental disorders are disorders like autism, spectrum disorders and Prader-Willi. In psychiatry, this category of disorders is defined as appearing in childhood and is characterized by delay in development of one or more psychological functions (i.e. language). Finally, prion diseases include Creutz-feldt-Jakob, otherwise known as spongiform encephalopathy. These diseases are rare, neurodegenerative disorders that can lead to death. 

    A neurocognitive disorder we will deconstruct is dementia, along with a specific type of it: Alzheimer's disease. Dementia is generally defined as the deterioration of intellectual abilities due to disease. Memory is affected along with judgement and concentration. Dementia also comes with personality changes and emotional instability and can be caused by strokes, diabetes, Huntington’s and Parkinson’s disease, and Korsakoff’s syndrome (severe amnesia). Biologically, there is damage to brain cells in dementia, which interferes with their ability to communicate with one another. As the brain cells get damaged, they become less able to reproduce and multiply to replenish the cells that have already died off. Due to this loss, parts of the brain begin to shrink and more issues begin to arise as a result. The brain as an entity has specific deficits in neurotransmitters like norepinephrine, serotonin, and acetylcholine, that also obstruct its ability to fully function. In psychology, there is a distinction between that scientific aspect, being the brain itself, and the emotional/ cognitive aspect: the mind. The brain is the tangible part, the one that is divided into the forebrain, the midbrain and the hindbrain. The mind is the intangible aspect that has three components to it as well: the conscious, the subconscious and the unconscious. Psychologically, people who have dementia are progressively experiencing changes in function such as memory, language, attention, visual perception, problem solving and concentration. These difficulties affect their sense of identity, how they behave, their mood, their overall well being and alter their social relationships. Once diagnosed, the “people centered” ideal to help individuals with dementia cope with their disorder can either amplify their symptoms or make their condition more manageable. It all depends on their conscious awareness of the disease, how they address their emotional distresses and what support system they have in place to aid them in their stages. The psychological view intertwines with humanism, the social theory that emphasizes common human needs and aims to seek rational ways to solve these human problems. In contrast, the biological view focuses on what can be measured, observed or seen inside the matrix of cells, tissues, organs, etc. Both are needed in order to fully understand the extent of dementia and its components. 

    A type of dementia we mentioned briefly is Alzheimer’s disease. We don’t know what the exact cause is (as is apparent in most brain disorders) but what we do know is that the risk of developing it is linked with genetics. Some patients with AD have a specific genetic problem that can cause an early onset of it as early as 45 years old. Most patients with AD, however, follow other irregular patterns that make it difficult to spot. In neuroimaging, it has been observed that AD patients have plaques (made up of proteins called beta-amyloid) in parts of the brain that show cell loss. The protein that makes up plaques comes from a protein called Amyloid Precursor Protein, or APP, and is needed for neurons to function normally. APP is unfortunately cut up by enzymes into abnormal amounts of beta amyloid. Neurons can get rid of beta amyloid, but only in small amounts. If there is too much, beta amyloid clumps together to form plaques inside of neurons. As a result, the neurons do not function normally and they die off. In addition to that, patients with AD also have “tangles” in neurons. The term is in relation to microtubules, long string-like structures that transport things from the cell body to the end of the axon and dendrites. Those microtubules break apart and collapse into loose nerve endings (axon terminals) and leave a tangled, dysfunctional and dead mess. Externally and simultaneously, the mind is detaching from the person’s body over time. People with AD start to lose their independence and begin to get lost in the memories they have already lived through. They start to digress. One moment, they may be with their spouse or their child and know they are in the car and who they are with, but the next, there may be a shift in their demeanor and they are suddenly confused with their surroundings, where they're going and who it is they were just speaking to. They need to be cared for in a way that helps them live through what goes in their mind. This shift is difficult for those going through these constant shifts and changes, but it is also hard for those that stand by them through it all.   

    There are some medications that have been approved by the US Food and Drug Administration to treat different types of dementia. Those medications include Cognex, Aricept, Reminyl, Exelon and Namenda. All of them actively inhibit acetylcholinesterase, aside from Namenda. Acetylcholine is a neurotransmitter that is released from the presynaptic neuron and then reabsorbed within the body. There is a lot of it in the hippocampus and the cortex. The enzyme acetylcholinesterase breaks down acetylcholine. So in inhibiting the enzyme, the brain is able to retain acetylcholine in the synaptic cleft in order to stimulate receptors on neurons in learning and memory areas. A key factor to consider in these inhibitory medications is that there is some improvement in daily living skills and there is some delay in the progression of the disease. However, it is typically to a small degree and occurs in a small percentage of patients. It can also be very toxic to the liver, which can backfire on life’s overall improvement and can worsen a patient’s mentality about their condition. Namenda, which is the medication we excluded prior, blocks the NMDA receptor for a very short period of time. NMDA receptors are hypothesized to contribute to neuron death in Alzheimer’s disease. There have been small effects in a small number of patients but they have had a dramatic impact on their quality of life.     

    In caring for individuals with dementia or Alzheimer’s disease, it is important to consider the overwhelming costs to treat the disease. According to the multinational biotechnology company Biogen, the direct costs for Alzheimer’s disease and other dementias are estimated at $305 billion for last year alone (Alzheimer’s Association, 2020). Treatment facilities like hospitals, nursing homes, hospice, and home healthcare are also taxed with the burden of having tons of patients but not enough geriatricians, nurse practitioners and other professionals to assist with caring for them. On top of that, an Alzheimer’s Association survey revealed that primary care physicians feel inadequate to manage the rising AD population: 39% of primary care physicians are uncomfortable making a diagnosis for AD, 55% are concerned that there are not enough specialists to meet the demand and 22% had absolutely no dementia training during their residency (after medical school) (AA, 2020). 

    It is impossible to have an ideal situation when dealing with an inevitable disease. However, looking at the biological component of what is going on, the patient’s well being and emotions along with the well being and emotions of those close to them and the primary care physicians involved in treating the patients, helps lessen the gaps in our own misconceptions or ideas. Everything in the body is connected, but the elements that come into play outside of the body are also tied to it.

Sources:

Alzheimer's disease is a serious, growing problem. using biomarkers may alter future care: Identify Alzheimer's disease (ad) - biogen. Alzheimer's Disease Is a Serious, Growing Problem. Using Biomarkers May Alter Future Care | Identify Alzheimer's Disease (AD) - Biogen. (n.d.). https://www.identifyalz.com/en_us/home/addressing-challenges/evolving-alzheimers-disease-care.html.

Psychological dimensions of dementia: Putting the person at the centre of care. www.basw.co.uk. (2018, April 27). https://www.basw.co.uk/resources/psychological-dimensions-dementia-putting-person-centre-care.

Stages of Alzheimer's disease. Johns Hopkins Medicine. (n.d.). https://www.hopkinsmedicine.org/health/conditions-and-diseases/alzheimers-disease/stages-of-alzheimer-disease.

U.S. Department of Health and Human Services. (2021, June 9). Brain basics: Know your brain. National Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Know-Your-Brain.