Issues in Aging:Issues in Aging:

Alzheimer’s DiseaseAlzheimer’s DiseasePresenter

Dawn DeStefani, BSW

Director Of Programs & Services

May 3, 2012

What is Normal Aging?What is Normal Aging?

Although we do experience minor changes in our memory and thinking as Although we do experience minor changes in our memory and thinking as we age, these changes do not affect daily functioning or the ability to live we age, these changes do not affect daily functioning or the ability to live independently.independently.

Memory changes are a normal part of the aging process—it's common to Memory changes are a normal part of the aging process—it's common to have less recall of recent memories and to be slower remembering names have less recall of recent memories and to be slower remembering names and details. and details.

Alzheimer’s disease is Alzheimer’s disease is notnot a normal part of aging or “just what happens a normal part of aging or “just what happens when we get old.”when we get old.”

If Alzheimer’s was part of the natural aging process, then every person If Alzheimer’s was part of the natural aging process, then every person over 65 years of age would have Alzheimer’s disease.over 65 years of age would have Alzheimer’s disease.

Source: About.com Health's Disease and Condition, Carrie Hill, PhD

Source: MSN Health, Healthwise, http://health.msn.com/health-topics/aging/articlepage.aspx?cp-documentid=100097440

ExamplesExamples

A person might forget part of an A person might forget part of an experience. experience.

A person who forgets something A person who forgets something will eventually remember the will eventually remember the information. information.

A person can follow instructions A person can follow instructions without difficulty.without difficulty.

A person is able to use notes or A person is able to use notes or reminders.reminders.

A person can still manage their A person can still manage their own personal care (bathing, own personal care (bathing, dressing, grooming, etc.).dressing, grooming, etc.).

A person is able to manage A person is able to manage their finances. their finances.

A person with Alzheimer’s disease will A person with Alzheimer’s disease will forget the whole experience.forget the whole experience.

A person with Alzheimer’s won't recall A person with Alzheimer’s won't recall the information at a later time.the information at a later time.

A person with Alzheimer’s disease is A person with Alzheimer’s disease is less and less able to follow less and less able to follow instructions over time.instructions over time.

A person with Alzheimer’s gradually A person with Alzheimer’s gradually become less able to benefit from become less able to benefit from memory aids or forgets to use them.memory aids or forgets to use them.

A person with Alzheimer’s loses the A person with Alzheimer’s loses the ability to engage in these kinds of ability to engage in these kinds of tasks.tasks.

A person is unable to track spending, A person is unable to track spending, pay bills, manage savings/checking pay bills, manage savings/checking accounts.accounts.

Source: About.com Health's Disease and Condition, Carrie Hill, PhD

Normal Aging Not Normal Aging

Brief HistoryBrief History Alois Alzheimer, a German physician, Alois Alzheimer, a German physician,

is credited with being the first to is credited with being the first to describe AD.describe AD.

In 1906, Dr. Alzheimer observed a In 1906, Dr. Alzheimer observed a patient, Auguste Deter, in a local patient, Auguste Deter, in a local asylum who exhibited strange asylum who exhibited strange behaviors. He followed her care and behaviors. He followed her care and noted her memory loss, language noted her memory loss, language difficulty and confusion.difficulty and confusion.

After her death at the age of 51 he After her death at the age of 51 he examined her brain tissue. The slides examined her brain tissue. The slides showed what are now known as showed what are now known as plaques and tangles that are plaques and tangles that are recognized as Alzheimer’s disease.recognized as Alzheimer’s disease.

In 1911, Doctors were using Dr. In 1911, Doctors were using Dr. Alzheimer’s research to base Alzheimer’s research to base diagnosis.diagnosis.

In the 1960’s British pathologists In the 1960’s British pathologists determined that AD was not a rare determined that AD was not a rare disease of the young but rather what disease of the young but rather what had been termed “senility.”had been termed “senility.”

In the 1990’s researchers identified In the 1990’s researchers identified that the beta amyloid protein was a that the beta amyloid protein was a factor in AD.factor in AD.

Alois Alzheimer

Auguste Deter

What is Alzheimer’s What is Alzheimer’s disease?disease?

Alzheimer’s is a progressive, Alzheimer’s is a progressive, degenerative and incurable degenerative and incurable neurological brain disease that neurological brain disease that causes deterioration of brain nerve causes deterioration of brain nerve cells and ultimately death.cells and ultimately death.

The deterioration is caused by:The deterioration is caused by: a build up of abnormal substances a build up of abnormal substances

called amyloid plaques (an insoluble called amyloid plaques (an insoluble protein deposit);protein deposit);

And neurofibrillary tangles. And neurofibrillary tangles.

Plaques and TanglesPlaques and Tangles Healthy neurons help guide Healthy neurons help guide

nutrients and molecules from the nutrients and molecules from the cell body to the ends of the axon cell body to the ends of the axon and back.and back.

Plaques form when protein pieces Plaques form when protein pieces called called beta-amyloid clump together. clump together. Beta-amyloid comes from a larger Beta-amyloid comes from a larger protein found in the fatty membrane protein found in the fatty membrane surrounding nerve cells.surrounding nerve cells.

Beta-amyloid is chemically "sticky" Beta-amyloid is chemically "sticky" and gradually builds up into and gradually builds up into plaques..

Neurofibrillary tangles (NFTs) which Neurofibrillary tangles (NFTs) which are found inside neurons, are are found inside neurons, are abnormal collections of a protein abnormal collections of a protein called called tautau..

In AD, when NFT’s build up nutrients In AD, when NFT’s build up nutrients and other essential supplies can no and other essential supplies can no longer move through the cells, longer move through the cells, which eventually die.which eventually die.

Source: Alzheimer’s Association: http://alz.org/alzheimers_disease_4719.asp Brain Tour

Axon – conducts nerve signal

Neuron-transmits to brain

Dendrites – signal receiver

Communication

Inside the BrainInside the Brain

In the Alzheimer brain:In the Alzheimer brain: The The cortexcortex shrivels up, shrivels up,

damaging areas involved damaging areas involved in thinking, planning and in thinking, planning and remembering. remembering.

Shrinkage is especially Shrinkage is especially severe in the severe in the hippocampushippocampus, an area of , an area of the cortex that plays a key the cortex that plays a key role in formation of new role in formation of new memories. memories.

VentriclesVentricles (cerebrospinal (cerebrospinal fluid-filled spaces within fluid-filled spaces within the brain) grow largethe brain) grow large

Source: Alzheimer’s Association: http://alz.org/alzheimers_disease_4719.asp Brain Tour

Cortex

Hippocampus

Ventricles

Source: Image from the Alzheimer’s Society of Saskatchewan with permission from Alzheimer’s Broken Brain.

Alzheimer’s Brain

Normal Brain

So what is Dementia?So what is Dementia? Dementia is a set of signs and symptoms, not a disease.Dementia is a set of signs and symptoms, not a disease. Dementia is characterized by memory loss, changes in mood and Dementia is characterized by memory loss, changes in mood and

communication difficulties. communication difficulties.

Types of diseases with the symptom of dementia are:Types of diseases with the symptom of dementia are: Alzheimer’s diseaseAlzheimer’s disease

Most common.Most common. Vascular dementiaVascular dementia

stroke related, 2stroke related, 2ndnd most common type of dementia most common type of dementia Dementia with Lewy BodyDementia with Lewy Body

Lewy bodies are deposits of a protein called alpha-synuclein Lewy bodies are deposits of a protein called alpha-synuclein that form inside the brain’s nerve cells. Affects memory, that form inside the brain’s nerve cells. Affects memory, concentration, speech.concentration, speech.

Frontotemporal dementiaFrontotemporal dementia a rare disorder that affects the frontal lobes and the temporal a rare disorder that affects the frontal lobes and the temporal

lobes (sides) of the brain. Affects behavior, personality and lobes (sides) of the brain. Affects behavior, personality and memory later.memory later.

Wernicke-Korsakoff syndrome Wernicke-Korsakoff syndrome most common cause is alcoholism, but the syndrome can also most common cause is alcoholism, but the syndrome can also

be associated with AIDS, cancers.be associated with AIDS, cancers.

Dementia…notDementia…not

In a few cases, dementia is caused by a problem that can be treated. In a few cases, dementia is caused by a problem that can be treated. Once treated, the symptom of dementia often disappears. Examples Once treated, the symptom of dementia often disappears. Examples include:include:

Having an underactive Having an underactive thyroid gland (hypothyroidism) can cause gland (hypothyroidism) can cause difficulty with concentration and forgetfulness.difficulty with concentration and forgetfulness.

Vitamin B12 deficiency. B12 supports the function and Vitamin B12 deficiency. B12 supports the function and development of the brain, nerves, blood cells, and many other development of the brain, nerves, blood cells, and many other parts of the body.parts of the body.

Dehydration – severe dehydration causes confusion.Dehydration – severe dehydration causes confusion. Malnutrition – prevents the brain from functioning properly.Malnutrition – prevents the brain from functioning properly. Urinary Tract Infections – a type of infection that affects brain Urinary Tract Infections – a type of infection that affects brain

function.function. In some, depression can cause memory loss; often referred to as In some, depression can cause memory loss; often referred to as

Pseudodementia.Pseudodementia. Medications - Taking some medicines together may cause Medications - Taking some medicines together may cause

symptoms that look like dementia. This includes prescribed, over symptoms that look like dementia. This includes prescribed, over the counter, herbals, vitamins and supplements. the counter, herbals, vitamins and supplements.

Source: WebMD http://www.webmd.com/alzheimers/tc/dementia-topic-overview

Source: About.com http://alzheimers.about.com/od/diagnosisofalzheimers/a/reversible.htm

What is Mild Cognitive What is Mild Cognitive Impairment?Impairment?

Mild cognitive impairment (MCI) is a condition in which a Mild cognitive impairment (MCI) is a condition in which a person has problems with memory, language, or another person has problems with memory, language, or another mental function severe enough to be noticeable to other mental function severe enough to be noticeable to other people and to show up on tests, but not serious enough people and to show up on tests, but not serious enough to interfere with daily life.to interfere with daily life.

Individuals with MCI have an increased risk of Individuals with MCI have an increased risk of developing Alzheimer’s disease over the next few years, developing Alzheimer’s disease over the next few years, especially when their main problem is especially when their main problem is memorymemory..

Not everyone diagnosed with MCI goes on to develop Not everyone diagnosed with MCI goes on to develop Alzheimer’s.Alzheimer’s.

There is currently no treatment for MCI approved by the There is currently no treatment for MCI approved by the FDA.FDA.

Source: Alzheimer’s Association: www.sanalz.org

Risk FactorsRisk Factors

Age – Biggest risk factorAge – Biggest risk factor 10% of individuals over the age 65 will have AD.10% of individuals over the age 65 will have AD. After age 85, the risk reaches nearly 50 percent.After age 85, the risk reaches nearly 50 percent.

Family HistoryFamily History Research has shown that those who have a parent, Research has shown that those who have a parent,

brother or sister with Alzheimer’s are more likely to brother or sister with Alzheimer’s are more likely to develop Alzheimer’s. The risk increases if more than develop Alzheimer’s. The risk increases if more than one family member has the illness. one family member has the illness.

Genetics –Genetics – Risk GenesRisk Genes Deterministic GenesDeterministic Genes

Source: Alzheimer’s Association San Diego Chapter – www.sanalz.org

Risk FactorsRisk Factors Risk GenesRisk Genes

Risk genesRisk genes increase the likelihood of developing a disease increase the likelihood of developing a disease but do not guarantee it will happen.but do not guarantee it will happen.

APOE-e4 is one of three common forms of the APOE APOE-e4 is one of three common forms of the APOE (apolipoprotein) gene.(apolipoprotein) gene.

Everyone inherits a copy of some form of APOE from Everyone inherits a copy of some form of APOE from each parent.each parent.

Those who inherit one copy of APOE-e4 have an Those who inherit one copy of APOE-e4 have an increased risk of developing Alzheimer’s.increased risk of developing Alzheimer’s.

Those who inherit two copies have an even higher risk, Those who inherit two copies have an even higher risk, but not a certainty.but not a certainty.

In addition to raising risk, APOE-e4 may tend to make In addition to raising risk, APOE-e4 may tend to make symptoms appear at a younger age than usual.symptoms appear at a younger age than usual.

Source: Alzheimer’s Association San Diego Chapter

Risk FactorsRisk Factors

Deterministic Genes/Early Onset :Deterministic Genes/Early Onset : directly cause a disease, guaranteeing that directly cause a disease, guaranteeing that

anyone who inherits them will develop the anyone who inherits them will develop the disorder.disorder.

Scientists have found rare genes that directly Scientists have found rare genes that directly cause Alzheimer’s in only a few hundred cause Alzheimer’s in only a few hundred extended families worldwide.extended families worldwide.

This type is known as “familial Alzheimer’s This type is known as “familial Alzheimer’s disease”, and many family members in multiple disease”, and many family members in multiple generations are affected. True familial AD generations are affected. True familial AD accounts for less than 5% of the cases.accounts for less than 5% of the cases.

Stages of ADStages of AD

Mild or Early StageMild or Early Stage Friends, family or co-workers begin to Friends, family or co-workers begin to

notice deficiencies. Some common notice deficiencies. Some common difficulties include:difficulties include:

Word finding problemsWord finding problems Decreased ability to remember namesDecreased ability to remember names Performance issues in social or work settingsPerformance issues in social or work settings Reading a passage and retaining little Reading a passage and retaining little

materialmaterial Losing or misplacing a valuable objectLosing or misplacing a valuable object Decline in ability to plan or organizeDecline in ability to plan or organize

Source: National Alzheimer’s Association

Stages of ADStages of AD

Moderate or Middle StageModerate or Middle Stage Major gaps in memory and deficits in cognitive function emerge. Major gaps in memory and deficits in cognitive function emerge.

Some assistance with day-to-day activities becomes essential. Some assistance with day-to-day activities becomes essential. Some common difficulties include:Some common difficulties include:

Inability to recall important details such as their current address, Inability to recall important details such as their current address, their telephone number. their telephone number.

Confused about where they are or about the date, day of the week or Confused about where they are or about the date, day of the week or season. season.

Need help choosing proper clothing for the season or the occasion.Need help choosing proper clothing for the season or the occasion. May have increasing episodes of urinary or fecal incontinence and May have increasing episodes of urinary or fecal incontinence and

need assistance with toileting and personal care.need assistance with toileting and personal care. Lose most awareness of recent experiences and events as well as of Lose most awareness of recent experiences and events as well as of

their surroundings.their surroundings. Tend to wander and become lost.Tend to wander and become lost. Experience significant personality changes and behavioral Experience significant personality changes and behavioral

symptoms. symptoms. including suspiciousness and delusions (for example, believing that their including suspiciousness and delusions (for example, believing that their

caregiver is an impostor)caregiver is an impostor) hallucinations (seeing or hearing things that are not really there)hallucinations (seeing or hearing things that are not really there) compulsive, repetitive behaviors such as hand-wringing or tissue compulsive, repetitive behaviors such as hand-wringing or tissue

shreddingshredding Source: National Alzheimer’s Association

Stages of ADStages of AD

Severe or Late StageSevere or Late Stage This is the final stage of the disease when individuals lose This is the final stage of the disease when individuals lose

the ability to respond to their environment, the ability to the ability to respond to their environment, the ability to speak and, ultimately, the ability to control movement.speak and, ultimately, the ability to control movement.

Frequently individuals lose their capacity for recognizable Frequently individuals lose their capacity for recognizable speech, although words or phrases may occasionally be speech, although words or phrases may occasionally be uttered.uttered.

Need full assistance with eating and toileting and there is Need full assistance with eating and toileting and there is general incontinence.general incontinence.

Individuals lose the ability to:Individuals lose the ability to: walk without assistancewalk without assistance sit without supportsit without support ability to hold their head upability to hold their head up Reflexes become abnormal and muscles grow rigidReflexes become abnormal and muscles grow rigid Swallowing is impairedSwallowing is impaired

Source: National Alzheimer’s Association

What is it like with AD?What is it like with AD?

Who was the story Who was the story about?about?

Who were the Who were the characters in the story?characters in the story?

What is the story What is the story about?about?

Where did the story Where did the story take place?take place?

When did the story When did the story take place?take place?

When was the last time you When was the last time you needed help with…?needed help with…?

BathingBathing Personal care Personal care

(toileting and all that (toileting and all that goes with it)goes with it)

Getting dressedGetting dressed Brushing your teethBrushing your teeth Combing your hairCombing your hair

Common BehaviorsCommon Behaviors

AnxietyAnxiety Paranoia, suspicionParanoia, suspicion DepressionDepression Outbursts – emotional, Outbursts – emotional,

verbal, physical verbal, physical aggression.aggression.

RummagingRummaging Poor grooming, Poor grooming,

dressing, hygienedressing, hygiene Sexually inappropriate Sexually inappropriate

behaviorsbehaviors

Refusal to eatRefusal to eat Eating non food itemsEating non food items Wandering, pacingWandering, pacing HoardingHoarding Repetitive behaviors Repetitive behaviors

such as actions, wordsuch as actions, word Inappropriate social Inappropriate social

behaviors such as behaviors such as undressing in public, undressing in public, inappropriate inappropriate conversation with conversation with others.others.

How Do We Know it is AD?How Do We Know it is AD? A process of elimination through testing.A process of elimination through testing. 100% diagnosis for AD comes at autopsy when the brain can be examined.100% diagnosis for AD comes at autopsy when the brain can be examined. Diagnosing ADDiagnosing AD

Physician will review your medical historyPhysician will review your medical history Mini Mental Status Exam administered (assesses mental function through a Mini Mental Status Exam administered (assesses mental function through a

series of questions)series of questions) A physical exam will be completedA physical exam will be completed Diagnostic tests will be ordered to rule out other illnesses or deficiencies that Diagnostic tests will be ordered to rule out other illnesses or deficiencies that

mimic memory loss. Such as: Anemia, malnutrition or certain vitamin mimic memory loss. Such as: Anemia, malnutrition or certain vitamin deficiencies, excessive use of alcohol, medication side effects, infections, deficiencies, excessive use of alcohol, medication side effects, infections, diabetes, kidney or liver disease, thyroid abnormalities, problems with the heart, diabetes, kidney or liver disease, thyroid abnormalities, problems with the heart, lung or blood vessels.lung or blood vessels.

Neurological Exam which includes: Reflexes, coordination and balance, muscle Neurological Exam which includes: Reflexes, coordination and balance, muscle tone and strength, eye movement, speech and sensation.tone and strength, eye movement, speech and sensation.

Brain Imaging through:Brain Imaging through: Structural imagingStructural imaging provides information about the shape, position or provides information about the shape, position or

volume of brain tissue. Structural techniques include magnetic resonance volume of brain tissue. Structural techniques include magnetic resonance imaging (MRI) and computed tomography (CT).imaging (MRI) and computed tomography (CT).

Functional imagingFunctional imaging reveals how well cells in various brain regions are reveals how well cells in various brain regions are working by showing how actively the cells use sugar or oxygen. Functional working by showing how actively the cells use sugar or oxygen. Functional techniques include positron emission tomography (PET) and functional MRI techniques include positron emission tomography (PET) and functional MRI (fMRI).(fMRI).

Treatments Treatments There are 2 types of FDA approved drugs to treat the cognitive There are 2 types of FDA approved drugs to treat the cognitive

symptoms of AD. These drugs affect the activity of two different symptoms of AD. These drugs affect the activity of two different chemicals involved in carrying messages between the brain’s nerve chemicals involved in carrying messages between the brain’s nerve cells.cells. The first type are calledThe first type are called Cholinesterase (KOH-luh-NES-ter- Cholinesterase (KOH-luh-NES-ter-

ays) inhibitorsays) inhibitors and they prevent the breakdown of acetylcholine and they prevent the breakdown of acetylcholine (a-SEA-til-KOH-lean), a chemical messenger important for (a-SEA-til-KOH-lean), a chemical messenger important for learning and memory. learning and memory.

Cholinesterase inhibitors commonly prescribed:Cholinesterase inhibitors commonly prescribed: Donepezil (Aricept)Donepezil (Aricept) Rivastigmine (Exelon)Rivastigmine (Exelon) Galantamine (Razadyne)Galantamine (Razadyne) Tacrine (Cognex)Tacrine (Cognex)

The second type isThe second type is Memantine (Namenda) Memantine (Namenda) and this works by and this works by regulating the activity of glutamate, a different messenger chemical regulating the activity of glutamate, a different messenger chemical involved in learning and memory. involved in learning and memory. Memantine:Memantine:

Approved in 2003 for treatment of moderate to severe Approved in 2003 for treatment of moderate to severe Alzheimer's disease.Alzheimer's disease.

Source: National Alzheimer’s Association www.alz.org

Preserving Cognitive Preserving Cognitive FunctionFunction

Bad News: You cannot prevent Alzheimer’s diseaseBad News: You cannot prevent Alzheimer’s disease

Good News: You can help keep your brain sharp with Good News: You can help keep your brain sharp with regular social activity; "mental exercise," such as doing regular social activity; "mental exercise," such as doing crossword puzzles and reading; and physical activity, which crossword puzzles and reading; and physical activity, which increases blood and oxygen flow to the brain and a healthy increases blood and oxygen flow to the brain and a healthy diet.diet.

ImpactImpact AD is the 7AD is the 7thth leading cause of death in the U.S. (Heart Disease is #1) leading cause of death in the U.S. (Heart Disease is #1) Length of the disease is 3 – 20 yearsLength of the disease is 3 – 20 years

Currently, there are 5.4 million with AD; SD/Imp Cty=90,000Currently, there are 5.4 million with AD; SD/Imp Cty=90,000

By 2029 all Baby Boomers (1946-1964) will be at least 65 – 10 By 2029 all Baby Boomers (1946-1964) will be at least 65 – 10 million of the 78 million are predicted to develop AD.million of the 78 million are predicted to develop AD.

More women than men will develop ADMore women than men will develop AD Avg life expectancy in 2010 – Women 80.8; Men 75.7 (US Census Avg life expectancy in 2010 – Women 80.8; Men 75.7 (US Census

projection)projection)

2010 Cost of Care is estimated at $172 billion (Healthcare and Long 2010 Cost of Care is estimated at $172 billion (Healthcare and Long Term Care)Term Care)

Skilled Care:$6K/mo; In Home Care: $3,800/mo; Daycare:$1,500/moSkilled Care:$6K/mo; In Home Care: $3,800/mo; Daycare:$1,500/mo Cost to businesses – lost work time, absenteeism, leaves of Cost to businesses – lost work time, absenteeism, leaves of

absence, quitting work.absence, quitting work.

In 2009 there were an estimated 10.9 million unpaid caregivers In 2009 there were an estimated 10.9 million unpaid caregivers (family, friends(family, friends

Several studies show hours of caregiving range from 21-40; higher number Several studies show hours of caregiving range from 21-40; higher number of hours as the disease progresses.of hours as the disease progresses.

Average age of the caregiver is 51.Average age of the caregiver is 51. 60% of the caregivers are female.60% of the caregivers are female.

Source: National Alzheimer’s Association http://www.alz.org/documents_custom/report_alzfactsfigures2010.pdf

For More Information on For More Information on Research/Clinical TrialsResearch/Clinical Trials

What is a clinical trial?What is a clinical trial? According to According to clinical trials.govclinical trials.gov, clinical trials are biomedical or , clinical trials are biomedical or

health-related research studies in human beings that follow a pre-health-related research studies in human beings that follow a pre-defined protocol. Clinical trials can include both interventional and defined protocol. Clinical trials can include both interventional and observational types of studies.observational types of studies.

Interventional studies are those in which the research subjects are Interventional studies are those in which the research subjects are assigned by the investigator to a treatment or other intervention, and assigned by the investigator to a treatment or other intervention, and their outcomes are measured.their outcomes are measured.

Observational studies are those in which individuals are observed and Observational studies are those in which individuals are observed and their outcomes are measured by the investigators. their outcomes are measured by the investigators.

http://adrc.ucsd.edu/trials.htmlhttp://adrc.ucsd.edu/trials.html What Research is going on?What Research is going on? Studies investigate treatments designed to improve thinking and Studies investigate treatments designed to improve thinking and

daily functioning as well as studying ways to slow decline or delay daily functioning as well as studying ways to slow decline or delay the onset of Alzheimer’s’ disease. the onset of Alzheimer’s’ disease.

http://adrc.ucsd.edu/research.htmlhttp://adrc.ucsd.edu/research.html

Source: UCSD Shiley Marcos Alzheimer’s Disease Research Center http://adrc.ucsd.edu

Additional ResourcesAdditional Resources

Alzheimer’s Disease Education and Referral Alzheimer’s Disease Education and Referral Center (ADEAR) – www.nia.nih.gov/AlzheimersCenter (ADEAR) – www.nia.nih.gov/Alzheimers

Alzheimer’s Association- San Diego Chapter – Alzheimer’s Association- San Diego Chapter – www.sanalz.orgwww.sanalz.org

Family Caregiver Alliance – www.caregiver.orgFamily Caregiver Alliance – www.caregiver.org Southern Caregiver Resource Center – Southern Caregiver Resource Center –

www.caregivercenter.orgwww.caregivercenter.org UCSD Shiley Marcos Alzheimer’s Disease UCSD Shiley Marcos Alzheimer’s Disease

Research Center – www.adrc.ucsd.eduResearch Center – www.adrc.ucsd.edu