Dementia & Alzheimers Disease

Whats the Latest???

Where did we start?

Alzheimers first diagnosed in 1907 OBS organic brain syndrome - common term 60s Hardening of the arteries & senility seemed normal Psychiatric illness mentally ill 60s-80s Drugs and restraints 60s-80s De-institutionalization - nursing homes 70s-80s Diagnosis of Alzheimers on autopsy only till 90s Little could be done once diagnosed until the 90s Families - do the best you can 60s 90s

Over the past 5-10 years research and knowledge has increased dramatically

Where are we NOW

Over 90-95% accuracy on diagnosis Early diagnosis - best treatment & planning Drugs can help delay symptoms Strategies to improve care & quality of life 4 million people in the US 300% increase 70-80 known causes of dementia Some causes are reversible We can reduce our risks New info each week

How Can You Help?

Encourage Durable PoA discussions early and with everyone before its needed Encourage caregivers to write down concerns ahead of visits Screen for changes in cognition & function Make referrals to support systems Encourage brain health

Help Caregivers Appreciate

By managing their own behaviors, actions, words & reactions they can change the outcome of interactions. Its the relationship that is MOST critical, NOT the outcome of one encounter Let health care providers be the Bad GUYS Its a marathon & they will need help!

SO What is Dementia?
It is NOT part of normal aging! It is a disease!
It is more than just forgetfulness - which is part of normal aging It makes independent life impossible

Aging Changes in Cognition

Normal aging changes = more forgetful & slower to learn MCI Mild Cognitive Impairment = 1 problem area
Immediate recall, word finding & complex problem solving problems ( of these folks will develop dementia in 5 yrs)

Dementia = Chronic thinking problems in > 2 areas Delirium =Rapid changes in thinking & alertness
(seek medical help immediately )

Depression = chronic unless treated, poor quality , I

dont know, I just cant responses, no pleasure
can look like agitation & confusion

DEMENTIA

Lewy Body Dementia

Alzheimers Disease
Early onset Normal onset

Vascular (Multiinfarct) Dementia

FrontoTemporal Lobe Dementias

Other Dementias Metabolic Drugs/toxic White matter disease Mass effects Depression Infections Parkinsons

Diagnosing AD
Definite AD - Histopathological evidence (requires autopsy) - Course and examination characteristic of AD Probable AD - Deficits in > 2 areas of cognition - Onset 40-90 (usually > 65); progressive course - Other causes excluded
Possible AD - Deficit in only 1 area of cognition - Atypical course - Other dementia causes present

Unlikely AD - Sudden onset - Focal signs - Seizures or gait disturbance early in course

What happens with Alzheimers Disease?

Two processes
Cells are shrinking & dying Cells are producing less chemical to send messages

AD Pathology
Amyloid plaques (Ab)

Normal Brain Cells

Neurotransmitters (AChE) being sent message being communicated to the next cell

Normal Brain Cells

Once the message is sent, then enzymes lock onto the messenger chemicals and take them out of circulation so a new message can be sent

Brain Cells with Alzheimers

Less neurotransmitter plaques tangles Further to go to get to the next cell

Enzymes (AChE inhibitors) get to them BEFORE they deliver their message

What do Alzheimers drugs DO?

Alzheimers drugs provide FAKE messenger chemicals that distract the enzymes. They attach to the Fake AChE & the message can get thru

Aricept, Exelon, Reminyl (Razadyne)

One New Drug

Memantine - Namenda
from Europe - 10 years of research coming this year to the US different effect moderates glutamate absorption - May show language, movement, interest, participation improvement

Keeps the cell from getting so much glutamate in it

Can use it with AChE inhibitors two actions

Vascular Dementia
Nerve cells are OK Blood supply is damaged
no oxygen gets to the cell no nutrients get to the cell

Then the nerve cells die

Vascular Damage
Healthy cell with oxygen and nourishment

No message

Dead nerve cell - no blood supply

Early Get good long term care insurance! Then - check out the possibility that something IS WRONG See someone who is interested in DEMENTIA and ALZHEIMERS DISEASE Consider a specialist
Neurologist, geriatrician, gero-psychiatrist

Key Issues
Early Diagnosis Medications & Treatment Legal Issues Financial Issues Care Options & Funding Family Support & Education Staff Support and Education

Early Diagnosis
Failure to ID
safety issues family disasters $$$ disasters mis-diagnosis untreated problems fear & stress panic

Early Detection
drugs work better personal planning decision making $$$ planning treat the treatable counseling & support

What Should be DONE

Neuropsychological testing screening for cognitive changes A thorough physical & medical history Blood work A neurological exam A good history from the person and the family of the problem A complete medication review A CAT scan or MRI (atypical Alzheimers PET scan) FOLLOW-UP and counseling or at least a referral

Intervention & Programming to:

physical activity mental activity social activity spiritual involvement well-being and self-worth minimize risky, challenging, or dangerous behaviors reduce anxiety or distress

Latest Thinking About Prevention

Help
Mental activity Aerobic activity Vitamin E (low dose) & C Heart Smart Diet Omega 3 fatty acids (fish, canola, flaxseed oils) Lower weight Not smoking Enough sleep De-stressing Moderate alcohol intake

Help
Keeping iron in limits Keeping homocysteine right Vitamin Bs Monitor thyroid function Staying socially active Getting depression treated Control diabetes better Control hypertension better Statins (if needed) Protect your head - prevent head injuries

The persons brain is dying

New Imaging Technology for AD

67 yo NL 79 yo AD

PET scan

Amyloid detection
Nordberg Lancet Neurology 2004

PET and Aging

PET Scan of 20-Year-Old Brain PET Scan of 80-Year-Old Brain

ADEAR, 2003

Positron Emission Tomography (PET) Alzheimers Disease Progression vs. Normal Brains
Normal Early Late Alzheimers Alzheimers Child

Alzheimers: a window of opportunity

Reiman et al PNAS 2004 FDG-PET
20-39 year olds (~30) e4 carriers vs controls

Purple: AD pts Blue: young carriers

Prevention Delayed progression

Brain atrophy

the brain actually shrinks cells wither then die abilities are lost with Alzheimers area of loss are fairly predictable as is the progression BUT the experience is individual

Memory

Memory Loss
Losses
Immediate recall Attention to selected info Recent events Relationships Long ago memories Confabulation! Emotional memories Motor memories

Preserved abilities

Understanding

Understanding
Losses Cant interpret information Cant make sense of words Gets off target Preserved abilities Can get facial expression Hears tone of voice Can get some non-verbals

Talking

Language
Losses
Cant find the right words Word Salad Vague language Single phrases Sounds & vocalizing Cant make needs known

Preserved abilities
singing automatic speech Swearing/sex words/forbidden words

Impulse Control

Impulse & Emotional Control

Losses
becomes labile & extreme think it - say it want it - do it see it - use it

Preserved
desire to be respected desire to be in control regret after action

How can we help better?

It all starts with your approach!

Positive Physical Approach

How you talk

How you say it What you say How you respond

Use empathy & Go with the flow

Reality Orientation

Telling Lies

How you help

Sight or Visual cues Verbal or Auditory cues Touch or Tactile cues

Hand-Under-Hand Assistance

Believe People with dementia Are doing The BEST they can!

So WHAT should we do???

Remember who has the healthy brain!

Being right doesnt necessarily translate into a good outcome the person with dementia OR the caregiver