DEMENTIADEMENTIAIS 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.

DEMENTIADEMENTIAINCIDENCE: About 1-2%/year (Individuals 65 years or greater)

AGE RELATED:

60-69 yrs.: 0.13%

70-79 yrs.: 0.74%

>80 yrs.: 2.17%

DEMENTIADEMENTIAPREVALENCE: 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%

>85 yrs.: about 50%

OVERALL: 4-5 Million: ALABAMA 79,000

OTHER FACTS ABOUT OTHER FACTS ABOUT ALZHEIMER’S DISEASEALZHEIMER’S 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

OTHER FACTS ABOUT OTHER FACTS ABOUT ALZHEIMER’S DISEASEALZHEIMER’S 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

DEMENTIADEMENTIAPHYSICIAN’S OBLIGATIONPHYSICIAN’S OBLIGATION

DIAGNOSIS

MANAGE

EDUCATE

RECOGNIZE

DEMENTIADEMENTIAMAKING THE DIAGNOSISMAKING THE DIAGNOSIS

HISTORY OF MEMORY PROBLEM

DOCUMENTATION OF MEMORY PROBLEM

NEUROLOGICAL EXAMINATION

DEMENTIADEMENTIACOGNITIVE IMPAIRMENTCOGNITIVE IMPAIRMENT

MINI-MENTAL STATE EXAM

CATEGORY GENERATION

MATH

REASONING

LANGUAGE

SPATIAL ABILITIES

DEMENTIADEMENTIACOGNITIVE IMPAIRMENTCOGNITIVE IMPAIRMENT

MINI-MENTAL STATE EXAM

ORIENTATION: 10 POINTS

IMMEDIATE RECALL: 3 POINTS

ATTENTION: 5 POINTS

DELAYED RECALL: 3 POINTS

HIGHER COGNITIVE FUNCTION: 9 POINTS

DEMENTIADEMENTIACOGNITIVE IMPAIRMENTCOGNITIVE IMPAIRMENT

MINI-MENTAL STATE EXAM

CATEGORY GENERATION

MATH

REASONING

LANGUAGE

SPATIAL ABILITIES

DEMENTIADEMENTIAPOTENTIALLY REVERSIBLE POTENTIALLY REVERSIBLE CAUSESCAUSES

STRUCTURAL BRAIN LESIONS

METABOLIC DISORDERS

CNS INFECTIONS

PSYCHIATRIC ILLNESSES

SUBSTANCE ABUSE

MEDICATIONS

DEMENTIADEMENTIAIRREVERSIBLE CAUSESIRREVERSIBLE CAUSES

ALZHEIMER’S DISEASE

DIFFUSE LEWY BODY DISEASE

FRONTO-TEMPEROL DEMENTIA

PARKINSON’S DISEASE

VIRAL AND PRION INFECTION

MULTIPLE STROKES

OTHER

DEMENTIADEMENTIALABORATORY EVALUATIONLABORATORY EVALUATION

BLOOD COUNTS & CHEMISTRIES

THYROID PANEL, B12, RPR

CRANIAL IMAGING (CT/MRI)

?PET/SPECT

NEUROPSYCH. TESTING

?LP?

PSYCHIATRIC EVALUATION

                                                                                                      

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).

MRI OF AD

PETPET SCAN ADSCAN AD

ALZHEIMER’S DISEASEALZHEIMER’S DISEASEEARLY PHASEEARLY PHASE

SHORT TERM MEMORY LOSS

LANGUAGE DIFFICULTY (naming)

PSYCHIATRIC DISTURBANCES (irritability/personality change)

PRESERVATION OF SOCIAL GRACES

SUPERIFCIALLY APPEAR NORMAL

ALZHEIMER’S DISEASEALZHEIMER’S DISEASEMIDDLE PHASEMIDDLE PHASE

INREASING INTELLECTUAL FAILURE

INCREASING APRAXIAS

SOCIAL WITHDRAWAL

INCREASING MEMORY PROBLEMS

INCREASING LANGUAGE PROBLEMS

SPATIAL & VISUAL AGNOSIAS

BEHAVIORAL PROBLEMS

ALZHEIMER’S DISEASEALZHEIMER’S DISEASELATE PHASELATE PHASE

LOSS OF RECOGNITON OF SELF & ENVIRONMENT

CHAIR/BED BOUND

DOUBLY INCONTINENT

FEEDING DIFFICULTIES

MUTE

ALZHEIMER’S DISEASEALZHEIMER’S DISEASEATYPICAL ATYPICAL PRESENTATIONSPRESENTATIONS

DOMINANT HEMISPHERE: APHASIA

WORD FINDING & HESISTENCY

PARAPHASIAS & NEOLOGISMS

NON-DOMINANT HEMISPHERE:

DRESSING APRAXIA

VISUAL AGNOSIAS

CONSTRUCTIONAL APRAXIA

ALZHEIMER’S DISEASEALZHEIMER’S DISEASEOTHER SIGNS & OTHER SIGNS & SYMPTOMSSYMPTOMS

PARKINSONISM

SEIZURES

MYOCLONUS

ALZHEIMER’S DISEASEALZHEIMER’S DISEASECRITERIA FOR DIAGNOSISCRITERIA 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)

ALZHEIMER’S DISEASEALZHEIMER’S DISEASEPATHOLOGICAL CHANGESPATHOLOGICAL CHANGES

VULNERABLE AREAS

Hippocampus

Association Cortex

Amygdala

Nucleus Basalis

Locus Cerulerous

Raphe Nuclei

ALZHEIMER’S DISEASEALZHEIMER’S DISEASEMICROSCOPIC PATH.MICROSCOPIC PATH.

NEUROFIBILLARY TANGLE

NEURITIC PLAQUE

AMYLOID PROTEINS

APP METABOLISMAPP METABOLISM

ALZHEIMER’S DISEASEALZHEIMER’S DISEASEPATHOLOGICAL PATHOLOGICAL MECHANISMSMECHANISMS

AMYLOID HYPOTHEISIS

NEUROFIBILLARY TANGLE HYPOTHESIS

FREE-RADICAL MECHANISMS

INFLAMMATORY MECHANISMS

CHOLINERGIC LOSS

CHOLESTREROL/ STATINS?

ALZHEIMER’S DISEASEALZHEIMER’S DISEASERISK FACTORSRISK 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

DOWN’S SYNDROME

All get Pathological Changes of AD ; 30-50% develop Dementia

ALZHEIMER’S DISEASEALZHEIMER’S DISEASERISK FACTORSRISK 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

ALZHEIMER’S DISEASEALZHEIMER’S DISEASEGENETICSGENETICS

AUTOSOMAL DOMINANT TRANSMISSON

EARLY ONSET : <65 YEARS

CHROMOSOME 1: Volga Germans; Presenilin 2

CHROMOSOME 14: 70%; Presenilin 1

CHROMOSOME 21: 5-10%

LATE ONSET: >65 YEARS

CHROMOSOME 19 families

ALZHEIMER’S DISEASEALZHEIMER’S DISEASEGENETICSGENETICS

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

ALZHEIMER’S DISEASEALZHEIMER’S DISEASEMEDICATIONSMEDICATIONS

CHOLINESTERASE INHIBITORS

Aricept (Donepezil)

Exelon (Rivastigimine)

Razadyne IR , ER (Reminyl; Galantamine)

NMDA RECEPTOR INHIBITORS Namenda (Memantine)

ALZHEIMER’S DISEASEALZHEIMER’S DISEASECAREGIVERSCAREGIVERS

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

ALZHEIMER’S DISEASEALZHEIMER’S DISEASECAREGIVER BURDENCAREGIVER 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

ALZHEIMER’S DISEASEALZHEIMER’S DISEASECAREGIVER CAREGIVER ADJUSTMENTADJUSTMENT

DENIAL

OVER INVOLVEMENT

ANGER

GUILT

ACCEPTANCE

ALZHEIMER’S DISEASEALZHEIMER’S DISEASEPROFESSIONAL PROFESSIONAL RESPONSIBILITIESRESPONSIBILITIES

RECOGNIZE CAREGIVERS STRESS

ACKNOWLEDGE CAREGIVERS’ FEELINGS

REFER TO SUPPORT GROUPS

REFER TO PROFESSIONALS

PROVIDE EDUCATION

BE AVAILABLE