Cholesterol

Increased cholesterol concentrations have been associated with AD. The cholesterol

increases ^-amyloid protein synthesis which can lead to plaque formation. Also, the apo E4 allele is thought to be involved in cholesterol metabolism and is associated

with higher cholesterol levels.

Estrogen

Estrogen appears to have properties that protect against memory loss associated with normal aging. It has been suggested that estrogen may block ^-amyloid protein pro-

21 22

duction and even trigger nerve growth in cholinergic nerve terminals. Estrogen is

also an antioxidant and helps prevent oxidative cell damage. It is important to note, however, that the Women's Health Initiative Memory Study reported that hormone replacement with either estrogen alone or estrogen plus medroxyprogesterone resulted

in negative effects on memory. CLINICAL PRESENTATION AND DIAGNOSIS ft

Diagnosing AD relies on a thorough medical and psychological history, mental status testing, and laboratory data to exclude other possible causes of dementia. There are no biological markers other than those pathophysiologic changes found at autopsy that can confirm AD.

The American Academy of Neurology has adopted practice guidelines for the

diagnosis and management of AD. The diagnostic criteria are based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) (Table 35-2 )25 or the National Institute of Neurological and Communicative Diseases and Stroke/Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA).

AD is a progressive disease that, over time, affects multiple areas of cognition. The symptoms of AD can be divided into cognitive symptoms, noncognitive symptoms, and functional symptoms for assessment and treatment purposes. Table 35-3 describes the stages of cognitive decline.26,27

Clinical Presentation and Diagnosis of AD General

The diagnosis of AD relies on thorough mental status testing and neuropsychological tests, medical and psychiatric history, neurologic examination, interview of caregivers and family members, and laboratory and imaging data to support the diagnosis and exclude other causes.

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