Oct 18, 2011

Systemic Infection and Inflammation Leads to Cognitive Decline and Behavioral Problems in Alzheimer's Patients

It is easy to believe that anger, meanness, irrationality, dullness, and cognitive decline are symptoms that come along with dementia. But, what if something treatable is causing the problem?

By Bob DeMarco
Alzheimer's Reading Room

A few years ago, I wrote an article about how my mother became disoriented and basically out of it in the morning.

Here is an excerpt from that article.

This has been a particularly bad week for my mother, and me.

Once again my mother has a urinary tract infection (UTI) -- the fourth time this year. Each time this happens my mother's Alzheimer's seems to worsen. This time around it was horrific.

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My mother seemed completely disoriented. On Monday morning, I woke up when I heard my mother yelling, Bobby, Bobby, Bobby. She came down to my room and asked me if I was in bed for the night. It was 6:45 AM. When I tried to explain to her it was morning, she started whimpering, and started telling me about how she was losing it.

My mother started on the antibiotics for the infection last week. Like I said she was just "out of it" in a way I had never seen before. On one morning she asked me where we were. I told her home. Her response, is this where we live?

From that point on, I started to feel like I was getting sick. I felt achy, lethargic, I didn't feel like doing anything. At first, I thought I was getting sick. After a couple of days, I finally realized I was getting stressed out. I actually thought to myself, is this how an Alzheimer's caregiver ends up depressed?

I can't tell you how many times a caregiver has told me directly, or via email, a story about how their loved one suffering from Alzheimer's got sick and took a turn for the worse. Most of these stories revolve around infections, or short trips to the hospital.

A study published in the journal Neurology -- Systemic inflammation and disease progression in Alzheimer disease -- indicates that infections (like UTI) can hasten memory loss in people with Alzheimer's.

The research describe below found a link between common infections, such as a cold, stomach bug or urine infection and an increase in inflammation like reactions in the brain which led to an increased rate of cognitive decline. Study results showed that people who got an infection had twice the rate of cognitive decline as people without infections.

Dr Susanne Sorensen, Head of Research, Alzheimer's Society said,
"It's important that older people, people with dementia and carers treat any infection seriously and seek medical help. Professionals treating people with Alzheimer's disease also have a responsibility to be vigilant in their efforts to treat infections in people with Alzheimer's disease early and effectively."
Bottom line here--stay on top of infections and get into the doctor's office immediately.


And now today.

With increasing frequency I am receiving emails from AD caregivers telling me how a person living with Alzheimer's starts to engage in "suspicious behaviors". Maybe they are irrational, angry, mean, disoriented, or just become downright dull and uncommunicative. Or, they evidence a combination of anger, irrationality, meanness, disorientation, and dullness.

Every time I read one of these emails I immediately think, is the person suffering from an infection? Did the doctor do a urine culture? And, administer a blood test (or culture) designed to look for infections that might cause inflammation to the brain and cause cognitive decline?

I doubt it. Why? Because it is all too easy to explain away the behavior as being part of the disease. A symptom of Alzheimer's disease. You are mean, angry, irrational, dull -- oh well it is a symptom of AD.

Is it?

Most of us assume that our doctor knows what they are doing. However, when it comes to dementia, few personal care doctors have received intense training with dementia patients while in medical school or any time thereafter. The typical older personal care doctor has about 4 days of training in dealing with dementia patients.

If a doctor hasn't treated patients in a learning setting, how can they be expected to treat symptoms effectively when they have no frame of reference to draw on. Typcially doctors experience an "AHA" moment when they examine a patients and pull all the symptoms together into a diagnosis. They saw it before and know what it is. Well, what if they never saw it before?

These same doctors might be excellent in diagnosing common problems. The kinds of symptoms that come along with common infections we all experience during the course of our lives.

However, keep this in mind. When you go to the doctor they ask, what is wrong? You then describe the symptoms.

Can the Alzheimer's patient you are caring for describe their symptoms? I doubt it. Can they tell you what is wrong, and then describe how they are feeling and try and describe the problem? I doubt it.

My mother can't. Never, not once.

Let me ask you a simple question. If you felt like crap day after day, week after week, and month after month, and you couldn't tell anyone how you felt, how do you think you would act? Mean, Angry, Aggressive, Dull?

Did you ever have a common cold and snap at someone because you weren't feeling well? How about if you had an infection for a month?

You tell me.

Folks, you have to go to great lengths to rule out infections instead of accepting that this is just the way it is with dementia. You have to find a doctor that is trained to diagnosis problems with dementia patients. This usually means a geriatric doctor that has a frame of reference and knows what to look for, and where to look, with persons suffering from dementia.

In the study described below, half of the Alzheimer's patients studied had acute systemic inflammatory events. These events can be associated with cognitive decline.


Background: Acute and chronic systemic inflammation are characterized by the systemic production of the proinflammatory cytokine tumor necrosis factor α (TNF-α) that plays a role in immune to brain communication. Previous preclinical research shows that acute systemic inflammation contributes to an exacerbation of neurodegeneration by activation of primed microglial cells.

Objective: To determine whether acute episodes of systemic inflammation associated with increased TNF-α would be associated with long-term cognitive decline in a prospective cohort study of subjects with Alzheimer disease.

Methods: Three hundred community-dwelling subjects with mild to severe Alzheimer disease were cognitively assessed, and a blood sample was taken for systemic inflammatory markers. Each subject’s main caregiver was interviewed to assess the presence of incident systemic inflammatory events. Assessments of both patient and caregiver were repeated at 2, 4, and 6 months.

Results: Acute systemic inflammatory events, found in around half of all subjects, were associated with an increase in the serum levels of proinflammatory cytokine TNF-α and a 2-fold increase in the rate of cognitive decline over a 6-month period. High baseline levels of TNF-α were associated with a 4-fold increase in the rate of cognitive decline. Subjects who had low levels of serum TNF-α throughout the study showed no cognitive decline over the 6-month period.

Conclusions: Both acute and chronic systemic inflammation, associated with increases in serum tumor necrosis factor α, is associated with an increase in cognitive decline in Alzheimer disease.

Original content Bob DeMarco, the Alzheimer's Reading Room