Alzheimer's

What it's like

The early signs, how they differ from normal ageing, and how it changes over time.

From the inside, early on

• Recent things slip: Forgetting recent events and conversations, while older memories stay.
• Familiar places feel strange: Getting lost on familiar routes; confused about where or when you are.
• Words go missing: Struggling to follow conversations or find the right word.
• Feelings first: Anxiety, sadness or anger about the memory loss — and mood changes can come before the memory problems are obvious.

Warning signs, against normal ageing

• Memory loss that disrupts daily life: Normal: forgetting a name or appointment and remembering it later.
• Trouble planning or solving problems: Normal: an occasional mistake with the bills.
• Difficulty with familiar tasks: Normal: sometimes needing help with an unfamiliar setting on a device.
• Confusion about time or place: Normal: getting the day wrong and working it out later.
• New problems with words: Normal: sometimes struggling for the right word.
• Misplacing things and being unable to retrace steps: Normal: losing things now and then and retracing your steps to find them.
• Poor judgement: Normal: a bad decision once in a while.
• Withdrawal and mood changes: Normal: sometimes not wanting to go out; getting irritable when a routine is disrupted.

Later, people need more help with personal care, may not recognise family or friends, find moving, eating and continence harder, and can become distressed or aggressive.

• Myth: Everyone gets dementia if they live long enough. In fact: It's more common after 65, but it isn't an inevitable part of ageing.
• Myth: Nothing can be done. In fact: Medicines can ease symptoms, and activity, social contact, cognitive stimulation and support for carers improve quality of life.
• Myth: It's all in the genes. In fact: Modelling suggests about 45% of dementia could be prevented or delayed by tackling 14 modifiable risk factors.

What's happening in the brain

A disease that follows a path. The model lights each stop as you read.

Where it starts

Alzheimer's tangles appear first in the transentorhinal region, at the edge of the entorhinal cortex, beside the hippocampus — and then spread in a predictable sequence of six stages.

Why recent memories go first

The hippocampus is needed to form new memories of events: patient H.M., whose hippocampi were removed, could no longer make new ones. With the damage starting right next to it, new memories are the first thing to stop being made well.

An early warning in the scan

In people whose memory was only starting to slip, the posterior cingulate's metabolism was already down by about a fifth — before Alzheimer's could be diagnosed. Amyloid builds up early there too.

Spreading outward

From beside the hippocampus, the damage spreads outward through the temporal lobe and beyond, in the sequence its six stages describe.

Risk and prevention

What raises the risk, and what can lower it.

• 57m living with dementia: Worldwide in 2021, with nearly 10 million new cases a year.
• 60–70% is Alzheimer's: The most common form of dementia.
• ~45% potentially preventable: If all 14 modifiable risk factors were removed — a modelled estimate.

Risks you can do something about

• Health: High blood pressure, diabetes, obesity, depression, hearing loss, poor sleep, head injury, stroke.
• Vision and cholesterol: Untreated vision loss and high LDL cholesterol — the two newest additions.
• Lifestyle: Smoking, harmful drinking, inactivity, social isolation, less education.
• Environment: Air pollution.

What helps

What medicine can and can't do, and what else helps.

• Symptom medicines (Cholinesterase inhibitors such as donepezil; memantine for severe Alzheimer's.): They manage symptoms but don't stop the disease.
• Anti-amyloid antibodies (Lecanemab, given by infusion in early Alzheimer's with confirmed amyloid.): Over 18 months, decline on the main rating scale was about a quarter slower than on placebo — but 12.6% had brain swelling or fluid on scans, and about a quarter had infusion reactions.

What else improves life with it

• Physical activity.
• Staying socially involved.
• Activities that keep the mind working.
• Treating hearing and vision loss, depression and poor sleep.

Supporting someone

Meeting them where they are — and looking after yourself.

• Instead of "Don't you remember? I told you this morning.", try "We're going to see Sarah at two — I'll remind you before we go.". Forgetting recent events is the disease itself. A quiz only adds embarrassment; a gentle repeat gives the answer.
• Instead of "You're wrong, Mum died years ago.", try "Tell me about your mum.". New memories are what the disease takes first. Going with the feeling is often kinder than making her relive the loss.

Looking after yourself as a carer

• Ask for help from family, friends and professionals.
• Take regular breaks.
• Use stress-management techniques — and look at training such as the WHO's free iSupport programme.

Put it into practice

Four real situations.

• Your 72-year-old dad sometimes forgets a neighbour's name, then remembers it an hour later. Is that a warning sign? Probably not — that's a typical age-related change. Forgetting names and remembering them later is the typical age-related change; the warning sign is memory loss that disrupts daily life.
• Your grandmother got lost driving home from the supermarket she's used for twenty years, and couldn't work out where she was. What's the right next step? Book a doctor's appointment with her. Getting lost in familiar places and confusion about where you are are early signs worth checking.
• Your mum has early Alzheimer's. She's read about the new antibody treatments and asks if they'll cure her. What's accurate? They're not a cure; in the main trial, decline was about a quarter slower over 18 months, with a real risk of brain swelling. Lecanemab slowed decline (1.21 against 1.66 points) and caused swelling or fluid on scans in 12.6% of people.
• You're caring for your husband, who has Alzheimer's. You haven't had a day off in months and you're exhausted. What's the most useful thing to do? Ask family, friends or services for help, and build in regular breaks. The WHO advises carers to seek help from family, friends and professionals and to take regular breaks.