For most people, occasional forgetfulness is normal as we age. However, Alzheimer’s Disease, or Alzheimer’s in short, is more than just “senior moments’ and should be taken seriously. According to the World Alzheimer Report, a new case of dementia occurs about every 3 seconds. In Hong Kong, 5-8% of the population above age 65 and 20-30% of those older than 80 years are diagnosed with dementia, with more than 60% of these cases caused by Alzheimer’s disease.
What is Alzheimer’s Disease?
Alzheimer’s disease is a chronic, progressive, irreversible brain disorder that kills brain cells and nerves. It causes ongoing loss of cognitive and intellectual function that impairs memory, ability to think and perform everyday tasks, and social skills, eventually requiring complete assistance from others. Some may also experience emotional and behavioural problems. More women than men are diagnosed with Alzheimer’s.
As degenerated brain cells cannot be replaced, the condition worsens over time; hence the disease is incurable. Medications are sometimes effective in slowing down the disease, but cannot halt or reverse the deterioration. The rate of progression of Alzheimer’s varies among individuals.
Contrary to popular belief, Alzheimer’s is not a disease that affects only the elderly. Younger people can also be affected. Early-onset Alzheimer’s occurs before the age of 65 and accounts for up to 1% of all cases. It usually results from an inherited genetic mutation. In this group, people may develop symptoms in their 40s or 50s. Late-onset Alzheimer’s is much more common and develops after the age of 65.
Alzheimer’s and Dementia
Dementia is a term used to describe a group of diseases associated with cognitive decline, resulting in difficulties and changes in numerous functions such as learning, communication and feelings. Dementia can be caused by at least 100 different types of disease, including Alzheimer’s, vascular dementia, dementia with Lewy bodies and frontotemporal dementia.
Alzheimer’s is the best-known and most common form of dementia, accounting for over half of all cases of dementia globally. It is important to note that some people develop more than one type of dementia. For example, it is not uncommon to have both vascular dementia and Alzheimer’s.
Signs and Symptoms
Alzheimer’s typically gets worse progressively. Symptoms vary from person to person and may include:
- Memory loss that interferes with daily activities, resulting in forgetting new information and/or asking questions repetitively.
- Reduced ability to plan or solve problems.
- Difficulty performing familiar and routine tasks, for example, driving to work.
- Confusion about time, dates or places.
- Impaired visuospatial functions, for instance, difficulty determining distance or colour contrasts.
- Struggles with speaking, writing and reading.
- Losing things and not being able to retrace steps.
- Decreased reasoning and judgement.
- Changes in personality and behaviour, such as becoming distrustful.
- Social withdrawal from hobbies, work or social events.
Stages of Alzheimer’s
The progression of Alzheimer’s can be broadly divided into three stages.
One of the primary and first problems is memory impairment. Patients can remain independent and active in social and work settings; however, family members and friends may start to detect problems. People with early Alzheimer’s may exhibit mood changes.
Symptoms become more pronounced as more areas of the brain become affected, including reasoning, language and sensory processing. Patients are still able to recall details of significant events in their lives, but display difficulties recognising family members and friends. They may also experience moodiness, confusion with words, delusions and paranoia. They are sometimes found wandering and getting lost. Patients in this stage usually require support from other people.
This stage is characterised by a significant shrinkage of the brain tissues, causing inability to perform everyday functions. Patients fail to respond to their surroundings and to control their movement. Communication is challenging. They may not be able to eat, swallow or walk properly. There is a complete loss of autonomy. They are at a higher risk of developing infections.
Is it Alzheimer’s or normal ageing?
People often confuse the symptoms of Alzheimer’s with age-related memory loss. The latter frequently occurs as people age but does not signify dementia.
Here are five common situations where Alzheimer’s can be confused with typical age-related issues:
Not remembering details of recent events or conversations
Not remembering details of events or conversations which occurred years ago
Frequently pausing, forgetting or misusing words, or repeating the same sentence
Having difficulty finding the right word sometimes
Not knowing people who are close to them
Forgetting names of acquaintances
Vision changes not related to eyesight problems
Vision problems caused by cataracts, glaucoma, etc
Challenges in thinking and calculation
Missing a monthly payment
Complications of Alzheimer’s
- Behavioural issues: e.g. agitation, hostility, aggression as patients gradually lose the ability to reason. They may also wander due to memory loss and confusion relating to place and time.
- Psychiatric issues: e.g. depression and anxiety.
- Physical issues: e.g. bladder and bowel problems such as incontinence. People with Alzheimer’s may not recognise or be able to control their bodily functions. Infections such as pneumonia are more common in the later stages.
- Metabolic issues: e.g. dehydration and malnutrition.
- Falls: risks of fractures increases as Alzheimer’s affects balance and coordination.
Causes and Risk Factors
Brains affected by Alzheimer’s are characterised by death and loss of connection between nerve cells, resulting in significant shrinkage of the brain. While it is not clear exactly why this happens, it is known that two proteins are involved in the disease process:
- Beta-amyloid is a small piece of protein that can form plaques toxic to nerve cells.
- Tau proteins transport and supply nutrients to cells and tissues in the brain. Tau proteins in Alzheimer’s form structures called neurofibrillary tangles that disrupt their original functions.
Some factors contributing to the development of the disease are:
- Age: it is the number one risk factor. The risk doubles each year after age 65.
- Gender: Alzheimer’s affects more women than men. This may be at least partly due to women’s longer life expectancy, as age is the most significant factor.
- Family history: having a close relative with Alzheimer’s increases risk by about 30%.
- Down’s syndrome: causes a build-up of amyloid plaques in the brain.
- Cardiovascular diseases: e.g. high blood pressure, high cholesterol and diabetes.
- Lifestyle: e.g. lack of physical activity, obesity and smoking.
- Education level: a lower education level may increase the risk.
- Severe head injury.
Diagnosis is often delayed as patients easily mistake early symptoms for signs of normal ageing. Your doctor will usually use several tests to diagnose Alzheimer’s. However, diagnosis can only be 100%, definitively, confirmed by autopsy after death.
Your doctor will assess symptoms by asking you and your family members or friends questions. The questions will cover topics such as ability to perform daily activities, medical and medication history, and changes in personality and behaviours.
A neurological examination will further help your doctor assess your coordination, balance and senses to eliminate other potential causes.
Various mental status tests, such as the Mini Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCa), can be conducted to more extensively evaluate your cognitive and mental function. These tests assess abilities such as orientation, language, recall and calculation.
Your doctor may also carry out laboratory tests, including blood tests and brain imaging, to rule out other possible causes for the symptoms you are experiencing.
How to treat Alzheimer’s
Despite significant funding allocated to research on Alzheimer’s, there is no known cure to date.
Medications for memory loss
They may temporarily improve the symptoms but do not work for everyone.
Mild to moderate Alzheimer’s
Cholinesterase -inhibitors prevent the breakdown of acetylcholine (an essential chemical for learning and memory) and therefore increase the availability of acetylcholine in the brain. Examples include donepezil, rivastigmine and galantamine.
Common side effects include nausea, vomiting, diarrhoea, abdominal pain, anorexia and headache.
Moderate to severe Alzheimer’s
Memantine protects the nervous system by preventing nerve cell degradation, which results from over-excitation of the nervous system by excessive levels of a chemical called glutamate. A frequent side-effect is dizziness.
Donepezil is also approved for the treatment of moderate to severe Alzheimer’s.
Medication for mental and behavioural symptoms
Behavioural and psychological symptoms become more pronounced in the late stages of Alzheimer’s and may include aggression, agitation, wandering, hallucinations, anxiety, and sleeping problems. You doctor may prescribe the following medications:
- Antidepressants: to treat depression and anxiety. They regulate chemicals responsible for mood and emotions in our brain. Examples include citalopram, escitalopram, fluoxetine and sertraline.
- Antipsychotics: to limit aggression, agitation and hallucinations. They work by blocking the action of dopamine, which is a chemical transmitting signals between brain cells. Examples are aripiprazole, olanzapine and quetiapine.
- Anti-anxiety medications: to treat anxiety and insomnia. These medications work by enhancing the effects of a specific natural chemical in the body (GABA).
Other medications or supplements
Some other drugs or supplements are proposed to play a role in maintaining cognition and neuronal integrity, for example, vitamin E, Ginkgo biloba, omega-3, aspirin, oestrogen, non-steroidal anti-inflammatory drugs such as ibuprofen, etc.
There is, however, minimal evidence supporting the use of these substances. Studies show inconsistent and conflicting results for their effectiveness. Be sure to consult your doctor before taking any drug or supplement.
There are several non-pharmacologic approaches to helping people with Alzheimer’s. For example:
- Cognitive Stimulation Therapy: a group of activities and tasks geared towards attention, creativity, orientation and numbers, which aim to improve memory and other life skills, and thus enhance patients’ quality of life.
- Reminiscence therapy: patients are encouraged to recall and share their past stories by using all senses. As well as maintaining memory, this kind of treatment promotes a sense of value and belonging.
- Music therapy: brain areas associated with music are relatively protected from Alzheimer’s. Research suggests that music therapy shows potential in slowing cognitive decline and improving other symptoms.
Although there are no proven prevention measures, adopting a healthy lifestyle can help reduce the likelihood of developing Alzheimer’s. These include:
- Regular physical exercise
- A balanced diet
- Smoking cessation
- Avoiding excessive alcohol consumption
- Staying mentally and socially active
- Regular check-ups
- Proper management of chronic conditions, e.g. diabetes and hypertension
Dementia Friendly Community Campaign in Hong Kong
To raise public awareness of dementia and help build a dementia-friendly community, the Hong Kong Government launched a 3-year Dementia Friendly Community Campaign in September 2018. It is a joint cooperation between government departments and non-governmental organisations active in Hong Kong.
The campaign consists of a series of educational programmes including television broadcasts and “Dementia Friends” information sessions. There are different activities organised every month in various local districts, including training workshops, support groups, reality orientation camps and funfairs for the public, patients and their carers.
The Dementia Community Support Scheme under the Campaign also provides support services to older adults with mild to moderate dementia and their caregivers according to individual needs.
Click here for more information.
What is the cost of Alzheimer’s Treatment in Hong Kong?
Cost of treatment in Hong Kong’s Public Sector:
For eligible persons with a HKID card, the cost for specialist outpatient services in public hospitals is $135 for the first attendance and $80 per subsequent attendance. Each drug item costs $15.
For non-eligible persons without a HKID card, the cost of attending specialist outpatient clinics is $1190 per attendance in public hospitals.
Beware of waiting times which can be very long in the public sector.
Cost of treatment in Hong Kong’s Private Sector:
The cost of Alzheimer’s treatment in the private sector varies according to the condition of the patient. It is best first to consult your doctor and discuss the options that are most appropriate for your situation. Generally, consultations by specialists in Hong Kong cost between $600 and $2000, excluding medication fees. Cognitive assessment provided by specialists costs around $1100 to $2400.
*All amounts are in HKD and were last updated in June 2020. No responsibility is accepted for any inaccuracies, errors, or omissions. It is always best to call ahead to make sure the information is still up-to-date.
Useful Resources in Hong Kong
- Hong Kong Alzheimer’s Disease Association
- The Charles Kao Foundation
- Dementia Friends Hong Kong
- Jockey Club Centre for Positive Ageing
- St. James Settlement Kin Chi Dementia Care (Chinese only)
- Christian Family Service Centre (Ming Delight Memory & Cognitive Training Centre) (Chinese only)
Dr. Sarah Borwein is a Canadian trained General Practitioner who co-founded the Central Health Group and has been practicing family medicine in Hong Kong for over 15 years. After obtaining Certification in Family Medicine from the College of Family Physicians of Canada, she completed a Masters degree in Infectious Diseases from the London School of Hygiene and Tropical Medicine. She worked as a staff physician at the Beijing United Family Hospital where she was Director of Infection control during the SARS outbreak in China. A French speaker, Sarah is the advising and referral doctor for the French Consulate in Hong Kong. She is the site director for GeoSentinel (an international disease surveillance network) in Hong Kong and is past President of the Asia Pacific Travel Health Society. In addition, she sits on the Centre for Health Protection's Scientific Committee on Vector-borne Diseases, which advises the Hong Kong Department of Health on this type of illness.