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The Memory Spectrum: Is it Alzheimer’s Disease?
Helle Brand, PABanner Alzheimer’s Institute
Normal Aging
DEMENTIA
MildCognitive
Impairment(MCI)
Time
Mem
ory
Fun
ctio
nThe Memory Spectrum
Memory Complaints in Normal Adults
Situation Percentage of elderlyNames 83 %Where I put things 60 %Knowing I have told someone 49 % somethingForgetting a task after starting 41 %Losing the thread of conversation 40 %
From: Boller et al, Arch Neurol 1991
Aging, memory and intellect
Verbal IQ
Vocabulary
Store of information
Comprehension
Speed of memory retrieval
Speed of processing
Multi-tasking ability
Memory-formation
efficiency
Don’t change Decrease
Types of Memory
Short termLong termMotor learning
These depend on different regions within the brain.
Brain memory regions
Brain changes with aging
Brain weight: decreases by about 0.5% per year after age 30
Neuron loss: region-specific
10-25% loss in cerebellum, cortex, hippocampus, substantia nigra
Loss of synapses (connections between neurons)
Mild degree of Alzheimer-type pathology
MRI Brain: Normal vs. AD
Age-Associated Cognitive Impairment
Loss of memory for words and namesSlowed processing speedDifficulty sustaining attention when faced with competing environmental stimuliNo functional impairment
Mild Cognitive Impairment (MCI)
Transitional state /evolving construct
Cognitive impairment greater than expected for age: Memory complaint corroborated by an informant Normal general cognitive function Normal activities of daily living Memory impairment for age and education criteria for dementia not met
Petersen, 2000
Outcome of an ‘MCI Diagnosis’
Increased risk for the development of AD within the next few yearsRates of conversion to AD:
MCI: 10-15% per yearNormal elderly – 1-2% per year
Amnestic MCI
Alzheimer’s disease
Mild CognitiveImpairment
Normal AgingNormal Aging
No change over time
Other dementias
Dementia
This term does not define a cause and is not a diagnosis!Progressive decline in cognitive functionDecline in functional abilityDue to damage or disease in the brainMany different causes
AD: most common dementia in the elderly
Clinical Presentation of Dementia
Cognition Function
Behavior
Progression of Dementia
Typically progresses over 7 – 10 yearsOften described using “stages”
Mild, Moderate, Advanced (Severe)Early , Middle, Late Stage
Has become the 6th leading cause of death among older peopleRequires different strategies and services along the way
Top 10 warning signs:
1. Changes in memory disrupting daily life: forgetting recently learned information; repetitive questioning; forgetting dates or events; relying on notes or others to remember things formerly handled on their own
2. Challenges in planning or in solving problems, difficulty concentrating and taking longer to do things they did before : can’t remember or follow a recipe, can’t track or pay bills
3. Difficulty completing familiar tasks at home, work, or leisure: trouble driving to familiar location, playing a game, keeping up with hobbies
The warning signs, continued
4. Confusion with time or place: losing track of dates, seasons, passage of time, forget where are or how they got there. Trouble understanding if something is not happening immediately
5. Trouble understanding visual images and spatial relationships: trouble judging distances, reading, driving, judging color or contrast. May see a mirror or window and think someone else is in room
6. Problems with words when speaking or writing: Have trouble following or joining in on a conversation, forget train of thoughts. May call things by wrong name, struggle to find or substitute a word.
The warning signs, continuing
7. Misplacing things, having difficulty retracing steps: May put things in unusual places, may accuse others of taking things.
8. Diminished or poor judgment: trouble with decision making, such as when dealing with money; may pay less to personal appearance, safety, or social appropriateness. Impulsive.
9. Withdrawal from work or social activities, hobbies, work projects or sports
The warning signs, completed
10. Changes in mood and personality: can be confused, suspicious or paranoid, depressed, more fearful or anxious, more easily upset, irritable. Less apt to get out of home/comfort zone
Sound familiar?
Early (MILD) Stage Dementia
FeaturesRecent memory loss that affects job skillsDifficulty performing tasks; Problems with language; Misplacing things; Problems with abstract thinking Disorientation of time Poor/ decreased judgmentChanges in mood /behavior; Loss of initiative; Changes in personalityMay have difficulty in a crowd
TreatmentCholinesterase InhibitorManage depression and other co-existing health problems
Maintaining Independence
Early changes in AD, continued
may get lost driving or be unsure of self in new surroundingsForget appointments, family eventsLists may not make sense
Special concerns early on
Medication managementDrivingWeight lossMood, especially depressionChanging awareness and concern for safetyNeed for life planning: financial, legal
Middle (MODERATE) Stage Features
More dependent in daily living tasks
Severe memory lossFluent aphasiaDisorientation to time and
placeImpaired judgment and
problem solvingPersonality and
behavioral changes
Living with help
TreatmentCholinesterase inhibitor and/orNamendaManage mood, behavior and co-existing illness
Moderate Stage Alzheimer’s
Memory loss, confusion and attention worsen over a 2-10 year spanJudgment and problem solving a problem Loss of ability to handle complex tasks, gradual problems with taking care of selfPersonality and behavior changesIncreasing dependenceCan’t think logically, organize thoughts
The concerns with mid stage AD
Behaviors: suspiciousness, irritability, restless, loss of impulse control, seeing or hearing things not present, agitation, wandering, sleep disturbanceChanging communication/expectationsIncreasing dependence, behaviors cause increasing caregiver burden/stressSafety/Vulnerability: need 24 hour supervision
Late (SEVERE) Stage Dementia
FeaturesSevere memory lossLimited verbal abilityOrientation only to selfNo independent self-care
functionNo judgment/problem solving
skillsIncontinence (bladder/bowel)
Anticipatory comfort care
TreatmentCholinesterase inhibitor and/orNamendaComfort strategies including mood and pain
Late to End Stage Alzheimer’s
Memory loss is severe, including long termLoss of recognition of others beyond selfProblems controlling bowel/bladderFully dependent for care needsMinimal to no speechChanges in posture/walking, may not walk and/or become bed bound
Issues in advanced Alzheimer’s
Risk for fallsMay be prone to infection or skin breakdown Weight lossPotential for seizuresIncreasing sleepPlanning for death and dying: medical decision making, timely hospice referrals
Alzheimer’s disease: diagnosis
Diagnosis of exclusionHistory: the changes over timePhysical and Neurologic examsCognitive TestingLabs and Imaging StudiesBy definition: insidious onset, gradual changes in multiple domains affecting function
The treatment of Alzheimer’s
Cholinesterase inhibitors: indicated for early/mild dementia, typical side effects are nausea, vomiting, anorexia ,frequent loose stool, vivid dreams, leg cramps. Start slow, assess tolerance, maintain at best tolerated level for continued cognitive benefit.
• Aricept (donepezil) 10 mg, 23 mg• Razadyne (galantamine) 8 mg bid or 16, 24, 32 mg daily in
extended release form• Exelon, oral or patch (Rivastigmine) 6-12 mg oral, 9.5 or
13.3mg/24 hours in patch form
Namenda (memantine) (NMDA receptor antagonist); indicated for moderate stages. 10 mg bid. NEW: 24 mg daily
• Typical side effects include headache, constipation, paradoxical confusion
Other treatments: It’s not just memory
Mood/ behavioral symptoms: address environmental factors, then medication ( antidepressants, antipsychotics)Sleep disturbance: non PM formulary, no benzos. (Trazodone, Mirtazapine, Melatonin)Pain: Routine Acetaminophen
Caregiver stress
Care becomes 24/7 jobCaregivers become socially isolatedFamily dynamics a considerationAt risk for deterioration of their own health, physical and emotional statusCaregivers more often die first
Sharing the care helps
Barriers include caregiver reluctance from stoicism, guilt, promises made, perfectionism, isolationMyths persist re: financial concernsThe system makes it hard!Family dynamics are definitely part of the equation, possibly the solution!
Options to extend care
Consider a volunteer network Senior centers Day Care programs Home care agencies Alternative residences Hospice care
Hope for the future:The Alzheimer’s Prevention Initiative
1st approved study to provide prevention therapies to people at greatest genetic risk of developing ADBuilding a registry of volunteers who may be interested in participating in future prevention research in the U.S.We need YOU!www.endalznow.org or call 602-839-6900
In closing….
Remember:
The mind forgets, but the heart remembers!
Questions?
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