Alzheimer's Disease and Related Disorders
Alzheimerís disease, the chronic decline in intellectual capabilities, was recognized by the ancient Greek physician Hippocrates. At the time "senility" was thought to be simply a normal part of aging. Later, Alois Alzheimer, a German doctor, more fully described the disease in 1907. He examined a 55-year-old women with dementia who had been sent to a psychiatric hospital. She initially displayed symptoms of unreasonable jealousy of her husband four years earlier. She declined rapidly demonstrating paranoid delusions, hallucinations, and a loss of memory. After her death at age 56, Dr. Alzheimer examined her brain and noticed senile plaques and neurofibrillary tangles in the neurons (brain cells.) Alzheimer wrote "On the whole, it is evident that we are dealing with a peculiar, little known disease process." Up until 1970 the diagnosis of Alzheimerís disease was restricted to patients less than 65 years-old.
Syrotuck was the first to mention the elderly and becoming lost in the search and rescue field. However, due to a lack of searches in his database he combined healthy elderly with those suffering from Alzheimer's. Koester was the first to report a statistical search profile of the Alzheimer's disease patient. He also showed that healthy elderly and Alzheimer's patients must be treated as two separate profiles.
The term "Alzheimerís" is rapidly being used by the general public to refer to any elderly person suffering from dementia. Everyone who suffers from Alzheimer's disease has dementia. However, not everyone with dementia has Alzheimer's disease. Dementia may be caused by several other diseases. The original name of the Alzheimer's Association was Alzheimer's and related diseases. Possible Alzheimerís and Related Disorders includes Alzheimerís disease and the less well known dementia causing disorders of Vascular dementia (formally called multi-infarct dementia), Parkinson's dementia, Symptomatic Hydrocephalic, Korsakoffís Syndrome, Pickís disease, Huntingtonís disease, and Spongiform Encephalopathy. In fact if you gather a bunch of researchers and doctors they will tell you that even the term Alzheimer's disease is used incorrectly. Since the disease can only be positively diagnosed after removing some brain tissue (ouch!) the more correct terms are probable/possible Alzheimer's disease (pAD) or Dementia of Alzheimer's Type (DAT). While, a bit picky, it is important for search planners to understand the distinction. On some searches the caregiver emphatically stated the lost subject "does not have Alzheimerís disease." Yet instead, the lost subject suffered from Vascular dementia or Parkinson's dementia. Both of which may be equally severe. At this time, it appears the nature of wandering, from a search perspective, is the same for all the Alzheimerís and Related Diseases. Therefore, this site will simply use the term Alzheimer's or Alzheimer's disease instead of always stating (more correctly) "possible/probable Alzheimer's disease and related disorders."
The hallmark of Alzheimerís disease is difficulty with memory. It typically starts with problems with short-term memory and then slowly progresses to long-term memory. Other major signs and symptoms include loss of reasoning, decreased judgment abilities, behavior changes, communications problems, and difficulty performing routine activities of daily living (balancing checkbooks, telephoning, etc). Disorientation is also a common problem that relates to wandering and becoming lost. The rate of progression varies from person to person along with the types of symptoms shown. In the severe stages, the patient becomes totally incapable of caring for themselves.
Alois Alzheimer was able to describe two of the major changes in brain structure caused by Alzheimerís disease. In addition to the neurofibrillary tangles and neuritic plagues, AD also results in granulovascular degeneration, brain shrinkage, and decreased amounts of neurotransmitters (brain chemicals involved in communication). All of these changes impair the function of brain cells (neurons) and eventually lead to cellular death. Unlike many other cells, the brain is unable to regenerate new neurons. The gradual and progressive death of neurons is mirrored in specific behavior changes. An understanding of the areas of the brain most affected by changes will give additional insight into the nature of wandering.
| Mild | Moderate | Severe |
The hallmark of AD is a gradual decline in the patient that the caregiver is unable to attach a specific date of onset. The affected individual gradually becomes forgetful and less productive in everyday abilities. The severity of AD can be described in three stages; mild, moderate, or severe. Each stages presents a different profile of a wanderer and impacts upon the planning of the search manager and prevention strategies.
The chief characteristic of mild Alzheimerís Disease is forgetfulness. Not only will the individual misplace items but will start to place them in unusual locations (i.e. keys in the freezer). Changes in ability to tell time and other visual-spatial tasks represents another sensitive indicator. Simple tests such as temporal orientation and clock drawing help uncover mild AD.21 Loss of a sense of time and direction greatly interferes with the ability to navigate and are important components of a "sense of direction." The characteristic of becoming lost, especially in unfamiliar territory is a common hallmark of the critical wanderer with mild AD. Wandering is reported in 18% of those suffering from mild dementia.22 However, the patient may experience no problems taking long walks of considerable distance in familiar territory. Instead, it is new activities and complex tasks that cause problems. More abstract tasks such as managing finances or making calculations deteriorate early. The decline may be so gradual that it may take family members years to notice since some forgetfulness is a natural part of aging.
Wandering during the mild stages requires both a search response and a strong investigative component. The wandering is often goal directed. Since the wanderer still has sufficient facilities to use public transportation or drive the search area grows rapidly. Determining possible goals of the lost person will become a major emphasis for the search. However, even if the wanderer seeks an initial goal, they may easily become lost along the way. Another common type of wandering seen among mild Alzheimerís disease subjects is escapist behavior.
Once Alzheimerís disease deteriorates to the moderate stage; profound memory loss that interferes with daily activities characterizes the disorder. The AD patient in the moderate stage is dependent upon others. The sufferer becomes lost even in familiar surroundings and has lost the ability to learn any new material. At this stage judgment and insight are severely impaired. The confusion often becomes worse in the evening, a phenomena called sun-downing. Behavioral problem such as wandering increase during this time. In addition, the AD patient often suffers from sleep disorders.
Behavioral problems become much more serious in the moderate Alzheimerís disease stage. Wandering occurs in AD patients that are often restless. The wandering is often described as pacing or searching at this stage. The trigger for wandering behavior at this stage is linked to the patient becoming agitated. Other behavioral problems include hostility, verbal outburst, aggression, and inappropriate behavior. Other patients become apathetic and deny any type of problem. Psychological problems also start becoming more common. Patients often suffer from delusions, hallucinations, and paranoia which occurs in 24% of the patients.
Once the disease progress to the severe stage the patient suffers from severe impairment of mind (cognitive functions) and body. The subject has reached the point they may no longer recognize their spouse and children. The AD patient no longer has any sense of time or current location. Verbal communication has decreased to the point of phrases, words, or merely syllables are constantly repeated. Eventually, even this simple communication degenerates to a complete inability to speak. Several physical problems also occur. Unsteadiness, falls, and reduced mobility should severely limit the distance the AD wanderer may travel. However, the overall incidence of wandering increases to 50%. The overall loss of coordination and body control means the patient may need help dressing, bathing, grooming, eating, and toileting.
Vascular Dementia (Multi-Infarct Dementia MID)
Vascular dementia (also known as multi-infarct dementia MID) is caused by several small strokes (infarcts) within the brain. The progression of the disease is not a gradual decline, but instead one marked by sharp "steps" downward. This stepwise decline in ability is caused by additional small strokes that further destroy parts of the brain. Vascular dementia is the second leading cause of dementia among the elderly. The old description of "hardening of the arteries" holds some accuracy in describing this type of dementia.
The onset of Parkinsonís disease usually occurs between age 50 to 65 years. It is commonly associated with tremors and a shuffle gait. Other symptoms include slowing of or difficulty starting movement and muscle stiffness. In Parkinsonís disease a deficiency exists in the neurotransmitter dopamine. Found within the brain cells that produce dopamine a microscope reveals a structural disorder called a Lewy body. In Parkinsonís disease their location is specific to certain structures. As cellular destruction progress and enough neurons die, the later stages of Parkinsonís disease results in dementia. In many cases a mixture of both Parkinsonís and Alzheimerís disease is possible. In fact, this mixture may be more common than just simple Parkinsonís dementia.
The difference between Lewy body dementia and Parkinsonís disease is the location of the abnormal protein deposits called Lewy bodies. The disorder is sometimes called diffuse Lewy-body disease to better describe that the abnormal proteins are found throughout the brain. While symptoms are similar to AD in that the patient suffers from memory loss, confusion, and language problems, in Lewy-body dementia hallucinations and paranoia are more common. Other features include visual hallucinations, progressive fluctuating decline, and mild extrapyramidal features. Extrapyramidal features are also seen in Parkinsonís disease and includes such problems as rigidity, shuffling gait, a flexed posture, and the slow movement.
Huntingtonís disease is caused by a dominant genetic defect that becomes apparent between the ages of 35 to 40. The defects concentrate in the fronto-temporal lobes and structures found under the cortex. The disease process results in mood disorders, personality changes, delusions, paranoia, explosive behavior, schizophrenia-like illness, suicidal behavior, sexuality changes, and specific cognitive deficits. Memory loss and a steady decline in cognitive abilities occur throughout the disease.
Normal pressure hydrocephalus (NPH) is simply extra pressure on the brain. The extra fluid can be caused by a variety of causes including bleeding, head trauma, and infections. The extra pressure can cause a wide spectrum of problems. The most common symptoms include dementia, urinary incontinence and difficulty walking. Mental disturbances are demonstrated in slow mental processing, impaired recall, and difficulties planning complex actions. The differences in gait will be of interest to mantrackers. Walking is characterized by a slow shuffling with wide-based difficulty with muscular control. The patient will have difficulty coordinating the lower extremities while standing. The stride is also reduced and appears awkward. Fortunately, in some individuals, NPH is reversible by a surgical procedure which reduces pressure in the brain.
Pickís disease is a rare form of dementia that only affects one in one million persons. The average age of onset is typically between 40 and 60 years. Since the disease process first affects only the frontal lobe of the neocortex, memory loss is not the first sign of early Pickís disease. Initial behaviorís often include sexually inappropriate behavior, wandering unclothed, touching and kissing strangers, impulsive behavior, childlike behavior, and urinating in inappropriate places. Other strange behaviorís consist of increased irritability, aggression, poor judgment, increased eating and weight gain, depression, wandering behavior, and traveling with the apparent purpose of exploration such as walking or driving away searching and examining a new area, and returning to the point of departure. Memory loss does not occur until the more final stages of the disease.
Creutzfeldt-Jakob disease (CJD) is another rare form of dementia. It affects one person per two million population. The disease is similar to Mad Cow disease (bovine spongiform encephalopathy) in the sense it may be due to a unique type of viral infection. The infectious agent is called a prion that is protein that lacks DNA. CJD results in dementia, loss of coordination, and a loss of higher brain functions. Additional symptoms include fatigue, physical discomfort, insomnia, loss of appetite, and the inability to concentrate. In the later stages of CJD severe memory loss, delusions, and hallucination become common.
These sections are excerpts from a book in progress on wandering and Alzheimer's.
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