John Stoukides MDChief, Division of Geriatrics and Palliative MedicineRoger Williams Medical CenterProvidence, R.I.

The Far Reaching Impact of ADPatient

4 million affected Increasing with aging population 70% live at home

Family Loss of productivity of caregivers Painful process Significant incidence of depression and

medical illnessSociety

$100 Billion / year

Impact of Alzheimer’s Disease on Caregivers More than 70% of patients with

Alzheimer’s disease live at home, and almost 75% of home care is provided by family and friends1

46% to 59% of caregivers reported depression, according to various studies2,3

1. Alzheimer’s Association. Available at: http://www.alz.org. Accessed October 7, 2004.2. Gallagher D et al. Gerontologist. 1989;29:449-456.3. Cohen D et al. Behavior, Health and Aging. 1990;1:171-182.

ALZHEIMER’SANNUAL COST TO U.S.

Heart Disease $ 183 Billion Diabetes 112

Cancer 109 Stroke 45 Pulmonary Disease 24 Pneumonic Influenza 22 Chronic Liver Disease 9 HIV/AIDS 7

Alzheimer’s 110

Alzheimer’s average cost to each family is$25,000/ year and 100 hours/week.

Dementia - Definition

An unusual loss of mental function Acquired, persistent impairment in

multiple areas of intellectual function not due to delirium.

A symptom of many diseases, not a diagnosis

Differential Diagnosis of Dementia

AD

Vascular dementiasMulti-infarct dementiaBinswanger’s disease

Vascular dementiasand Alzheimer’s disease (AD)

AD and Lewy body dementias

Lewy body dementiasParkinson’s diseaseDiffuse Lewy body diseaseLewy body variant of AD

Other dementias

Frontal lobe dementiaCreutzfeldt-Jakob diseaseCorticobasal degenerationProgressive supranuclear

palsyMany others

Adapted with permission from Zurad E. Drug Benefit Trends. 2001;13:27-40.

5%5% 10%10% 65%65% 8%8% 7%7% 5%5%

Normal Brain

Alzheimer’s Brain

Beginning Symptoms of AD

Progressive memory loss recent events including time and place

Difficulty with complex tasks Inability to use reasoning strategies Problems finding words Disorientation to location and

direction Have difficulty reorienting them

selves to recent event Depression

Mid-Stage Alzheimer’s Disease Requires assistance with activities of daily living Language and communications degrade Impaired judgment Emotional instability Psychiatric instability Personal hygiene decreases Inappropriate responses Unaware of surroundings Trouble distinguishing people - familiar vs.

strangers Are mostly unaware of their cognitive loss

Late Stage Alzheimer’s Disease

Agitation, depression, delusions diminishNeed for tranquilizers lessenedBrain activity severely disruptedVulnerable to seizures, aspirations and

pneumoniaMotor skills deteriorate

Lose ability toWalkCommunicateChew and swallow

Assume fetal position Ultimate outcome - death

MILD MODERATE SEVEREMILD MODERATE SEVERE ADVANCED ADVANCED

MEMORYMEMORYPERSONALITYPERSONALITYSPATIALSPATIALDISORIENTATIONDISORIENTATION

APHASIAAPHASIAAPRAXIAAPRAXIACONFUSIONCONFUSIONAGITATIONAGITATIONINSOMNIAINSOMNIA

RESISTIVENESSRESISTIVENESSINCONTINENCEINCONTINENCEMOTOR MOTOR IMPAIRMENTIMPAIRMENT

BEDFASTBEDFASTMUTEMUTENO MEMORYNO MEMORY

TIMETIME

IINNDDEEPPEENNDDEENNCCEE

EATING EATING PROBLEMSPROBLEMS

RECURRENT RECURRENT INFECTIONSINFECTIONS

??

??INSTITUTIONALIZATIONINSTITUTIONALIZATION

DRIVINGDRIVING

†

Delirium in the Elderly

Acute decline in attention and cognition Potentially life threatening Preventable in most cases

Accounts for 49% of all hospital days in pts over 65

Complicates 20% of all hospital admissions

Precipitating factor in most hospitalizations

Associated with very high mortality rate Is a medical emergency

Clinical Features

Acute onset Fluctuating course Inattention(difficulty focusing, sustaining attention,

maintaining conversation)

Disorganized thinking (disorganized or incoherent speech rambling or irrelevant or illogical)

Altered level of consciousness Cognitive deficits Perceptual disturbances

Psychomotor changes Hyperactive Delirium: agitation, hyper-

vigilance, inappropriate excitement and perceptual disturbances

Hypoactive Delirium: reduced motor activity, inattentive, easily distracted and unable to sustain a train of thought.

Additional Features

Various Emotional Disturbance Fear Depression Euphoria perplexity

Baseline Characteristics Vulnerability Advanced age Organic Brain disease (stroke, dementia,

PD) Acute Medical Illness Sensory Impairment Diminished ADL’s (activities of daily living) Polypharmacy Alcohol Use Medication misuse Toxin ingestion

Precipitating Factors

Addition of more than three medications to medical regimen

Infection Dehydration Immobility (restraints) Malnutrition Temperature extremes

Examples of symptoms

You ask the person for his phone number after probing it is clear he doesn’t know it

Memory impairment

During the interview the person dozes off while you are asking questions

Alerted level of consciousness (lethargy)

As you ask a question the person keeps repeating the answer from a previous question

inattention

Examples of symptoms

The person is in a restaurant for breakfast and angrily says “why the F%@$ are they giving me eggs for dinner”

Disorientation

Person startles easily at any sound or touch, eyes open wide

ALOC vigalant

You ask why the person is stopped is sitting in their car and he says “I’ve gotta get to the yellow brick road”

Disorganized thinking

Examples of symptoms

As you interview the person she keeps looking at the corner then blurts out “what is that man doing there”

Perceptual disturbance (visual hallucinations)

As you begin the interview the person is looking around the room. You call her name and touch her she momentarily looks at you then starts looking around again

Inattention

Examples of symptoms

You introduce yourself and he says what are you doing in my home

Disorientation

You walk into the room and the person says “lucy where have you been, You said you’d be right back”

Disorientation

During the encounter the person is continuously fidgeting, dressing and undressing himself

Psychomotor agitation

Examples of symptoms

Between questions the person is carrying on a conversation with her husband who is not present

Perceptual disturbance (auditory hallucinations)

You ask the person if she is able to call a family member and she says “it depends on the type of party I’m at: I need a comb”

Disorganized thinking

The person remains motionless in a chair and performs tasks very slowly

Psychomotor retardation

Helping Patients with Troublesome Behaviors Patients with significant cognitive

impairment in most cases can not be reality oriented

Patients with agitation should be considered acutely medically ill until proven otherwise

Pacify and re-direct is usually best approach

Conclusion

Alzheimer’s disease is a extremely common and unfortunately incurable condition in the elderly

It has a slow steady progression, acute changes in it’s course frequently represent an acute medical illness

Alzheimer’s patients have an inability to accurately report reality or be reoriented to their current situation

Confronting an Alzheimer’s patient will frequently escalate the unwanted behaviors.