Dementia

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Dementia Alzheimers Disease Whats the
Latest???
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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

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Over the past 5-10 years research and knowledge
has increased dramatically
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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 ½ 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

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What is on the horizon

• Ways to reduce the risk of developing dementia
• Ways to delaying its onset
• Better ways to help people with dementia live
  their lives

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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

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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!

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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

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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 (½ of these folks will develop
  dementia in 5 yrs)
• Dementia Chronic thinking problems in gt 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

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DEMENTIA
Lewy Body Dementia

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

• Alzheimers
• Disease
• Early onset
• Normal onset

Fronto- Temporal Lobe Dementias
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Diagnosing AD
Definite AD - Histopathological evidence
(requires autopsy) - Course and examination
characteristic of AD
Probable AD - Deficits in gt 2 areas of
cognition - Onset 40-90 (usually gt 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
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What happens with Alzheimers Disease?

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

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AD Pathology
Amyloid plaques (Ab)
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Normal Brain Cells
Neurotransmitters (AChE) being sent message
being communicated to the next cell
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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
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Brain Cells with Alzheimers
Less neurotransmitter
Further to go to get to the next cell
plaques
tangles
Enzymes (AChE inhibitors) get to them BEFORE
they deliver their message
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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)
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Acetylcholinesterase inhibitors for AD
Galantamine Coyle and Kershaw, 2001
Donepezil (Aricept) Rivastigmine
(Exelon) Galantamine (Reminyl)
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ACIs and functional decline

• Loss of ADLs
• Telephone
• Household task
• Household appliances
• Managing money
• Shopping
• Food preparation
• Orientation around home
• Hobbies and leisure
• Handling mail
• Grasp of situations

Mohs et al., 2001 RCT
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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

Can use it with AChE inhibitors two actions
Keeps the cell from getting so much glutamate in
it
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AD treatment blocking excitotoxicity
glutamate
Memantine (Namenda)
NMDA receptors
Ca2/Na
Budd and Rao, 2000
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Aricept Namenda
Tariot et al., JAMA 2004 mod-severe AD Already
on donepezil memantine 5/20 mg/d 24 wks
0-100
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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

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Vascular Damage
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ACIs vascular dementia
Donepezil (Aricept) Rivastigmine
(Exelon) Galantamine (Reminyl)
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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

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Key Issues

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

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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

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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

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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

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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

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Brain Failure
The persons brain is dying
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New Imaging Technology for AD
67 yo NL
79 yo AD
PET scan
Amyloid detection
Nordberg Lancet Neurology 2004
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PET and Aging
ADEAR, 2003
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Positron Emission Tomography (PET) Alzheimers
Disease Progression vs. Normal Brains
Early Alzheimers
Late Alzheimers
Normal
Child
G. Small, UCLA School of Medicine.
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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
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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

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Memory
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Memory Loss

• Losses
• Immediate recall
• Attention to selected info
• Recent events
• Relationships
• Preserved abilities
• Long ago memories
• Confabulation!
• Emotional memories
• Motor memories

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Understanding
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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

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Talking
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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

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Impulse Control
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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

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How can we help better?

• It all starts with
• your approach!

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Positive Physical Approach
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How you talk

• How you say it
• What you say
• How you respond

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Use empathyGo with the flow
Reality Orientation
Telling Lies
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How you help

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

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Hand-Under-Hand Assistance
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Believe -

• People with dementia
• Are doing
• The BEST they can!

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So WHAT should we do???

• Remember
• who
• has the healthy brain!

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