People with dementia forget things chronologically

Creeping into oblivion

Copyright: ruewi /

Alzheimer's dementia doesn't come overnight. Experts assume it will be asymptomatic for around 30 years before the disease becomes noticeable. Then the mist of oblivion condenses in three phases.

Scientific supervision: Prof. Dr. Frank Jessen

Published: 09/20/2013

Level: medium

  • Long before the diagnosis of Alzheimer's disease, the disintegration raged in the brain. Experts put the asymptomatic phase of the disease at around 30 years.
  • If the accumulation of misfolded amyloid beta peptides exceeds a critical limit, the pre-dementia phase begins. The first cognitive failures become noticeable.
  • The actual clinical course of the disease can be divided into three stages, in which dementia progresses: from forgetfulness to memory loss and personality changes to complete loss of speech and bed restraint.

At some point, Ms. R. suddenly got weird, recalls a neighbor. One day, for example, she stood in front of the front door with a pile of bank statements in her hand and tried to open the lock with the wad of paper. Later on, the old lady kept showing up at the tenants in the house and insisting on visiting her niece, who had previously lived there. At some point there were no spontaneous visits: Ms. R. was no longer able to climb stairs. She only left the apartment with the help of a nurse and a stair lift - often with loud shouts of protest, as the old lady simply no longer knew what was happening to her.

At this point in time, Ms. R. had probably been suffering from Alzheimer's dementia for many years. Because the disease creeps in slowly. Nobody notices anything about it for years. Then the first seemingly harmless dropouts happen: The person concerned looks bumbling and somehow nervous. Sometimes she can't find the keys or glasses, sometimes she gets tangled up in the middle of a sentence and doesn't finish it. Then again she feels unable to read a newspaper article in full or concentrate on the television news. As the disease progresses, more and more everyday skills are lost. Personal hygiene, food intake, locomotion - all of these require support. The sick person becomes a need for care.

Long asymptomatic phase

"Alzheimer's begins long before the first symptoms become noticeable," says Wolf D. Oswald, Professor of Psychology at the University of Erlangen-Nuremberg and head of the Prevention and Dementia research group. “Already after puberty, the first indications of changes in the direction of Alzheimer's can be seen, even if the amyloid plaques only become visible later.” Alois Alzheimer discovered these deposits in the intercellular space - accumulations of misfolded beta-amyloid peptides - in his brain for the first time deceased patient Auguste Deter. (Alois Alzheimer - mad doctor with microscope) While at that time the detection was only possible with brain slices of deceased patients, today the plaques can be identified with the help of modern imaging such as positron emission tomography (PET), even in living people.

Konrad Beyreuther, one of the world's leading Alzheimer's researchers and founding director of the Aging Research Network at Heidelberg University, puts the asymptomatic phase at around 30 years: “This is how early changes in the brain can be detected with imaging methods - and 20 years before the disease breaks out detect various biomarkers in the cerebral fluid, ”he says. Experts use biomarkers to describe characteristic biological features and changes that may indicate a disease, for example. In the case of Alzheimer's disease, beta amyloid peptides and tau protein, another altered protein molecule, can be detected.

With this in mind, an Australian research group published a model in spring 2013 according to which the misfolded beta-amyloid peptides, the so-called plaques, slowly accumulate over an average of 12 years before a critical limit is exceeded. Then the so-called predemence phase begins, which is only noticeable in everyday life through occasional cognitive failures. For example, those affected find it harder to retain new information. The Australians calculate that it will take another four years for clinical manifestation. During this time, a significant decrease in brain mass in the hippocampus can be followed with the help of magnetic resonance imaging.

Everyday skills are lost: what to do with the plate? Photo: Michael Hagedorn

We speak of dementia when cognitive disorders such as forgetfulness have a clearly disruptive effect in everyday life, over a period of at least six months. There are three stages in Alzheimer's disease.

Slight cognitive impairments are characteristic of the early stage. The ability to remember declines, those affected forget their names and telephone numbers and are less able to concentrate - whether on conversations, read texts or the television news. Often times, they get caught in the middle of a sentence or are desperately looking for certain words. In addition, the first problems with orientation become noticeable, especially in an unfamiliar environment. The way to the pub can be a real challenge.

It is not uncommon for those affected to appear depressed in this phase. They respond to their change with grief, fear, and shame. Therefore, Alzheimer's disease is often difficult to distinguish symptomatically from depression in the early stages. Important differentiating feature: while depressed people tend to lament their situation, dementia patients tend to cover up their failures.

But it would be better to face forgetting. Because if the disease is recognized early, there is still room for maneuver. "We cannot cure Alzheimer's, but we can delay the progression of the disease through appropriate cognitive and psychomotor therapies," explains Oswald. His observation: if Alzheimer's patients train perception, coordination and balance in the early stages, the symptoms can be kept stable over the course of a year. In control persons without appropriate exercise units, the cognitive abilities deteriorated further. “The primary goal of such a therapy is to improve the quality of life of the patient,” says Oswald.

Forgetting on the rise

Language and language comprehension suffer more and more in the middle stage: Conversations become more difficult, not only because of word-finding disorders and twisted sentence structures, but because those affected constantly lose the common thread. They are also finding it increasingly difficult in everyday life. Skills that used to be in demand every day at work are being lost, driving a car is no longer an option. Time of day and date are mixed up, and spatial orientation is becoming increasingly difficult - even within your own four walls. And while at first only the short-term memory seemed to suffer, now the long-term memory is also disappearing: memories from the past decades, spouses, children - they all disappear in the fog of oblivion. Instead, episodes from childhood and adolescence appear - and appear to those affected as if they had just happened.

Over time, the patient's personality also changes. Those affected often seem nervous and restless, some feel unloved and suspect that one wants to betray them and steal from them. Mistrust, irritability, nervousness and aggressive outbursts - all of this is an expression of the progressive disorientation.

Towards the end of the middle phase and in the transition to the late stage, everyday life for many affected people is characterized by abrupt changes in mood and great motor restlessness. If the patient was just sitting there motionless, the next moment he might jump up to march for hours - within his own four walls. Or he is wrong, if he can leave the house, aimlessly and aimlessly through the streets. Alzheimer's patients often wander in the middle of the night, because the sense of time is increasingly lost. Day and night, yesterday and tomorrow blur into a unity.

At some point even that will end. In the late stages of the disease, the body no longer allows such excursions. Many patients suffer from increased muscle tension and stiff joints. Climbing stairs, personal hygiene, eating - all of these are gradually becoming impossible. The patient becomes a bedridden nursing case.

As the disease progresses, language continues to dry up. Those affected only have a few words left, many fall silent. Relatives and caregivers now have to find other ways to communicate with patients: Alzheimer's patients sometimes react surprisingly emotionally to gentle touches, to music, smells or prayers - especially when they bring memories from early childhood to life. With a lot of empathy, those affected can still be touched in the midst of the fog of oblivion.

for further reading:

  • Guide to dementia, information page of the Federal Ministry of Education and Research; URL: www .weg weiser -demenz .de [as of: 20.9.2013]; to the website.
  • Dementia research Oswald; Internet presence of the research group Prevention and Dementia; URL: http: // www .demen z research -oswald .de [as of September 20, 2013]; to the website.
  • Villemagne VL et al; Amyloid β deposition, neurodegeneration, and cognitive decline in sporadic Alzheimer's disease: a prospective cohort study. Lancet Neurol 2013 Apr; 12 (4): 357 - 67 (to the abstract).