September 21 marks the World Alzheimer’s Day. This would be the tenth year of this vital global awareness-raising campaign.

The plan for 2021 is to shed light on the warning signs of dementia, encouraging people to seek information, advice and support by reaching out to Alzheimer’s or dementia associations in their countries. Through global effort, awareness can be created, and stigma and misinformation surrounding the disease are challenged.

Pakistan has an estimated 150,000-200,000 patients with dementia. There is an alarming increase in the incidence of Alzheimer’s disease, in the country. According to the latest WHO data, published in 2018, Alzheimer’s and dementia-caused deaths have reached 17,248 or 1.39 per cent of the total.

Alzheimer’s is a neurodegenerative disease. Neurodegeneration is the progressive loss of structure or function of neurons, which may ultimately involve cell death. The disease starts slowly and progressively worsens. It is the most common form of dementia. Dementia is not a disorder of consciousness, as that is not usually affected. However, it can have a significant effect on individual relationships and caregivers. As the disease advances, symptoms can include problems with language and disorientation. It can trigger mood swings, which can be disruptive. Loss of motivation, self-neglect and behavioural issues are common. As a patient’s condition declines, they often withdraw from family and society. Gradually, bodily functions are lost, ultimately leading to death.

No treatments stop or reverse its progression, though some may temporarily improve symptoms. Affected people increasingly rely on others for assistance. It most often begins in people over 65 years of age, although up to 10 per cent of the cases are early-onset, affecting those in their 30s to mid-60s. The disease is named after German psychiatrist and pathologist Alois Alzheimer, who first described it in 1906.

The course of Alzheimer’s is generally described in three stages, described as early or mild; middle or moderate; and late or severe. The disease is known to affect the part of the brain associated with memory. As the disease progresses, so does the degree of memory impairment.

The first symptoms are often mistakenly attributed to ageing or stress. These early symptoms can affect the most complex activities of daily life. The most noticeable deficit is a short-term memory loss, which shows up as difficulty in remembering recently learned facts and inability to acquire new information.

Problems with the executive functions of attentiveness, planning flexibility and abstract thinking, or impairments in memory of meanings and relationships, can also be symptoms of the early stages of Alzheimer’s disease. Lack of interest (apathy) and depression can be seen at this stage, with apathy remaining the most persistent symptom throughout the disease. There is an increasing impairment of learning and memory. Alzheimer’s disease does not affect all memory capacities equally. Older memories of the person’s life, facts learned, and the memory of the body on how to do things, such as using a spoon to eat or how to drink from a glass, are affected to a lesser degree than new facts or memories.

Language problems are mainly characterised by a shrinking vocabulary and decreased word fluency. At this stage, the person is usually capable of communicating basic ideas adequately. While performing delicate motor tasks such as writing, drawing or dressing, certain movement coordination and planning difficulties may be present, but they are commonly unnoticed. As the disease progresses, people with Alzheimer’s disease can often continue to perform many tasks independently but may need assistance or supervision with the most cognitively demanding activities.

Progressive deterioration eventually hinders independence, with persons being unable to perform the most common activities of daily living. Speech difficulties become evident, which leads to frequent incorrect word substitutions. Reading and writing skills are also progressively lost. Complex motor functions become less coordinated as time passes, so the risk of falling increases. During this phase, memory problems worsen and the person may fail to recognise close relatives. Long-term memory, which was previously intact, becomes impaired.

Behavioural and neuropsychiatric changes become more evident. Common manifestations are wandering, irritability and emotional liability, leading to crying, outbursts of aggression or resistance to caregiving. Sundowning, a state of confusion occurring in the late afternoon and spanning into the night, can also appear. Approximately 30 per cent of people with Alzheimer’s disease develop illusionary misidentifications and other delusional symptoms, something a person believes and wants to be true when it is not. Urinary incontinence can develop.

During the final stage, known as the late-stage or severe stage, the patient is completely dependent upon caregivers. Language is reduced to simple phrases or even single words, eventually leading to complete loss of speech. Despite the loss of verbal language abilities, people can often understand and return emotional signals. Although aggressiveness can still be present, extreme apathy and exhaustion are much more common symptoms. People with Alzheimer’s disease will ultimately not be able to perform even the simplest tasks independently; muscle mass and mobility deteriorate to the point where they are bedridden and unable to feed themselves. The cause of death is usually an external factor, such as infection of pressure ulcers or pneumonia, not the disease itself.

The cause of Alzheimer’s disease is poorly understood. There are many environmental and genetic risk factors associated with its development. Some risk factors include a history of head injury, clinical depression and high blood pressure. There are no medications or supplements that have been shown to decrease risk.

Alzheimer’s disease is usually diagnosed based on the person’s medical history, history from relatives and behavioural observations. The presence of characteristic neurological and neuropsychological features and the absence of alternative conditions can be supportive. Advanced medical imaging, CT scan or MRI, and PET can be used to help exclude other cerebral pathology or subtypes of dementia.

Cognitive tests such as the mini-mental state examination (MMSE) can help diagnosis. Interviews with family members are also utilised in the assessment of the disease. Caregivers can supply important information on the daily living abilities and the decrease, over time, of the person’s mental function.

Intellectual activities such as playing chess or regular social interaction have been linked to a reduced risk of Alzheimer’s disease in epidemiological studies, although no causal relationship has been found. Cardiovascular risk factors are associated with a higher risk of onset and worsened course of Alzheimer’s disease. Blood pressure medications may decrease the risk. A review found that the use of statins, which lower cholesterol, may benefit Alzheimer’s disease.

Evidence suggests that higher education, occupational attainment, and participation in leisure activities show a reduced risk of developing Alzheimer’s or delaying the onset of symptoms. Education delays the onset of Alzheimer’s disease, and learning a second language even later in life can help.

Physical exercise is associated with a decreased rate of dementia and effectively reduces symptom severity in those with Alzheimer’s disease. Diet is seen to be a modifiable risk factor for the development of dementia. A diet that is generally low in saturated fats while providing a good source of carbohydrates lowers the risk of disease. Raised blood sugar levels can damage nerves and cause memory problems if they are not managed over a long time. Nutritional factors associated with the proposed diets for reducing dementia risk include unsaturated fatty acids, antioxidants, Vitamin C, B, D, selenium, zinc and copper. Olive oil may be one of the most important components in reducing the risk of cognitive decline and dementia.

There is tentative evidence that caffeine may be protective. A number of foods high in flavonoids, such as cocoa and tea, may decrease the risk of Alzheimer’s disease. There is no cure for Alzheimer’s disease; available treatments offer relatively small symptomatic benefits but remain palliative in nature.

The writer is a psychologist. She has worked at the Fountain House, Lahore