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Abnormal Brain Changes

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Title: Abnormal Brain Changes


1
Abnormal Brain Changes
  • What happens when something goes wrong..

2
Objectives
  • Identify manifestations of abnormalities in brain
    function associated with aging.
  • Explore interventions and treatments to maximize
    functioning when pathology is present.

3
The Three Ds
  • Delirium
  • Depression
  • Dementia

4
Delirium
  • Delirium is often unrecognized
  • Delirium might be the only indication of a life
    threatening condition
  • Extremely important to identify

5
Delirium
  • Approximately 14-80 of hospitalized elderly
    patients experience an episode of delirium
  • Can represent a medical emergency and is a
    potentially reversible condition
  • Requires immediate interventions to prevent
    permanent disability and health risks including
    death

6
Delirium in older adults results in
  • increased length of hospitalization and increased
    hospital mortality rates of approximately 25-33
  • greater intensity of nursing care
  • more frequent use of physical restraints
  • greater in-hospital functional decline
  • greater health care costs
  • worse outcomes in severe delirium especially at 6
    months (e.g., ADL and ambulatory decline, nursing
    home placement and death)

7
Delirium DSM-5
  • Disturbance in attention (reduced ability to
    direct, focus, sustain, and shift attention) and
    awareness (reduced orientation to environment)
  • Develops over a short period of time, a change
    from baseline, fluctuates during the course of a
    day

8
Delirium DSM-5
  • An additional disturbance in cognition (memory
    deficit, disorientation, language, visuospatial
    ability, or perception)
  • The disturbances are not better explained by
    another preexisting, established, or evolving
    neurocognitive disorder

9
Delirium DSM-5
  • Evidence from history, physical exam, or lab
    findings that the disturbance is a direct
    physiological consequence of another medical
    condition, substance intoxication or withdrawal,
    or exposure to a toxin, or is due to multiple
    etiologies

10
Confusion Assessment Method (CAM)
  • 1) Acute onset and fluctuating course
  • 2) Inattention
  • 3) Disorganized thinking
  • 4) Altered level of consciousness
  • Delirium requires the presence of 1 and 2 plus
    either 3 or 4

11
Types of Delirium
  • Hyperactive
  • Agitated
  • Restless
  • Yelling
  • Hypoactive
  • Inactivity
  • Withdrawal
  • Mixed

12
Hypoactive Delirium
  • Hardest to recognize
  • May look like depression
  • Subdued, quiet
  • Extremely important to recognize and look for
    medical cause

13
Delirium Causes and Risks
  • Chronological age very young and very old
  • Sensory deficits
  • Dehydration
  • Sleep disturbances
  • Pre-existing dementia
  • Cognitive impairment
  • Immobility or use of restraints
  • Medicationsanticholinergic meds
  • Metabolic abnormalities
  • Comorbidities
  • Presence of urinary catheter
  • Under and over treatment of pain
  • Withdrawal

14
Treatment of Delirium
  • First have to recognize it
  • Search for underlying cause
  • Environment conducive for orientation
  • Maintain safety and comfort
  • Encourage mobility avoid bedrest
  • Environment conducive for sleep
  • Optimize hearing and vision
  • Avoid dehydration
  • Avoid catheters
  • Avoid deliriogenic medications
  • Maximize the familiar and avoid distractions

15
Depression
  • Most common psychiatric condition affecting older
    adults
  • Common cold of psychiatry
  • Leading cause of disability in the US and the
    world (NIMH)
  • Often under-diagnosed and under-treated

16
Important to recognize depression because
  • Robs elderly of late life satisfaction
  • Causes impairment in cognitive, social and
    personal functioning
  • Involves undue suffering for patient and often
    their family
  • Causes excess morbidity and mortality
  • Could be a symptom of an underlying medical
    condition

17
Important to recognize depression because
  • Increased risk of suicide
  • Increased economic burden
  • Could lead to substance abuse or misuse
  • Treatment is often very effective

18
Depression
  • In older adults, depression may mask, or be
    masked by, other physical disorders.
  • Is difficult to disentangle depression from the
    many other disorders affecting older people

19
Statistics
  • Of the 35 million over age 65 in US, 2 million
    meet criteria for major depression and another 5
    million have depressive symptoms
  • One primary care study found that 11 of
    depressed patients were adequately treated, 34
    were inadequately treated, and 55 received no
    treatment.

20
Criteria for Major Depression
  • At least 5 symptoms must be present in the same
    2-week period and must include either
  • 1) Depressed mood
  • 2) Loss of interest or pleasure

21
Major Depression
  • 3) Change in appetite or weight
  • 4) Insomnia or hypersomnia
  • 5) Psychomotor agitation or retardation
  • 6) Fatigue or loss of energy
  • 7) Feelings of worthlessness or guilt
  • 8) Difficulty with thinking or concentration
  • 9) Thoughts of death or suicide

22
Low Mood
  • Elderly may not admit or report sadness
  • In general, elderly are less verbal about
    feelings
  • May be masked by somatic complaints
  • Common are headache, nausea, constipation,
    anorexia, Just dont feel well, GI upset, pain
  • Preoccupation with physical health

23
Decreased Interest
  • Less interest in hobbies or recreational
    activities
  • Daily chores left undone
  • Social withdrawal
  • Less interest in sex
  • May neglect personal hygiene or appearance
  • Less able to experience pleasure

24
Appetite Changes
  • Most often, decreased appetite but may be
    increased
  • Monitor weight
  • May complain that food has no taste
  • At risk for dehydration, electrolyte imbalance,
    and malnutrition

25
Sleep Disturbance
  • Insomnia or hypersomnia
  • Early morning awakening
  • Middle insomnia
  • Waking too early

26
Psychomotor symptoms
  • Agitation restlessness, irritable, appear
    anxious and distressed, hand wringing
  • Slowness in movement, slowed speech, latency of
    response

27
Lack of energy
  • Tired and worn out
  • Everything is just too much effort
  • Poor time management
  • Apathetic
  • Its too much work.

28
Feelings of worthlessness/guilt
  • Blames self for things done and undone
  • Feelings of being of no value
  • Hopelessness, worry
  • Future is bleak
  • Self-reproach, critical of self and others
  • Dont spend time with me Im not worth it.
  • May be delusional

29
Difficulty with concentration
  • Slowed thinking
  • Inability to focus or concentrate
  • Indecisive
  • Feels confused and bewildered
  • Ruminations about insignificant problems
  • Negativity

30
Thoughts of death or suicide
  • Weary of life
  • Life isnt worth living
  • Id be better off dead.
  • Youd be better off if I werent here.
  • Passive suicide
  • Refuse to eat
  • Refuse medications

31
Causes of Depression
  • Interaction of biological and psychosocial
    factors
  • Possible genetic contribution
  • Reaction in response to losses
  • Unresolved grief
  • Physical illnesses may lead to depression
  • Medications may cause symptoms of depression

32
Interventions for Depression
  • Involve the persons family
  • Obtain an evaluation by a professional
  • Every interaction has the potential to help
  • Communicate a caring attitude
  • Support and encourage
  • Provide opportunity for social interactions
  • Involve in scheduled or structured activities
  • Spend time with the person and listen

33
Interventions for Depression
  • Encourage physical activity
  • Mobilize support systems
  • Monitor physical health
  • Medication monitoring
  • Nutrition and weight
  • Sleep
  • Comfort and relaxation
  • Management of pain
  • Beware of being too cheerful

34
Interventions for Depression
  • Antidepressant medications take time to exert a
    therapeutic effect
  • Monitor for suicidal thoughts, especially as
    depression starts to improve
  • Promote a positive attitude toward the future
    I know that you feel this way now, but you wont
    always.
  • Remember that depression is usually very
    treatable over time

35
Anxiety
  • A subjective state of dysphoric apprehension or
    expectation accompanied by physiological
    responses
  • Symptom of many disorders including depression,
    dementia, delirium
  • Primary symptom of anxiety disorders

36
Symptoms of Anxiety
  • Excessive worry that person finds difficult to
    control
  • Complaints of shakiness, restlessness,
    jitteriness, jumpiness, trembling, tension,
    irritability, impatience, poor concentration,
    memory problems, unrealistic fears
  • Feeling of impending doom
  • Anticipation of the worst that could happen

37
Symptoms of Anxiety
  • Physical symptoms including
  • palpitations, chest pain
  • dizziness, lightheadedness
  • tingling, numbness
  • stomach upset, diarrhea
  • too hot or too cold, sweating
  • shortness of breath, sensation of lump in throat
    or choking
  • sleep disturbance

38
Potential Causes of Anxiety
  • Medical illnesses
  • hypoglycemia, hyperthyroidism
  • Medications
  • caffeine, stimulants, sympathomimetics
  • Withdrawal states
  • alcohol, benzodiazepines
  • Situational anxiety
  • going to a dentist, flying

39
Anxiety Disorders
  • Panic disorder
  • Agoraphobia
  • Phobias
  • Obsessive-Compulsive disorder
  • Posttraumatic stress disorder
  • Acute stress disorder
  • Generalized anxiety disorder

40
Interventions for Anxiety
  • Minimize caffeine
  • Social interaction
  • Relaxation techniques
  • Diversion and recreational activities
  • Physical exercise
  • Counseling or psychotherapy
  • Medication, if use is justified

41
DSM 5 Neurocognitive Disorders
  • Minor Neurocognitive Disorder
  • Major Neurocognitive Disorder

42
DSM-5 Cognitive Domains
  • Complex attention (Sustained and divided
    attention, processing speed)
  • Executive ability (Planning and decision making)
  • Learning and memory (Recall and recognition)
  • Language (Expressive and receptive)
  • Visuoconstructional-perceptual activity
    (Construction and visual perception)
  • Social cognition (Emotions and behavioral
    regulation)

43
Minor Neurocognitive Disorder
  • Evidence of minor cognitive decline from a
    previous level of performance
  • Deficits not sufficient to interfere with
    independence
  • Deficits do not occur exclusively in context of
    delirium

44
Major Neurocognitive Disorder
  • Greater cognitive deficits in at least one
    (typically 2 or more) cognitive domains
  • Evidences of significant cognitive decline from
    previous level of performance
  • Deficits sufficient to interfere with
    independence
  • Deficits do not occur exclusively in context of
    delirium

45
Alzheimers Disease
  • A chronic, progressive, irreversible,
    neurological disorder affecting memory,
    cognition, ability to function, personality,
    language, and behavior

46
Three Stages of Alzheimers Disease
  • Preclinical pathophysiological changes in the
    brain, but cognitively normal
  • Mild cognitive impairment due to AD clinical
    and research criteria
  • Dementia due to Alzheimers Disease Possible,
    Probable, Probable with evidence of AD
    pathophysiology

47
Biomarkers used in research
  • Cerebral spinal fluid
  • Phospho-tau concentration elevated
  • Amyloid beta (1-42) peptide reduced
  • AT Index lt1 consistent with Alzheimers
  • PET scan with special imaging agent
  • Demonstrates amyloid burden
  • Blood or urine tests not available yet

48
Alzheimers Disease
  • Alzheimers is the most common form of dementia
  • 5.4 million people in US have DAT
  • 1 in 8 elderly has DAT
  • About 500,000 Americans lt65 years old have a
    dementia 40 of those have DAT
  • Alzheimers is the 6th leading cause of death in
    the US

49
Pathophysiological Changes
  • Neurofibrillary tangles
  • Amyloid plaques
  • Cerebral atrophy

50
Brain Functions Affected
  • Short-term memory
  • - Hippocampus involved
  • Cant make deposits into memory bank
  • Like a computer with a faulty save function
  • Floating reference point for time

51
Brain Functions Affected
  • Memory
  • Judgment and decision making
  • Abstract thinking
  • Inhibition control
  • Organizational skills
  • Motivation and attention

52
Brain Functions Affected
  • Personality stability
  • Emotions
  • Language
  • Praxis
  • Visual spatial skills

53
Vascular Dementia
  • Sudden onset
  • Step-wise progression
  • Focal neurological signs and symptoms
  • Evidence of cerebrovascular disease on brain
    imaging
  • History of hypertension, diabetes, dyslipidemia,
    atrial fib, smoking, prior TIAs or stroke

54
Small Vessel Cerebrovascular Disease
  • Likely accounts for 75 of vascular dementia
    cases
  • Affects small arterioles, venules and
    capillaries in the brain
  • Hypertension is a major risk factor
  • Seen on MRI as small focal areas of infarction,
    hyperintensities, microbleeds, or enlarged
    perivascular spaces
  • Subacute symptoms include cognitive impairment
    (executive dysfunction, slowing of psychomotor
    speed, memory problems), mood disorders, gait
    disturbances

55
Vascular Dementia
  • Progression less predictable
  • Focus on stroke prevention
  • Manage hypertension
  • Treat diabetes
  • Lipid lowering agents
  • Alzheimers drugs generally not beneficial

56
Lewy Body Disease
  • Memory impairment evident with progression, but
    not always early
  • Abnormal proteinaceous (alpha-synuclein)
    cytoplasmic inclusions called Lewy bodies develop
    in cells throughout the brain

57
Dementia with Lewy Bodies Diagnostic
Criteria
  • Progressive dementia deficits in attention,
    executive function, memory, language and visual
    spatial abilities
  • Two of three core features
  • Parkinsonism
  • Recurrent visual hallucinations
  • Fluctuating attention and concentration
  • Dementia onset before or within one year of
    parkinsonism onset

58
Dementia with Lewy Bodies Diagnostic
Criteria
  • Supportive Features
  • REM sleep behavior disorder
  • Antipsychotic medication sensitivity
  • Syncope
  • Repeated falls
  • Autonomic dysfunction
  • Complex delusions

59
Parkinsons Disease
  • Tremor at rest
  • Rigidity
  • Bradykinesia
  • Postural instability
  • Usually asymmetric onset of symptoms
  • Dementia in 20 60

60
Parkinsons Plus Syndromes
  • Multiple System Atrophy
  • Corticobasal Degeneration
  • Progressive Supranuclear Palsy
  • FTD with Parkinsonism

61
Frontotemporal Dementia
  • A neurodegenerative disorder affecting the
    frontal and/or temporal lobes of the brain that
    presents predominantly with behavioral or
    language disturbance, with relative preservation
    of memory and spatial skills early in the illness

62
Frontotemporal Dementia
  • -Earlier age of onset - 50 before age 65
  • -Survival 6.6 10 years after symptoms onset
  • -Personality changes and decline in social skills
  • -Impaired executive functions
  • -Emotional blunting apathy
  • -Behavioral disinhibition bizarre behavior
  • -Language changes
  • -Prominent temporal and/or frontal atrophy

63
Frontotemporal Dementia - Types
  • Behavioral variant prominent changes in
    behavior and personality
  • Progressive nonfluent aphasia expressive
    language changes
  • Semantic dementia cant understand words or
    recognize familiar people and objects

64
Frontotemporal Disorders Core
Diagnostic Features
  • Insidious onset and gradual progression
  • Early decline in social interpersonal conduct
  • Early impairment in regulation of personal
    conduct
  • Early emotional blunting
  • Early loss of insight

65
Frontotemporal Disorders Supportive
Features
  • Decline in personal hygiene and grooming
  • Mental rigidity and inflexibility
  • Distractibility and impersistance
  • Hyperorality and dietary changes
  • Perseverative and stereotyped behavior
  • Utilization Behavior
  • Speech and language changes

66
Creutzfeldt-Jakob Disease
  • Rapidly progressive, fatal
  • Cognitive and behavioral changes
  • Loss of coordination
  • Myoclonus
  • Spongiform changes in frontal cortex
  • A type of prion disease misfolded proteins

67
Huntingtons Disease
  • Autosomal dominant pattern of inheritance
  • Defect of chromosome 4
  • Basal ganglia affected
  • Movement and coordination affected
  • Loss of intellectual abilities and emotional and
    behavioral disturbances

68
Traumatic Dementia
  • Subdural hematoma
  • Traumatic brain injury
  • Hypoxemic anoxia

69
Toxic Disorders
  • Alcohol/substance abuse
  • Heavy metals
  • Carbon monoxide poisoning
  • Drugs

70
Infectious and Inflammatory Diseases
  • AIDS dementia
  • Viral encephalitis
  • Bacterial meningitis
  • Neurosyphilis

71
Normal Pressure Hydrocephalus
  • Dementia
  • Ataxia
  • Urinary Incontinence
  • Wild, wet, and wacky

72
It is important to know what PERSON the disease
has, not what disease the person has. -Sir
William Osler 1849-1919
73
Memory
  • Difficulty learning new things
  • Misplaces items
  • Forgets to tend to appliances
  • Trouble following recipes/directions
  • Cant remember the date/time
  • Trouble recalling recent events or conversations
  • Forgets to pay bills or repays
  • Trouble following plot in stories or on TV

74
Interventions for Memory Loss (Early)
  • Use calendars, notes, reminders
  • Write important information
  • Repeat explanations or directions
  • Try to limit distractions and simplify
  • One specific location for keys, glasses,
    important items
  • Supervise medications, finances, and for safety
    needs

75
Interventions for Memory Loss (Later)
  • Provide reminder cues in conversations or in the
    environment
  • Try to endure repetitiveness
  • Help locate missing items
  • Monitor appetite and weight
  • Dont force reality orientation
  • Discuss positive memories from the past

76
Brain Functions Affected
  • Judgment and decision making
  • Abstract thinking
  • Inhibition control
  • Organizational skills
  • Motivation and attention

77
Judgment and Decision Making
  • Loss of sense of risk and danger
  • Financial vulnerability
  • Difficulty problem-solving
  • May appear more dependent and indecisive
  • May trust strangers or be inappropriately
    familiar
  • Unable to prioritize activities

78
Interventions for Impaired Judgment
  • Identify surrogate decision maker/s
  • Avoid extended logical explanations
  • Set limits on unrealistic demands
  • Anticipate safety needs and safety proof
    surroundings
  • Avoid situations where failure is likely
  • Use distraction rather than confrontation
  • Maintain the persons integrity

79
Abstract Thinking
  • Takes more time to understand
  • Difficulty with time relationships
  • Trouble with calculations and money
  • Unable to figure out complex problems
  • Poor interpretation of social cues
  • Change in sense of humor

80
Interventions for Concrete Thinking
  • Allow time to process verbal communication
  • Be alert for misunderstandings
  • Interpret what is occurring in the environment
  • Help identify the function of objects
  • Use discretion with humor

81
Inhibition Control
  • More impulsive desires immediate gratification
  • Frustrated easily quick to react
  • May make hurtful/insensitive comments
  • May have inappropriate social behavior
  • Possibility for sexual disinhibition

82
Interventions for Disinhibition
  • Anticipate needs and possible overreaction
  • Maintain a calm environment
  • Dont take insensitive comments personally
  • Use a matter of fact approach for socially
    inappropriate behavior
  • Assist in covering social mistakes

83
Organizational Skills
  • Unable to plan, organize, sequence activities
  • Dont remember how to get started on tasks
  • May appear apathetic or disinterested
  • Trouble following directions

84
Interventions for Disorganization
  • Simplify the environment
  • Continue with familiar routine
  • Provide structured activities, but be flexible
  • Break tasks into individual steps
  • Give one-step directions
  • Inconspicuously give cues
  • Avoid sounding controlling or bossy
  • If resistive, stop and try again later

85
Motivation and Attention
  • Problems with initiation
  • Cant switch mental gears easily
  • Trouble completing tasks or gets stuck
  • Loss of mental flexibility
  • Difficulty maintaining effortful activities
  • Distractibility

86
Interventions to Enhance Attention
  • Eliminate competing stimuli in the environment
  • Provide cues and prompts
  • Plan activities that do not require sustained
    periods of concentration
  • Attempt distraction if the person is stuck
  • Plan frequent rest periods

87
Overview of Executive Dysfunction
  • Problems with
  • Stopping
  • Starting
  • Switching
  • Socialization
  • Planning
  • Judgment

88
Stopping
  • Disinhibited/impulsive
  • Blurt out socially inappropriate remarks
  • Frontal release signs (grasp reflex, palmomental
    reflex)
  • Compulsive eating
  • Unable to resist impulse to use or touch objects

89
Starting
  • Lack of motivation
  • Unable to initiate
  • Inability to maintain effortful behavior
  • Apathy

90
Switching
  • Perseveration
  • Lack of mental flexibility
  • Self management difficulty to make any change
  • Improper emotional responses

91
Socialization
  • Poor interpretation of social cues
  • Difficulties secondary to lack of motivation,
    personality changes, and uninhibited behavior
  • Insensitive to others
  • Unable to read social signals from others

92
Planning
  • Inability of volition
  • Cannot multitask
  • Non compliance because cant plan
  • Stubborn Uncooperative

93
Judgment
  • Unable to anticipate consequences
  • Cant prioritize
  • Lack empathy
  • Little or no insight

94
Brain Functions Affected
  • Personality stability
  • Emotions
  • Language
  • Praxis
  • Visual spatial skills

95
Personality Stability
  • Apathy vs irritability
  • Paranoia
  • Abnormal beliefs
  • Delusions or hallucinations
  • Fearfulness
  • Clinging/shadowing
  • Anger/frustration

96
Interventions for Personality Changes
  • Try to exhibit the desired demeanor
  • Be aware of your limits and stress level
  • Clearly identify the purpose of cares
  • Avoid arguments about abnormal beliefs

97
Emotions
  • Depression
  • Anxiety
  • Denial lack of insight
  • Labile emotions
  • Withdrawal

98
Interventions for Emotional Changes
  • Address depression if it is suspected
  • Provide environmental and interpersonal supports
    to minimize fears and anxiety
  • Distract rather than confront
  • Maintain a calm, routine, predictable environment
  • Encourage social activities

99
Language
  • Word-finding problems
  • Trouble with names talks around names
  • Loses train of thought in mid-sentence
  • Cant filter out distractions during
    conversations
  • Less use of nouns
  • May not recognize objects

100
Interventions for Communication
  • Approach slowly from the front or side and gain
    the persons attention before talking
  • Speak slowly and clearly
  • Maintain relaxed body language
  • Face the person, establish eye contact, and smile
  • Introduce yourself and call the person by name

101
Interventions for Communication
  • Eliminate distracting background noises
  • Speak in low pitched tones
  • Begin with social conversation or small talk
  • Keep sentences short
  • Keep to one clearly defined subject at a time

102
Interventions for Communication
  • Use nouns or names rather than pronouns
  • Use the same word every time to refer to common
    tasks/objects
  • Avoid open ended questions
  • Limit the number of decisions the person has to
    make
  • Accompany verbal communication with appropriate
    non-verbal cues

103
Interventions for Communication
  • Exaggerate gestures or facial expressions if
    hearing or vision impaired
  • Use gentle touch that is not task oriented
  • Break down tasks into individual steps and ask
    the person to do one at a time
  • Repeat explanations or directions as needed
  • Try to match requests to the persons current
    level of functioning

104
Interventions for Communication
  • Allow sufficient time for the person to process
    information
  • Focus on the feeling tone of the conversation
    rather than content of words
  • State positive directions limit the use of
    donts
  • Talk about pleasant memories from the past

105
Interventions for Communication
  • Try supplying a word if it is appreciated
  • Repeat the last few words to help regain train of
    thought if blocking is a problem
  • Allow word mistakes to go by unnoticed if the
    general meaning is understood
  • Inconspicuously give prompts during interactions

106
Interventions for Communication
  • Avoid quizzing or forcing a response
  • Make educated guesses of what intent could be
    if verbal statements are unclear
  • Give reassurance by making general statements if
    that provides comfort
  • Use humor appropriately

107
Praxis
-Loss of motor memory -Need more time to
complete tasks -Need assistance with daily
tasks -Dont rush well
108
Interventions for Apraxia
  • Allow more time to complete tasks
  • Provide prompts and step-by-step directions
  • Demonstrate the desired action
  • Do not rush the person

109
Visual Spatial Skills
  • Unaware of relationship to environment
  • Might fall
  • Unable to find way or gets lost
  • May wander
  • Geographic disorientation

110
Interventions for Visuospatial Changes
  • Evaluate fall risk
  • Use way finding cues
  • Use personal items to help recognize room
  • Be aware of social distance in conversations
  • Avoid abrupt movements toward the person

111
Behavioral Symptoms
  • Aggression/Agitation
  • Delusions/hallucinations
  • Depression
  • Apathy
  • Sleep disorders
  • Wandering
  • Sexually inappropriate behavior
  • Others

112
-Prevention Trial -Asymptomatic AD -65
years -Monthly IV x 3yr -Solanezumab -a4study.org
-Mild AD study -MMSE 20-26 -ages 55-90 -Monthly
IV x 18m -Solanezumab -expedition3study.com
-Moderate AD study -MMSE 12-22 -ages 55-85 -oral
med x 1yr -T-817MA -adcs.org (studies)
Current Alzheimers Trials at UNMC
Interested? Call 402-552-6241
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