Clinical Presentation

The following are some of the most commonly observed signs early in the course of AD.

Other helpful references include the Alzheimer Association's 10 warning signs of early trigger symptoms.

Clinicians recognize that AD typically affects 3 primary domains - cognition, behavior and function. Memory loss is typically one of the presenting symptoms and may identified by a family member or friend initially. Although cognitive impairment in AD is often associated with short-term memory impairment, it is important to realize that the problem involves multiple functions such as recall, recognition, language, judgment and problem solving. Early difficulties are often seen as getting lost traveling to familiar places, inability to recognize or name familiar objects, repeating of phrases or stories, and problems balancing a checkbook or preparing a meal.

Psychiatric or behavioral symptoms are also frequently associated with AD, but the onset, type, and course of the symptoms is much less predictable than with the cognitive domain. Personality changes such as increased irritability, anxiety, apathy, or suspiciousness may be noted early in the course of the illness by the individual's spouse. Depression is extremely common in the early stages of AD, with varying prevalence rates of 10-80% reported from a variety of populations. A large study published earlier this year which was designed to examine the prevalence of dementia and neuropsychiatric symptoms present in community-dwelling elderly identified nearly 1/3 of the subjects met criteria for AD and 24% of those with AD were diagnosed with depression.4.

Due to significant symptom overlap, depression and dementia are difficult to differentiate. It is interesting to note that a significant proportion of individuals presenting with new onset of late life depression may later develop dementia; according to the work of Alexopoulos and colleagues, nearly 50% of elderly patients with reversible dementia and depression will develop irreversible dementia within 5 years. 5

As the person moves into the middle stages of the illness, the overall prevalence of neuropsychiatric symptoms dramatically increases. A variety of symptoms are observed; many individuals experience psychotic symptoms - paranoid delusions and visual hallucinations are most common. In addition, reversal of sleep-wake cycle (diurnal reversal), psychomotor restlessness and pacing, elopement attempts, and combative behaviors are reported. Neuropsychiatric sequelae and behavioral symptoms are very distressing to caregivers and if unmanageable, lead to caregiver burnout and institutionalization. Appropriate assessment and treatment of behavioral symptoms by utilizing education strategies for caregivers and judicious pharmacotherapy when necessary, will decrease caregiver stress and may delay institutional placement.