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by Marsha Berry
There are an estimated 5.3 million people in the U.S. with Alzheimer's disease. By the year 2030, that number is expected to increase to 7.7 million. Alzheimer's disease is the most common form of dementia, a group of symptoms characterized by loss in memory and at least one other cognitive skill. Sixty to 80% of people with dementia have Alzheimer's disease (Alzheimer's Association, 2009). The most significant risk factor for Alzheimer's is age. For most people the disease begins with difficulty remembering new or current information, and other cognitive abilities such as the ability to plan, use language, and understand time and spatial relations deteriorate as the disease progresses.
People with intellectual and developmental disabilities develop Alzheimer's disease at rates similar to older adults in the general population. However, adults with Down syndrome develop Alzheimer's disease at greater rates. Recent studies for adults with Down syndrome show that 10-25% of individuals between ages 40-49, 20-50% of individuals between ages 50-59, and 60-75% of individuals with Down syndrome older than age 60 have Alzheimer's disease (Alvarez, 2008). Because people with Down syndrome experience accelerated aging, they are at greater risk for this disease of the aging brain. Additionally, the amyloid precursor protein gene sits on chromosome 21; most people with Down syndrome have two copies of this chromosome in every cell and therefore double the risk of having one of the genes implicated in the brain degeneration associated with Alzheimer's. Clinical studies have also noted that the volume of the hippocampus, the area of the brain responsible for beginning the process of memory storage, is reduced in people with Down syndrome (Piner, et al., 2001).
For years, the Alzheimer's Association has provided the public with a list of the "10 Warning Signs" of Alzheimer's disease. These include memory changes significant enough to impact daily life, challenges in planning or problem solving, difficulty completing familiar tasks and confusion with time or place. (For a complete list of the warning signs see www.alz.org). The warning signs for people with intellectual and developmental disabilities focus on functional capabilities (see Figure 1). Most often, the first change that family members or professionals notice is a change in activity of daily living skills. For example, if an individual has worked independently in a restaurant for many years she may begin to lose attention for the task, make many errors or become frustrated with the task. A man who has enjoyed going out with others in his group home may seem reluctant to do this and want to stay home. Families and staff will most often notice that the individual loses the ability to perform skills he or she has been able to do for many years.
They may notice other changes as well. She may ask the same question repeatedly. An individual who has been outgoing may seem more withdrawn. She may seem less alert and move more slowly. He may cry easily and appear frustrated when completing tasks that have been part of his daily routine in the past. He may be confused and get lost in familiar places. These changes will not happen quickly, but will be noticeable when compared to previous abilities.
With individuals who have severe developmental disabilities it may be more difficult to identify changes in behavior. However, among those changes that may appear are becoming more socially withdrawn, being less responsive to others, seeming easily frustrated even in familiar surroundings, appearing much less interested in activities that engaged them in the past, and having shortened attention.
Having a clear and specific understanding of the individual's skills, abilities, and interests is important for comparing current behaviors to those from the past and noticing changes. A baseline evaluation of skills at work, abilities at home, and interests will help caregivers to notice possible signs of Alzheimer's disease, and share changes with medical professionals.
There is no one test for the diagnosis of Alzheimer's disease. Physicians may suggest several tests as a way to rule out other issues. There are many reasons why an individual may experience difficulties with activities of daily living or show changes in his or her personality. If caregivers notice changes and losses in skills, it is important to seek a medical evaluation. A medical professional will want to rule out issues which can be corrected such as thyroid disorders, depression, physical health problems, and medication side effects. Clear documentation as to current abilities is important so that staff and medical professionals can compare current abilities to past.
Alzheimer's is a progressive disease, and while it does not progress at the same rate in every person, there are some general stages of the disease. For individuals with mild to moderate developmental disabilities the changes first noticed in the early stages of Alzheimer's disease include loss of activity of daily living skills, personality changes, and disorientation to time and place.
As the disease progresses the symptoms seen in the early stage increase. Individuals become increasingly confused and their frustration may increase. Many individuals will experience disruptions in their sleep schedule and become very confused about day and night. Some individuals may attempt to leave their residence and become lost.
Late in the disease process individuals are very disoriented to time and place and exhibit physical issues. They may have difficulty swallowing, be incontinent, and have difficulty walking. They will need total care for survival.
The FDA has approved four medications for treating the cognitive symptoms of Alzheimer's disease. The approved medications are three cholinesterase inhibitors -- donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne) -- and memantine (Namenda), a glutamate receptor antagonist. While these have been tested in older adults without intellectual or developmental disabilities, there have been no large randomized controlled studies in adults with intellectual or developmental disabilities. It is important for caregivers to seek advice from a medical professional about the use of these medications.
The University of Stirling (Scotland), the University at Albany, and the University of Illinois at Chicago called a group of international experts together in 2001 to define internationally applicable working practices for the community supports of adults with intellectual and developmental disabilities who have Alzheimer's disease. Known as "The Edinburgh Principles," these guidelines focus on quality of life and promote care management. The group proposed that "governments, organizations, and providers adopt these and promote their use in aiding those adults with intellectual disabilities affected by Alzheimer's disease and other similar conditions resulting in dementia" (http://www.rrtcadd.org/TA/Dementia_Care/Resources/Edinburgh_Principle/Info.html). The Principles are as follows:
The Edinburgh Principles are the foundation of the caregiving suggestions in the following section.
There are a number of things caregivers can do to support quality of life, as well as safety and well-being of individuals with intellectual or developmental disabilities who have Alzheimer's disease. Among them are the following:
As people with intellectual and developmental disabilities continue to age more successfully and live longer, the numbers with Alzheimer's disease and other dementias will increase. To promote quality of life it is important that caregivers understand the early warning signs of dementia. Being aware of changes individuals experience will allow individuals and their caregivers to seek an evaluation by a medical professional to diagnose dementia or treat another medical condition. Having a diagnosis and understanding the progress of dementia will allow caregivers to adjust supports and services to meet the new and changing needs of the individual.
Alvarez, N. (2008). Alzheimer disease in individuals with Down syndrome. Retrieved 10/1/09 from www.emedicine.medscape.com/article/1136117-overview.
Alzheimer's Association. 2009 Alzheimer's disease facts and figures (www.alz.org).
Piner, J.D., Brown, W.E., Eliez, S., Schmitt, J.E., Capone, G.T., & Reiss, A.L. (2001). Amygdala and hippocampal volumes in children with Down syndrome: A high-resolution MRI study. Neurology, 56, 972.
Marsha Berry is Professional Education Manager with the Alzheimer's Association of Minnesota North Dakota, Edina, Minnesota. She may be reached at 952/857-0541 or firstname.lastname@example.org.
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Retrieved from the Web site of the Institute on Community Integration, University of Minnesota (http://ici.umn.edu/products/impact/231). Citation: Heller, T., Stafford, P., Davis, L.A., Sedlezky, L., & Gaylord, V. (Eds.). (Winter 2010). Impact: Feature Issue on Aging and People with Intellectual and Developmental Disabilities, 23(1). [Minneapolis: University of Minnesota, Institute on Community Integration].
The PDF version of this Impact, with photos and graphics, is also online at http://ici.umn.edu/products/impact/231/231.pdf.
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