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The Memory Spectrum: Is it Alzheimer’s Disease?

Helle Brand, PABanner Alzheimer’s Institute

Normal Aging

DEMENTIA

MildCognitive

Impairment(MCI)

Time

Mem

ory

Fun

ctio

nThe Memory Spectrum

Memory Complaints in Normal Adults

Situation Percentage of elderlyNames 83 %Where I put things 60 %Knowing I have told someone 49 % somethingForgetting a task after starting 41 %Losing the thread of conversation 40 %

From: Boller et al, Arch Neurol 1991

Aging, memory and intellect

Verbal IQ

Vocabulary

Store of information

Comprehension

Speed of memory retrieval

Speed of processing

Multi-tasking ability

Memory-formation

efficiency

Don’t change Decrease

Types of Memory

Short termLong termMotor learning

These depend on different regions within the brain.

Brain memory regions

Brain changes with aging

Brain weight: decreases by about 0.5% per year after age 30

Neuron loss: region-specific

10-25% loss in cerebellum, cortex, hippocampus, substantia nigra

Loss of synapses (connections between neurons)

Mild degree of Alzheimer-type pathology

MRI Brain: Normal vs. AD

Age-Associated Cognitive Impairment

Loss of memory for words and namesSlowed processing speedDifficulty sustaining attention when faced with competing environmental stimuliNo functional impairment

Mild Cognitive Impairment (MCI)

Transitional state /evolving construct

Cognitive impairment greater than expected for age: Memory complaint corroborated by an informant Normal general cognitive function Normal activities of daily living Memory impairment for age and education criteria for dementia not met

Petersen, 2000

Outcome of an ‘MCI Diagnosis’

Increased risk for the development of AD within the next few yearsRates of conversion to AD:

MCI: 10-15% per yearNormal elderly – 1-2% per year

Amnestic MCI

Alzheimer’s disease

Mild CognitiveImpairment

Normal AgingNormal Aging

No change over time

Other dementias

Dementia

This term does not define a cause and is not a diagnosis!Progressive decline in cognitive functionDecline in functional abilityDue to damage or disease in the brainMany different causes

AD: most common dementia in the elderly

Clinical Presentation of Dementia

Cognition Function

Behavior

Progression of Dementia

Typically progresses over 7 – 10 yearsOften described using “stages”

Mild, Moderate, Advanced (Severe)Early , Middle, Late Stage

Has become the 6th leading cause of death among older peopleRequires different strategies and services along the way

Top 10 warning signs:

1. Changes in memory disrupting daily life: forgetting recently learned information; repetitive questioning; forgetting dates or events; relying on notes or others to remember things formerly handled on their own

2. Challenges in planning or in solving problems, difficulty concentrating and taking longer to do things they did before : can’t remember or follow a recipe, can’t track or pay bills

3. Difficulty completing familiar tasks at home, work, or leisure: trouble driving to familiar location, playing a game, keeping up with hobbies

The warning signs, continued

4. Confusion with time or place: losing track of dates, seasons, passage of time, forget where are or how they got there. Trouble understanding if something is not happening immediately

5. Trouble understanding visual images and spatial relationships: trouble judging distances, reading, driving, judging color or contrast. May see a mirror or window and think someone else is in room

6. Problems with words when speaking or writing: Have trouble following or joining in on a conversation, forget train of thoughts. May call things by wrong name, struggle to find or substitute a word.

The warning signs, continuing

7. Misplacing things, having difficulty retracing steps: May put things in unusual places, may accuse others of taking things.

8. Diminished or poor judgment: trouble with decision making, such as when dealing with money; may pay less to personal appearance, safety, or social appropriateness. Impulsive.

9. Withdrawal from work or social activities, hobbies, work projects or sports

The warning signs, completed

10. Changes in mood and personality: can be confused, suspicious or paranoid, depressed, more fearful or anxious, more easily upset, irritable. Less apt to get out of home/comfort zone

Sound familiar?

Early (MILD) Stage Dementia

FeaturesRecent memory loss that affects job skillsDifficulty performing tasks; Problems with language; Misplacing things; Problems with abstract thinking Disorientation of time Poor/ decreased judgmentChanges in mood /behavior; Loss of initiative; Changes in personalityMay have difficulty in a crowd

TreatmentCholinesterase InhibitorManage depression and other co-existing health problems

Maintaining Independence

Early changes in AD, continued

may get lost driving or be unsure of self in new surroundingsForget appointments, family eventsLists may not make sense

Special concerns early on

Medication managementDrivingWeight lossMood, especially depressionChanging awareness and concern for safetyNeed for life planning: financial, legal

Middle (MODERATE) Stage Features

More dependent in daily living tasks

Severe memory lossFluent aphasiaDisorientation to time and

placeImpaired judgment and

problem solvingPersonality and

behavioral changes

Living with help

TreatmentCholinesterase inhibitor and/orNamendaManage mood, behavior and co-existing illness

Moderate Stage Alzheimer’s

Memory loss, confusion and attention worsen over a 2-10 year spanJudgment and problem solving a problem Loss of ability to handle complex tasks, gradual problems with taking care of selfPersonality and behavior changesIncreasing dependenceCan’t think logically, organize thoughts

The concerns with mid stage AD

Behaviors: suspiciousness, irritability, restless, loss of impulse control, seeing or hearing things not present, agitation, wandering, sleep disturbanceChanging communication/expectationsIncreasing dependence, behaviors cause increasing caregiver burden/stressSafety/Vulnerability: need 24 hour supervision

Late (SEVERE) Stage Dementia

FeaturesSevere memory lossLimited verbal abilityOrientation only to selfNo independent self-care

functionNo judgment/problem solving

skillsIncontinence (bladder/bowel)

Anticipatory comfort care

TreatmentCholinesterase inhibitor and/orNamendaComfort strategies including mood and pain

Late to End Stage Alzheimer’s

Memory loss is severe, including long termLoss of recognition of others beyond selfProblems controlling bowel/bladderFully dependent for care needsMinimal to no speechChanges in posture/walking, may not walk and/or become bed bound

Issues in advanced Alzheimer’s

Risk for fallsMay be prone to infection or skin breakdown Weight lossPotential for seizuresIncreasing sleepPlanning for death and dying: medical decision making, timely hospice referrals

Alzheimer’s disease: diagnosis

Diagnosis of exclusionHistory: the changes over timePhysical and Neurologic examsCognitive TestingLabs and Imaging StudiesBy definition: insidious onset, gradual changes in multiple domains affecting function

The treatment of Alzheimer’s

Cholinesterase inhibitors: indicated for early/mild dementia, typical side effects are nausea, vomiting, anorexia ,frequent loose stool, vivid dreams, leg cramps. Start slow, assess tolerance, maintain at best tolerated level for continued cognitive benefit.

• Aricept (donepezil) 10 mg, 23 mg• Razadyne (galantamine) 8 mg bid or 16, 24, 32 mg daily in

extended release form• Exelon, oral or patch (Rivastigmine) 6-12 mg oral, 9.5 or

13.3mg/24 hours in patch form

Namenda (memantine) (NMDA receptor antagonist); indicated for moderate stages. 10 mg bid. NEW: 24 mg daily

• Typical side effects include headache, constipation, paradoxical confusion

Other treatments: It’s not just memory

Mood/ behavioral symptoms: address environmental factors, then medication ( antidepressants, antipsychotics)Sleep disturbance: non PM formulary, no benzos. (Trazodone, Mirtazapine, Melatonin)Pain: Routine Acetaminophen

Caregiver stress

Care becomes 24/7 jobCaregivers become socially isolatedFamily dynamics a considerationAt risk for deterioration of their own health, physical and emotional statusCaregivers more often die first

Sharing the care helps

Barriers include caregiver reluctance from stoicism, guilt, promises made, perfectionism, isolationMyths persist re: financial concernsThe system makes it hard!Family dynamics are definitely part of the equation, possibly the solution!

Options to extend care

Consider a volunteer network Senior centers Day Care programs Home care agencies Alternative residences Hospice care

Hope for the future:The Alzheimer’s Prevention Initiative

1st approved study to provide prevention therapies to people at greatest genetic risk of developing ADBuilding a registry of volunteers who may be interested in participating in future prevention research in the U.S.We need YOU!www.endalznow.org or call 602-839-6900

In closing….

Remember:

The mind forgets, but the heart remembers!

Questions?