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Dementia and Alzheimer'Ó Disease

Lynne Tomasa, PhD, MSWCarol Howe, MD, MLS

February 25, 2010Support Coordinator TrainingCo-sponsored by Sonoran UCEDDand AZ DES DDD, District II

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What is Dementia?

Loss of short term memory

Confusion

Not remembering how to do certain tasks: operate appliances

Loss of long term memory

Failure of thrive

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Dementia is…

“A set of symptoms” and not the disease itself. It is characterized by loss of or decline in

memory and other cognitive abilities.

It is caused by various diseases and conditions that result in damaged brain cells.

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To be classified as dementia, the following criteria must be met:

It must include decline in memory and in at least one of the following cognitive abilities: Ability to generate coherent speech or understand spoken or written

language Ability to recognize or identify objects Ability to execute motor activities, sensory function and

comprehension of the required task Ability to think abstractly, make sound judgments and plan and carry

out tasks

The decline in cognitive abilities must be severe enough to interfere with daily life

Alzheimer’s Association, 2009 Alzheimer’s Disease Facts and Figures

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Mild Cognitive Impairment

Problems with memory, language or cognitive function

Severe enough that others notice the problems and it show up on tests

BUT, not severed enough to interfere with daily life

Some people with MCI go on to develop dementia

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Alzheimer Disease OR Dementia of the Alzheimer’s Type

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A Scary Thought

Estimated 5.3 million Americans of all ages have Alzheimer’s disease

This includes 5.1 people aged 65+

Every 70 seconds, someone in America develops Alzheimer’s disease

Due to longer life spans and the aging of the baby boomers, this number is expected to reach 13 million by the year 2050

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Epidemiology of Alzheimer’s

Less than 10% of all Alzheimer’s patients have the rare genetic variant which strikes individuals in their 40’s and 50’s

At age 65, 1-10% of individuals have Alzheimer’s.

Numbers double every five years so that by age 85 as many as 50% of individuals have it.

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Prevalence of Dementia by Age and Sex

Alzheimer’s Association: 2009 Facts and figureshttp://www.alz.org/national/documents/report_alzfactsfigures2009.pdf

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Economic Issues

Psychological comorbidities result in an exponential increase in the cost of Alzheimer disease, both to individual families and to the country as a whole.

Average lifetime cost of caring for an individual with AD is about $174,000.

Average accumulated annual cost of caring for patients with AD, according to Alzheimer’s Association, is estimated to be

$100 BILLION dollars

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Not all Dementia is Alzheimer

MOST COMMON TYPES OF DEMENTIA

Alzheimer disease (60-80%)

Vascular dementia

Dementia with Lewy bodies

Parkinson disease with dementia

Frontotemporal dementia

Reversible dementias

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(Potentially) Reversible Dementias

Dementia secondary to alcohol

Dementia secondary to infectious diseases Syphilis AIDS

Normal Pressure Hydrocephalus

Dementia due to severe B12 deficiency

Dementia due to sever hypothyroidism

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Table 365-1. Differential Diagnosis of Dementia in: Bird, T.D. and Miller, B. L. Dementia in: Fauci, A. S., Fauci, A., STAT!Ref, & Teton Data Systems. (2008). Harrison's principles of internal medicine (17th ed.). New York: McGraw-Hill Medical Pub. Division.

LESS COMMON CAUSES OF DEMENTIAVitamin deficienciesThiamine (B1): Wernicke's encephalopathyB12 (pernicious anemia)aNicotinic acid (pellagra)a

Endocrine and other organ failureHypothyroidismAdrenal insufficiency and Cushing's syndromeHypo- and hyperparathyroidismRenal failureLiver failurePulmonary failure

Chronic infectionsHIVNeurosyphilisPapovavirus (progressive multifocal leukoencephalopathy)Prion (Creutzfeldt-Jakob and Gerstmann-Straussler-Scheinker

diseases)Tuberculosis, fungal, and protozoalSarcoidosisWhipple's disease

Head trauma and diffuse brain damageDementia pugilisticaChronic subdural hematomaPostanoxiaPost encephalitisNormal-pressure hydrocephalus

NeoplasticPrimary brain tumorMetastatic brain tumorParaneoplastic limbic encephalitis

Toxic disordersDrug, medication, and narcotic poisoningHeavy metal intoxicationDialysis dementia (aluminum)

Organic toxinsPsychiatricDepression (pseudodementia)SchizophreniaConversion reaction

Degenerative disordersHuntington's diseasePick's diseaseDementia with Lewy bodiesProgressive supranuclear palsy (Steel-Richardson syndrome)Multisystem degeneration (Shy-Drager syndrome)Hereditary ataxias (some forms)Motor neuron disease [amyotrophic lateral sclerosis (ALS);

some forms]Fronto-temporal dementiaCortical basal degenerationMultiple sclerosisAdult Down's syndrome with Alzheimer'sALS-Parkinson's-Dementia complex of Guam

MiscellaneousVasculitisCADASILAcute intermittent porphyriaRecurrent nonconvulsive seizure

Additional conditions in children or adolescentsHallervorden-Spatz diseaseSubacute sclerosing panencephalitisMetabolic disorders (e.g., Wilson's and Leigh's diseases,

leukodystrophies, lipid storage diseases, mitochondrial mutations)

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10 Signs of Alzheimer’s http://www.alz.org/alzheimers_disease_10_signs_of_aslheimers.asp

1. Memory loss that disrupts daily life

2. Challenges in planning or solving problems

3. Difficulty completing familiar tasks at home, work, leisure

4. Confusion with time or place5. Trouble understanding visual

images and spatial relationships

6. New problems with words in speaking or writing

7. Misplacing things and losing the ability to retrace steps

8. Decreased or poor judgment9. Withdrawal from work or

social activities10. Changes in mood or

personality

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Stages of Alzheimer Disease

A. Early Stage(s)1. Some forgetfulness2. Difficulty with check book3. Trouble with shopping or cooking

B. Middle Stage(s)1. Suspiciousness/Paranoia2. Wandering3. Sundowning (especially restless in the evenings)4. Hypersexuality

C. Late Stage(s)1. Failure to recognize loved ones2. Incontinence3. Difficulty eating4. Sleep all the time

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Criteria for diagnosis:

Memory impairment (decreased ability to learn new information or to recall previously learned information. In Alzheimer Disease, usually the first thing to go is short term memory) AND one or more of the following:

1. Aphasia (language disturbance)2. Apraxia (difficulties with motor activities—such as getting

dressed)3. Agnosia (difficulty recognizing familiar objects)4. Difficulties with executive function such as organizing or

planning. DSM-IV, 2000)

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Diagnostic Tools

1. Screening exams such as the Folstein Mini-Mental Status Exam, SLUMS, or Clock-Drawing Test

2. Imaging test such as an MRI or a PET scan

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Frequently used tools: FolsteinMini-mental Status Exam

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Mini Cog

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Shulman KI. Clock-drawing: is it the ideal cognitive screening test?Int J Geriatr Psychiatry. 2000 Jun;15(6):548-61.

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Diagnostic tools cont’d.3. Lab-work—primarily to rule out reversible

causes of dementia. Check: blood count electrolytes, kidney and liver function, thyroid function, B12 and Folate levels markers for inflammation (sed rate, C-reactive

protein) ? tests for syphilis

4. More extensive neuropsychiatric testing

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Diagnosis can really only be made….

with a brain biopsy (most patients opt out)

www.ahaf.org/alzdis/about/AmyloidPlaques.htm

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Risk Factors for Alzheimer Disease1. Age2. Age3. Age4. Low “brain reserve”

a. “low educational and occupational attainment; low mental ability in early life’’.

b. decreased activity -both mental and physical in later life

5. Head injury

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?

Risk Factors Continued: Same as for Cardiovascular Disease

****

1. ↑ cholesterol (especially during mid life)

2. High blood pressure3. Smoking4. Coronary artery disease5. Obesity 6. Diabetes7. ↑ homocysteine levels

caused by low folate and low B12 levels

Although most other risk factors are the same for AD and CV Disease, women are actually at greater risk for AD while men are at greater risk for CV disease.

I get blamedfor everything!

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How does family history work?

On Chromosome 19, there is a gene called ApolipoproteinE (APOE) which can express itself as APOEe2, APOEe3 and APOEe4. We receive one allele from each of our parents.

APOEe2-protective (least common, of course)

APOEe3- neutral risk ;most common

APOEe4-strongly associated with AD 1allele(heterozous)—3X risk.

2 alleles (homozygous)- 15X risk.

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Percent of Subjects with apoE Alleles with and without AD

Source: Polvikoski T et al. N Engl J Med 1995;333:1242-1247

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Equal Opportunity Genes

Although there is a genetic component, (APOE) why or whether it gets expressed as actual disease

is not understood.

Alzheimer’s is an equal opportunity disease. It does not seem to affect any particular ethnic

group more than another

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Current Clinical Treatment/Drug Therapy

No Cure for Alzheimer Disease (yet)

Most drug treatment aimed at correcting underlying neurotransmitter imbalances. First neurotransmitter targeted: acetylcholine Cholinesterase Inhibitors-approved for mild to moderate AD Donepezil (Aricept)

Galantamine (was Reminyl, now Razadyne)

Rivastigmine (Excelon)

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Current Clinical Treatment/Drug Therapy cont’d

Second neurotransmitter target: NMDA (N-methyl-D-aspartic acid)

Memantine (Namenda)- NMDA antagonist (Approved for moderate to severe AD.) Tends be a little more effective when used in combination with the cholinesterase inhibitors.

There is a lot of research on other neuroactive transmitters and chemicals but that’s all that is officially approved for now.

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Grasping at straws:

Other agents which have been tried but which have little, questionable or no evidence for use: Non-steroidal, anti-inflammatory medications (NSAIDS) Hormones Estrogen Progesterone Testosterone

Nicotine Patches Gingko Biloba Turmeric Melatonin Vitamin E Statins (used to treat ↑cholesterol)

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Treating the Symptoms

Medications aimed at treating accompanying depression, psychosis, agitation, extreme apathy, sleep disorders.

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Non-pharmacological Treatment

Cognitive Therapy

Light Therapy

Yoga

Meditation

Music Therapy

Art Therapy

Horticultural Therapy

Pet Therapy

Physical and Occupational Therapies

Supportive psychotherapy For the patient For the caregivers For the doctors!

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Nutritional Therapies

Emphasis no longer on “tube feeding” formulas to combat the inevitable weight loss of end stage Alzheimer’s.

Some research into micronutrients and “nutraceuticals.” Nothing definitive yet but “our understanding of dietary influences on Alzheimer's disease is in its infancy” (Morris,2004)

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Psychological Issues

Psychological symptoms of Alzheimer’s disease (and other dementias) are soprevalent that, in coding, physicians actually distinguish between

Dementia of the Alzheimer’s Type with behavioral disturbance and Dementia of the Alzheimer’s Type without behavioral disturbance.

The most prevalent of these comorbidities are: Depression-present in 50% of patients with AD (and 99% of their care givers.

Severe depression in elderly used to be called “pseudo-dementia” because it presented so similarly

to AD. Now thought to truly be a precursor of dementia. Delusions and Paranoia-can be present in 40-50% of patients

Most common delusion is that spouse is an impostor or That there are intruders in the home—often “little people”

Aggression-Can be present in 10-65% of patients

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Working with Individuals and

Families

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Situations Affecting Behavior http://www.alz.org/alzheimers_disease_standard_prescriptions.asp

Admission to a hospital

Misperceived threats

Changes in the environment: moving furniture, things,etc.

Changes in caregivers

Changes in one’s daily routine

Moving to a new residence, room, nursing home

Fear and fatigue resulting from trying to make sense of it all

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What Families and Caregivers Can Do

Create a calm environment Avoid noise, glare, minimize background distraction

Simplify the environment, minimize clutter

Redirect behaviors or the person’s attention

Remain flexible, patient and supportive

Avoid being confrontational

Don’t argue about facts – go along with their story

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What Families and Caregivers Can Do (continued)

Maintain a comfortable room temperature

Keep the person with AD comfortable: monitor pain, hunger, thirst, constipation, infections, skin irritations

Allow enough rest between major or stimulating events

Safe proof the environment: lock gates, remove guns

Alzheimer’s Organization

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Signs of Unsafe DrivingAlzheimer’s Association Safety Center

A person with AD will eventually have to stop driving. Monitor the following behaviors that may signal when to stop driving.

Cannot locate familiar places

Fails to observe traffic signals

Makes slow or poor decisions

Drives at inappropriate speeds

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More Signs of Unsafe DrivingAlzheimer’s Association Safety Center

Becomes angry and confused while driving

Hits curbs

Uses poor lane control

Makes errors at intersections

Confuses the brake and gas pedals

Returns from a routine drive later than usual;

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Associations/Advocacy Groups: Alzheimer’s Association

Probably does live up to its claim of being “the world leader in Alzheimer

research and support.” (Out of 53 of the resources listed in MedlinePlus, 19 of

them are actually authored by the Alzheimer’s Association).

They have a vast connection of local networks (see Alzheimer’s Association:

Desert Southwest Chapter) which provide support for caregivers, (including

a 24/7 help line), sponsor conferences, and offer educational programs.

Alzheimer’s Disease International

National Hospice and Palliative Care Organization

Alzheimer’s Foundation of America

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Consumer/Patient Health Information Sites

MedlinePlus: Alzheimer's Disease

The Alzheimer’s Disease Education and Referral Center (ADEAR)

MayoClinic.com: Alzheimer’s Disease

NOAH: Brain and Nervous System: Alzheimer's Disease

The Alzheimer’s Store (An Ageless Design Company)

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References 1

Aarsland, D., Sharp, S., & Ballard, C. (2005). Psychiatric and behavioral symptoms in Alzheimer's disease and other dementias: Etiology and management. Current Neurology and Neuroscience Reports, 5(5), 345-354.

Abraham, I. L. (2006). Dementia and Alzheimer's disease: A practical orientation.The Nursing Clinics of North America, 41(1), 119-27.

Abraham, I.L., Macdonald K. M, Nadzam, M.N. (2006) Measuring the quality of nursing care to Alzheimer’s patients.The Nursing Clinics of North America, 41(1), 95-104.

Administration on Aging. Aging statistics. Retrieved 02/23/2010 from http://www.aoa.gov/AoARoot/Aging_Statistics/index.aspx

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References 2

Alzheimer’s Association: 10 signs of Alzheimer's. Retrieved 02/24/2010 from http://www.alz.org/alzheimers_disease_10_signs_of_alzheimers.asp

Alzheimer’s Association: 2009 Alzheimer’s disease facts and figures.Retrieved 02/24/2010 from http://www.alz.org/national/documents/report_alzfactsfigures2009.pdf

Alzheimer’s Association: Safety center. Retrieved 02/24/2010 from http://www.alz.org/safetycenter/we_can_help_safety_center.asp

Alzheimer’s Association: Standard treatments. Retrieved 02/24/2010 from http://www.alz.org/alzheimers_disease_standard_prescriptions.asp

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References 3

Bird, T.D. and Miller, B. L. Dementia in: Fauci, A. S., Fauci, A., STAT!Ref, & Teton Data Systems. (2008). Harrison's principles of internal medicine (17th ed.). New York: McGraw-Hill Medical Pub. Division.

Birks, J. (2006). Cholinesterase inhibitors for Alzheimer's disease. Cochrane Database of Systematic Reviews, 3.

Blennow, K., de Leon, M. J., & Zetterberg, H. (2006). Alzheimer's disease. Lancet, 368(9533), 387-403.

Clark, C. M., DeCarli, C., Mungas, D., Chui, H. I., Higdon, R., & Nunez, J., et al. (2005). Earlier onset of Alzheimer disease symptoms in latino individuals compared with anglo individuals. Archives of Neurology, 62(5), 774-778.

Cotelli, M., Calabria, M., & Zanetti, O. (2006). Cognitive rehabilitation in Alzheimer's disease. Aging Clinical and Experimental Research, 18(2), 141-143.

Cotter, V. T. (2006). Alzheimer's disease: Issues and challenges in primary care. The Nursing Clinics of North America, 41(1), 83-93.

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References 4

Family Caregiver Alliance, http://www.caregiver.org/caregiver/jsp/content_node.jsp?nodeid=567accessed 02/25/10

First, M. B. (Ed.). (2000). Diagnostic and statistical manual - text revision (DSM-IV-TR™, 2000). Washington, DC: American Psychiatric Association.

Fisher, A. E., & Naughton, D. P. (2005). Why nutraceuticals do not prevent or treat Alzheimer's disease. Nutrition Journal [Electronic Resource], 4, 14.

Glueckauf, R. L., Ketterson, T. U., Loomis, J. S., & Dages, P. (2004). Online support and education for dementia caregivers: Overview, utilization, and initial program evaluation. Telemedicine Journal and e-Health : The Official Journal of the American Telemedicine Association, 10(2), 223-232.

Hebert, L. E., Scherr, P. A., Bienias, J. L., Bennett, D. A., & Evans, D. A. (2003). Alzheimer disease in the US population: Prevalence estimates using the 2000 census. Archives of Neurology, 60(8), 1119-1122.

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References 5

Luchsinger, J. A., & Mayeux, R. (2004). Dietary factors and Alzheimer's disease. Lancet Neurology, 3(10), 579-587.

Lyketsos, C. G., & Lee, H. B. (2004). Diagnosis and treatment of depression in Alzheimer's disease. A practical update for the clinician.Dementia and Geriatric Cognitive Disorders, 17(1-2), 55-64.

McShane, R., Areosa Sastre, A., & Minakaran, N. (2006). Memantinefor dementia. Cochrane Database of Systematic Reviews, 3.

Modrego, P. J., & Ferrandez, J. (2004). Depression in patients with mild cognitive impairment increases the risk of developing dementia of Alzheimer type: A prospective cohort study. Archives of Neurology, 61(8), 1290-1293.

Morris, M. C. (2004). Diet and Alzheimer's disease: What the evidence shows. MedGenMed [Electronic Resource] : Medscape General Medicine, 6(1), 48.

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References 6

Alzheimer’s disease Murman, DL and Dolenda, CC (2005). The economic impact of neuropsychiatric symptoms in: can drugs ease the burden? Pharmacoeconomis23(3), 227-42.

National Institute on Aging. Alzheimer’s Disease Genetics Fact Sheet.0 2/24/10 from http://www.nia.nih.gov/Alzheimers/Publications/geneticsfs.htm

Olazaran, J., Muniz, R., Reisberg, B., Pena-Casanova, J., del Ser, T., & Cruz-Jentoft, A. J., et al. (2004). Benefits of cognitive-motor intervention in MCI and mild to moderate Alzheimer disease. Neurology, 63(12), 2348-2353.

Overshott, R., Byrne, J., & Burns, A. (2004). Nonpharmacological and pharmacological interventions for symptoms in Alzheimer's disease. Expert Review of Neurotherapeutics, 4(5), 809-821.

Prasher, V. P., & SpringerLink (Online service). (2009). Neuropsychological assessments of dementia in down syndrome and intellectual disabilities. http://dx.doi.org/10.1007/978-1-84800-249-4;

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References 7

Raber, J., Huang, Y., & Ashford, J. W. (2004). ApoE genotype accounts for the vast majority of AD risk and AD pathology.Neurobiology of Aging, 25(5), 641-650.

Riggs, J. A. (2001). The health and long-term care policy challenges of Alzheimer's disease. Aging & Mental Health, 5 Suppl 1, S138-45.

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References 8

Staehelin, H. B. (2005). Micronutrients and Alzheimer's disease.The Proceedings of the Nutrition Society, 64(4), 565-570.

Stampfer, M. J. (2006). Cardiovascular disease and Alzheimer's disease: Common links. Journal of Internal Medicine, 260(3), 211-223.

Waelde, L. C., Thompson, L., & Gallagher-Thompson, D. (2004). A pilot study of a yoga and meditation intervention for dementia caregiver stress. Journal of Clinical Psychology, 60(6), 677-687.

Zhu, C. W., Scarmeas, N., Torgan, R., Albert, M., Brandt, J., & Blacker, D., et al. (2006). Longitudinal study of effects of patient characteristics on direct costs in Alzheimer disease. Neurology, 67(6), 998-1005.