Dear Dr. Ron:
I think I understand that the main problem in Alzheimer's Disease is that many nerve cells in the brain die, making it difficult for the brain to operate properly, kind of like how traffic piles up if a lot of roads are closed -- information just does not get through. What I don't understand is why the nerve cells die and what can be done to prevent it? Signed -- Tell Me More About Alzheimer's.

Dear Tell Me More:
Thank you for writing! Alzheimer's Disease (AD) has been difficult to precisely understand because we do not yet have the ability to directly study what happens in the living human brain at the microscopic level. We can only study living human brains by using evidence from brain scans, spinal taps and blood tests, and by collecting data from animal research.

The weight of data about AD points to an inflammatory process that occurs in the brain. The inflammation is thought to begin with the deposit of a substance called amyloid. Amyloid deposits are found primarily in the gray matter of the brain cortex and in the hippocampus, which controls short-term memory (among other things). Gray matter contains the bodies of nerve cells. Brain amyloid appears to cause the production of toxic chemicals which kill nerve cells. In a person with AD, gray matter is largely destroyed.

Large deposits of amyloid in the brain are an absolute hallmark of AD. Although researchers can now do brain scans with living mice that show amyloid deposits, it cannot yet be done with living humans. No one yet knows why amyloid is abnormally deposited in the brain. However, whether destructive processes in the brain start before amyloid is deposited or after, it appears that anti-inflammatories, such as aspirin, decrease the risk of AD. This brings me to the main subject matter of this column -- "a new drug on the block."

Until this month, in the United States, we have only had one class of medications proven to be helpful with AD -- the acetylcholinesterase inhibitors. They include tacrine (Cognex), donepezil (Aricept©), rivastigmine (Exelon©) and galantamine (Reminyl©). They all do essentially the same thing -- increase a neurotransmitter in the brain called acetylcholine. The effect is to boost the power of nerve cells. They are approved for use in persons with mild to moderate dementia. They help maintain and improve activities of daily living. Even though there is evidence that three-year use of these medications has some effect on decreasing amyloid deposits, you can appreciate that as neurons continue to die, the effectiveness of cholinergic medications also becomes greatly reduced because there are fewer nerve cells to boost.

The new medication that becomes available in the United States this month is memantine (Namenda©). It is a very complex drug to explain, but it significantly prevents the continuing death of neurons. Among other things, it prevents nerve cell death by not allowing more than normal amounts of calcium to enter into nerve cells. There is also evidence that it prevents further deposits of amyloid and its toxic byproducts. This is the only medication approved for use in persons with moderate to severe dementia. Memantine has been available and used in Europe since early 2002.

Other symptoms associated with AD, such as depression, anger, hostility, or hallucinations may require other types of medications. Using cholinergic medications with memantine may be a strategy for boosting nerve cells and preventing damage at the same time. Such medication decisions should be made with the help of a dementia medical expert. For more about the prevention of dementia processes, please visit AgingBrain.org. -- Best wishes, Dr. Ron.

Author Bio:

Ron Sterling, M.D. is a 61 year-old General and Geriatric Psychiatrist with a private practice in Seattle. He invites you to e-mail him at with any questions about mental wellness or emotional, relationship, or aging concerns. He is the only person who reads e-mail sent to Dr. Ron. Please be assured that your questions and identities are completely confidential and protected. He has no financial or other interests and no income, whatsoever, connected to or generated by any pharmaceutical manufacturer and does not accept medication samples of any kind, nor participates in any pharmaceutical company speaker's bureaus. For more information about Dr. Ron and for resources related to senior mental health, please go to SeniorMentalHealth.org. Read our Disclaimer.

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