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DEMENTIA

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dementia is a loss of intellectual function. it is a broad term used to describe a condition where a person exhibits impairments in higher cortical functions ... – PowerPoint PPT presentation

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Title: DEMENTIA


1
DEMENTIA
IS A LOSS OF INTELLECTUAL FUNCTION. IT IS A BROAD
TERM USED TO DESCRIBE A CONDITION WHERE A PERSON
EXHIBITS IMPAIRMENTS IN HIGHER CORTICAL FUNCTIONS
(language, orientation, perception, agnosias,
aprexias, etc), IMPAIRMENTS IN SHORT-TERM MEMORY,
WITH OR WITHOUT BEHAVIORAL /PERSONALITY CHANGE IN
THE SETTING OF A NORMAL LEVEL OF CONCIOUSNESS.
2
DEMENTIA
INCIDENCE About 1-2/year (Individuals 65 years
or greater) AGE RELATED 60-69 yrs. 0.13
70-79 yrs. 0.74 gt80 yrs. 2.17
3
DEMENTIA
PREVALENCE About 4.5-50 (Individuals 65 years
or greater) AGE RELATED 60-64 yrs. about
1 65-75 yrs. about 5-9 75-85 yrs.
about 10-15 gt85 yrs. about 50 OVERALL
4-5 Million ALABAMA 79,000
4
OTHER FACTS ABOUT ALZHEIMERS DISEASE
1 in 8 people (13) have AD ½ million cases/yr
by 2010 1 million/yr by 2050 1 case every 77
sec. by 2050 1 every 33 sec. Fifth case of death
in people older than 60 Morality rate increased
by 45 between 2000 and 2005, while it decreased
for heart disease, stroke, prostate and breast
cancer
5
OTHER FACTS ABOUT ALZHEIMERS DISEASE
Direct cost to Medicare/Medicaid and indirect
costs to businesses with employees who are
caregivers was 148 billion annually. In 2000,
Medicare cost for AD was 3 time higher than for
other illnesses (13,000 vs 4,500) In 2007, 10
million Americans 18 yrs and older provided 8.4
billion hrs. of unpaid care (89 million), 4
times what Medicare pays for nursing home
care
6
DEMENTIAPHYSICIANS OBLIGATION
  • DIAGNOSIS
  • MANAGE
  • EDUCATE
  • RECOGNIZE

7
DEMENTIAMAKING THE DIAGNOSIS
  • HISTORY OF MEMORY PROBLEM
  • DOCUMENTATION OF MEMORY PROBLEM
  • NEUROLOGICAL EXAMINATION

8
DEMENTIACOGNITIVE IMPAIRMENT
  • MINI-MENTAL STATE EXAM
  • CATEGORY GENERATION
  • MATH
  • REASONING
  • LANGUAGE
  • SPATIAL ABILITIES

9
DEMENTIACOGNITIVE IMPAIRMENT
  • MINI-MENTAL STATE EXAM
  • ORIENTATION 10 POINTS
  • IMMEDIATE RECALL 3 POINTS
  • ATTENTION 5 POINTS
  • DELAYED RECALL 3 POINTS
  • HIGHER COGNITIVE FUNCTION 9 POINTS

10
DEMENTIACOGNITIVE IMPAIRMENT
  • MINI-MENTAL STATE EXAM
  • CATEGORY GENERATION
  • MATH
  • REASONING
  • LANGUAGE
  • SPATIAL ABILITIES

11
DEMENTIAPOTENTIALLY REVERSIBLE CAUSES
  • STRUCTURAL BRAIN LESIONS
  • METABOLIC DISORDERS
  • CNS INFECTIONS
  • PSYCHIATRIC ILLNESSES
  • SUBSTANCE ABUSE
  • MEDICATIONS

12
DEMENTIAIRREVERSIBLE CAUSES
  • ALZHEIMERS DISEASE
  • DIFFUSE LEWY BODY DISEASE
  • FRONTO-TEMPEROL DEMENTIA
  • PARKINSONS DISEASE
  • VIRAL AND PRION INFECTION
  • MULTIPLE STROKES
  • OTHER

13
DEMENTIALABORATORY EVALUATION
  • BLOOD COUNTS CHEMISTRIES
  • THYROID PANEL, B12, RPR
  • CRANIAL IMAGING (CT/MRI)
  • ?PET/SPECT
  • NEUROPSYCH. TESTING
  • ?LP?
  • PSYCHIATRIC EVALUATION

14
MRI OF AD
                                               
                                                  
      Figure 2. MRI in(a) normal, (b) mild
Alzheimer's disease, and (c) moderate Alzheimer's
disease subjects, showing medial temporal
atrophy, which is worse on the left in subject
(b).
15
PET SCAN AD
16
ALZHEIMERS DISEASEEARLY PHASE
  • SHORT TERM MEMORY LOSS
  • LANGUAGE DIFFICULTY (naming)
  • PSYCHIATRIC DISTURBANCES (irritability/persona
    lity change)
  • PRESERVATION OF SOCIAL GRACES
  • SUPERIFCIALLY APPEAR NORMAL

17
ALZHEIMERS DISEASEMIDDLE PHASE
  • INREASING INTELLECTUAL FAILURE
  • INCREASING APRAXIAS
  • SOCIAL WITHDRAWAL
  • INCREASING MEMORY PROBLEMS
  • INCREASING LANGUAGE PROBLEMS
  • SPATIAL VISUAL AGNOSIAS
  • BEHAVIORAL PROBLEMS

18
ALZHEIMERS DISEASELATE PHASE
  • LOSS OF RECOGNITON OF SELF ENVIRONMENT
  • CHAIR/BED BOUND
  • DOUBLY INCONTINENT
  • FEEDING DIFFICULTIES
  • MUTE

19
ALZHEIMERS DISEASEATYPICAL PRESENTATIONS
  • DOMINANT HEMISPHERE APHASIA
  • WORD FINDING HESISTENCY
  • PARAPHASIAS NEOLOGISMS
  • NON-DOMINANT HEMISPHERE
  • DRESSING APRAXIA
  • VISUAL AGNOSIAS
  • CONSTRUCTIONAL APRAXIA

20
ALZHEIMERS DISEASEOTHER SIGNS SYMPTOMS
  • PARKINSONISM
  • SEIZURES
  • MYOCLONUS

21
ALZHEIMERS DISEASECRITERIA FOR DIAGNOSIS
  • DEFINITE Requires Clinical and Brain tissue
  • PROBABLE 6 Month Hx of Cognitive Decline
    STM loss Loss in at least 2 other Cognitive
    Domains Functional Impairment at Work or Home
    No other Illness know to cause Dementia
  • POSSIBLE Atypical Presentation or
    Progression Only 1 Cognitive Domain affected
    Other illness known to cause Dementia but not
    felt to be the cause (i.e. B12 deficiency)

22
ALZHEIMERS DISEASEPATHOLOGICAL CHANGES
  • VULNERABLE AREAS
  • Hippocampus
  • Association Cortex
  • Amygdala
  • Nucleus Basalis
  • Locus Cerulerous
  • Raphe Nuclei

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26
ALZHEIMERS DISEASEMICROSCOPIC PATH.
  • NEUROFIBILLARY TANGLE
  • NEURITIC PLAQUE
  • AMYLOID PROTEINS

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33
APP METABOLISM
34
ALZHEIMERS DISEASEPATHOLOGICAL MECHANISMS
  • AMYLOID HYPOTHEISIS
  • NEUROFIBILLARY TANGLE HYPOTHESIS
  • F REE-RADICAL MECHANISMS
  • INFLAMMATORY MECHANISMS
  • CHOLINERGIC LOSS
  • CHOLESTREROL/ STATINS?

35
ALZHEIMERS DISEASERISK FACTORS
  • AGE
  • 1 Population over Age 65
  • 5 at Age 65
  • 20-50 at Age 80 and Over
  • FAMILY HISTORY
  • Autosomal Dominant Transmission
  • Increased Risk for 1O Relatives
  • DOWNS SYNDROME
  • All get Pathological Changes of AD
    30-50 develop Dementia

36
ALZHEIMERS DISEASERISK FACTORS
  • GENDER
  • More women than men 1.5-2 w/m
  • EDUCATIONAL LEVEL
  • Lower education greater risk
  • VASCULAR RISK FACTORS
  • Heart Healthy is Brain Healthy i.e.
    Hypertension and elevated Cholesterol are
    Risks for AD

37
ALZHEIMERS DISEASEGENETICS
  • AUTOSOMAL DOMINANT TRANSMISSON
  • EARLY ONSET lt65 YEARS
  • CHROMOSOME 1 Volga Germans
    Presenilin 2
  • CHROMOSOME 14 70 Presenilin 1
  • CHROMOSOME 21 5-10
  • LATE ONSET gt65 YEARS
  • CHROMOSOME 19 families

38
ALZHEIMERS DISEASEGENETICS
  • APOLIPOPROTEIN E (Apo-E)
  • 3 isoforms E1,2 3 E4 found in 50 of
    AD and only 10 of normals Chromosome 19
  • MUTATIONS IN APP
  • CHROMOSOME 21 Variety of point
    mutations

39
ALZHEIMERS DISEASEMEDICATIONS
  • CHOLINESTERASE INHIBITORS
  • Aricept (Donepezil)
  • Exelon (Rivastigimine)
  • Razadyne IR , ER (Reminyl
    Galantamine)
  • NMDA RECEPTOR INHIBITORS
  • Namenda (Memantine)

40
ALZHEIMERS DISEASECAREGIVERS
  • IDENTITY OF CAREGIVERS
  • Spouse
  • Adult Childern
  • SPECIAL STRESS
  • Spouse may be older in ill health
    role reversals increased work
  • Adult Childern often working own
    family childern

41
ALZHEIMERS DISEASECAREGIVER BURDEN
  • AD CAREGIVERS SPEND 69-100 HRS/WK PROVIDING
    CARE
  • AD CAREGIVER REPORT MORE
  • 40 MORE MD VISITS
  • 70 MORE PRESCRIBED DRUGS
  • MORE HOSPITALIZATIONS
  • 50 AT RISK FOR DEPRESSION

42
ALZHEIMERS DISEASECAREGIVER ADJUSTMENT
  • DENIAL
  • OVER INVOLVEMENT
  • ANGER
  • GUILT
  • ACCEPTANCE

43
ALZHEIMERS DISEASEPROFESSIONAL RESPONSIBILITIES
  • RECOGNIZE CAREGIVERS STRESS
  • ACKNOWLEDGE CAREGIVERS FEELINGS
  • REFER TO SUPPORT GROUPS
  • REFER TO PROFESSIONALS
  • PROVIDE EDUCATION
  • BE AVAILABLE

44
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