Alzheimer's disease classification

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Overview

Classification

The disease course is divided into four stages, with a progressive decline in cognition and functional capabilities.

Predementia

The first symptoms are commonly misattributed to normal ageing or stress.[1] Detailed neuropsychological testing can reveal mild cognitive difficulties up to eight years before a person meets the clinical criteria for diagnosis of AD.[2] These early symptoms can affect the most complex daily living activities.[3] The most noticeable early deficit is memory loss. The patient has difficulty remembering recently learned facts and acquiring new information.[4][5] Subtle problems with the executive functions of attentiveness, planning, flexibility, and abstract thinking, or impairments in semantic memory (memory of meanings, and conceptual relationships), can also be symptomatic of the early stages of AD.[6][7] Apathy can be observed at this stage, and remains the most persistent neuropsychiatric symptom throughout the course of the disease.[8][9][10] The preclinical stage of the disease has also been termed mild cognitive impairment,[11] but there is still debate on whether this term corresponds to a different and separate diagnostic entity or is just a first step of Alzheimer's disease.[12]

Early dementia

In people with AD the increasing impairment of learning and memory eventually leads to a definitive diagnosis. In a small proportion of them, difficulties with language, executive functions, perception (agnosia), or execution of movements (apraxia) are more prominent than memory problems.[13] AD does not affect all memory capacities equally. Older memories of the person's life (episodic memory), facts learned (semantic memory), and implicit memory (the memory of the body on how to do things, such as using a fork to eat) are less affected than new facts or memories.[14][15] Language problems include a shrinking vocabulary and decreased word fluency, which lead to a general impoverishment of oral and written language. In this stage, the person with Alzheimer's is usually capable of adequately communicating basic ideas.[16][17][18] Sufferers may appear clumsy when performing fine motor tasks such as writing, drawing or dressing, as their brain has more difficulty with planning and coordinating certain movements (apraxia).[19] As the disease progresses, people with AD often continue to perform many tasks independently, but may need assistance or supervision with cognitively demanding activities.[13]

In 1994 United States ex-president R. Reagan informed the country of his AD diagnosis via a hand-written letter.

Moderate dementia

Progressive deterioration eventually hinders independence.[13] Speech difficulties become more evident, with an inability to recall vocabulary leading to frequent incorrect word substitutions (paraphasias). Reading and writing skills are also progressively lost.[16][20] Complex motor sequences become less coordinated as time passes, reducing the ability to perform most normal daily activities.[21] During this phase, memory problems worsen, and the person may fail to recognize close relatives.[22] Long-term memory, which was previously intact, becomes impaired,[23] and behavioural changes become more prevalent. Common neuropsychiatric manifestations are wandering, sundowning,[24] irritability and labile affect, leading to crying, outbursts of unpremeditated aggression, or resistance to caregiving. Approximately 30% of patients also develop illusionary misidentifications and other delusional symptoms.[8][25] Urinary incontinence can develop.[26] These symptoms create stress for relatives and caretakers, which can be reduced by moving the person from home care to a long-term care facility.[13][27]

Advanced dementia

During this last stage of AD, the patient is completely dependent upon caregivers. Language is reduced to simple phrases or even single words, eventually leading to complete loss of speech.[16] Despite the loss of verbal language abilities, patients can often understand and return emotional signals.[28] Although aggressiveness can still be present, extreme apathy and exhaustion are much more common.[13] Patients will ultimately not be able to perform even the most simple tasks without assistance. Muscle mass and mobility deteriorate to the point where the patient is bedridden,[29] and they lose the ability to feed themselves.[30] When death comes, it is usually directly caused by some external factor such as pressure ulcers or pneumonia, rather than the disease itself.[31][32]

References

  1. ↑
  2. ↑ Preclinical:
    • Linn RT, Wolf PA, Bachman DL; et al. (1995). "The 'preclinical phase' of probable Alzheimer's disease. A 13-year prospective study of the Framingham cohort". Arch. Neurol. 52 (5): 485–90. PMID 7733843. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
    • Saxton J, Lopez OL, Ratcliff G; et al. (2004). "Preclinical Alzheimer disease: neuropsychological test performance 1.5 to 8 years prior to onset". Neurology. 63 (12): 2341–7. PMID 15623697. Unknown parameter |month= ignored (help)
    • Twamley EW, Ropacki SA, Bondi MW (2006). "Neuropsychological and neuroimaging changes in preclinical Alzheimer's disease". J Int Neuropsychol Soc. 12 (5): 707–35. doi:10.1017/S1355617706060863. PMC 1621044. PMID 16961952. Unknown parameter |month= ignored (help)
  3. ↑ Perneczky R, Pohl C, Sorg C, Hartmann J, Komossa K, Alexopoulos P, Wagenpfeil S, Kurz A (2006). "Complex activities of daily living in mild cognitive impairment: conceptual and diagnostic issues". Age Ageing. 35 (3): 240–245. doi:10.1093/ageing/afj054. PMID 16513677.
  4. ↑ Arnáiz E, Almkvist O (2003). "Neuropsychological features of mild cognitive impairment and preclinical Alzheimer's disease". Acta Neurol. Scand., Suppl. 179: 34–41. doi:10.1034/j.1600-0404.107.s179.7.x. PMID 12603249. |access-date= requires |url= (help)
  5. ↑ Kazui H, Matsuda A, Hirono N; et al. (2005). "Everyday memory impairment of patients with mild cognitive impairment". Dement Geriatr Cogn Disord. 19 (5–6): 331–7. doi:10.1159/000084559. PMID 15785034. Retrieved 2008-06-12.
  6. ↑ Rapp MA, Reischies FM (2005). "Attention and executive control predict Alzheimer disease in late life: results from the Berlin Aging Study (BASE)". American Journal of Geriatric Psychiatry. 13 (2): 134–141. doi:10.1176/appi.ajgp.13.2.134. PMID 15703322.
  7. ↑ Spaan PE, Raaijmakers JG, Jonker C (2003). "Alzheimer's disease versus normal ageing: a review of the efficiency of clinical and experimental memory measures". Journal of Clinical Experimental Neuropsychology. 25 (2): 216–233. PMID 12754679.
  8. ↑ 8.0 8.1 Craig D, Mirakhur A, Hart DJ, McIlroy SP, Passmore AP (2005). "A cross-sectional study of neuropsychiatric symptoms in 435 patients with Alzheimer's disease". American Journal of Geriatric Psychiatry. 13 (6): 460–468. doi:10.1176/appi.ajgp.13.6.460. PMID 15956265.
  9. ↑ Robert PH, Berr C, Volteau M, Bertogliati C, Benoit M, Sarazin M, Legrain S, Dubois B (2006). "Apathy in patients with mild cognitive impairment and the risk of developing dementia of Alzheimer's disease: a one-year follow-up study". Clin Neurol Neurosurg. 108 (8): 733–736. doi:10.1016/j.clineuro.2006.02.003. PMID 16567037.
  10. ↑ Palmer K, Berger AK, Monastero R, Winblad B, Bäckman L, Fratiglioni L (2007). "Predictors of progression from mild cognitive impairment to Alzheimer disease". Neurology. 68 (19): 1596–1602. doi:10.1212/01.wnl.0000260968.92345.3f. PMID 17485646.
  11. ↑ Small BJ, Gagnon E, Robinson B (2007). "Early identification of cognitive deficits: preclinical Alzheimer's disease and mild cognitive impairment". Geriatrics. 62 (4): 19–23. PMID 17408315. Unknown parameter |month= ignored (help)
  12. ↑ Petersen RC (2007). "The current status of mild cognitive impairment—what do we tell our patients?". Nat Clin Pract Neurol. 3 (2): 60–1. doi:10.1038/ncpneuro0402. PMID 17279076. Unknown parameter |month= ignored (help)
  13. ↑ 13.0 13.1 13.2 13.3 13.4 Förstl H, Kurz A (1999). "Clinical features of Alzheimer's disease". European Archives of Psychiatry and Clinical Neuroscience. 249 (6): 288–290. PMID 10653284.
  14. ↑ Carlesimo GA, Oscar-Berman M (1992). "Memory deficits in Alzheimer's patients: a comprehensive review". Neuropsychol Rev. 3 (2): 119–69. PMID 1300219. Unknown parameter |month= ignored (help)
  15. ↑ Jelicic M, Bonebakker AE, Bonke B (1995). "Implicit memory performance of patients with Alzheimer's disease: a brief review". International Psychogeriatrics. 7 (3): 385–392. doi:10.1017/S1041610295002134. PMID 8821346.
  16. ↑ 16.0 16.1 16.2 Frank EM (1994). "Effect of Alzheimer's disease on communication function". J S C Med Assoc. 90 (9): 417–23. PMID 7967534. Unknown parameter |month= ignored (help)
  17. ↑ Becker JT, Overman AA (2002). "[The semantic memory deficit in Alzheimer's disease]". Rev Neurol (in Spanish; Castilian). 35 (8): 777–83. PMID 12402233.
  18. ↑ Hodges JR, Patterson K (1995). "Is semantic memory consistently impaired early in the course of Alzheimer's disease? Neuroanatomical and diagnostic implications". Neuropsychologia. 33 (4): 441–59. PMID 7617154. Unknown parameter |month= ignored (help)
  19. ↑ Benke T (1993). "Two forms of apraxia in Alzheimer's disease". Cortex. 29 (4): 715–25. PMID 8124945. Unknown parameter |month= ignored (help)
  20. ↑ Forbes KE, Shanks MF, Venneri A (2004). "The evolution of dysgraphia in Alzheimer's disease". Brain Res. Bull. 63 (1): 19–24. doi:10.1016/j.brainresbull.2003.11.005. PMID 15121235. Unknown parameter |month= ignored (help)
  21. ↑ Galasko D, Schmitt F, Thomas R, Jin S, Bennett D (2005). "Detailed assessment of activities of daily living in moderate to severe Alzheimer's disease". Journal of the International Neuropsychology Society. 11 (4): 446–453. PMID 16209425.
  22. ↑ Galasko D, Schmitt F, Thomas R, Jin S, Bennett D (2005). "Detailed assessment of activities of daily living in moderate to severe Alzheimer's disease". J Int Neuropsychol Soc. 11 (4): 446–53. PMID 16209425. Unknown parameter |month= ignored (help)
  23. ↑ Sartori G, Snitz BE, Sorcinelli L, Daum I (2004). "Remote memory in advanced Alzheimer's disease". Arch Clin Neuropsychol. 19 (6): 779–89. doi:10.1016/j.acn.2003.09.007. PMID 15288331. Unknown parameter |month= ignored (help)
  24. ↑ Volicer L, Harper DG, Manning BC, Goldstein R, Satlin A (2001). "Sundowning and circadian rhythms in Alzheimer's disease". Am J Psychiatry. 158 (5): 704–11. PMID 11329390. Retrieved 2008-08-27. Unknown parameter |month= ignored (help)
  25. ↑ Neuropsychiatric symptoms:
    • Scarmeas N, Brandt J, Blacker D; et al. (2007). "Disruptive behavior as a predictor in Alzheimer disease". Arch. Neurol. 64 (12): 1755–61. doi:10.1001/archneur.64.12.1755. PMID 18071039. Unknown parameter |month= ignored (help)
    • Tatsch MF, Bottino CM, Azevedo D; et al. (2006). "Neuropsychiatric symptoms in Alzheimer disease and cognitively impaired, nondemented elderly from a community-based sample in Brazil: prevalence and relationship with dementia severity". Am J Geriatr Psychiatry. 14 (5): 438–45. doi:10.1097/01.JGP.0000218218.47279.db. PMID 16670248. Unknown parameter |month= ignored (help)
    • Volicer L, Bass EA, Luther SL (2007). "Agitation and resistiveness to care are two separate behavioral syndromes of dementia". J Am Med Dir Assoc. 8 (8): 527–32. doi:10.1016/j.jamda.2007.05.005. PMID 17931577. Unknown parameter |month= ignored (help)
  26. ↑ Honig LS, Mayeux R (2001). "Natural history of Alzheimer's disease". Aging (Milano). 13 (3): 171–82. PMID 11442300. Unknown parameter |month= ignored (help)
  27. ↑ Gold DP, Reis MF, Markiewicz D, Andres D (1995). "When home caregiving ends: a longitudinal study of outcomes for caregivers of relatives with dementia". J Am Geriatr Soc. 43 (1): 10–6. PMID 7806732. Unknown parameter |month= ignored (help)
  28. ↑ Bär M, Kruse A, Re S (2003). "[Situations of emotional significance in residents suffering from dementia]". Z Gerontol Geriatr (in German). 36 (6): 454–62. doi:10.1007/s00391-003-0191-0. PMID 14685735. Unknown parameter |month= ignored (help)
  29. ↑ Souren LE, Franssen EH, Reisberg B (1995). "Contractures and loss of function in patients with Alzheimer's disease". J Am Geriatr Soc. 43 (6): 650–5. PMID 7775724. Unknown parameter |month= ignored (help)
  30. ↑ Berkhout AM, Cools HJ, van Houwelingen HC (1998). "The relationship between difficulties in feeding oneself and loss of weight in nursing-home patients with dementia". Age Ageing. 27 (5): 637–41. PMID 12675103. Unknown parameter |month= ignored (help)
  31. ↑ Wada H, Nakajoh K, Satoh-Nakagawa T; et al. (2001). "Risk factors of aspiration pneumonia in Alzheimer's disease patients". Gerontology. 47 (5): 271–6. PMID 11490146.
  32. ↑ Gambassi G, Landi F, Lapane KL, Sgadari A, Mor V, Bernabei R (1999). "Predictors of mortality in patients with Alzheimer's disease living in nursing homes". J. Neurol. Neurosurg. Psychiatr. 67 (1): 59–65. PMC 1736445. PMID 10369823. Unknown parameter |month= ignored (help)
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