Definition of DementiaDefinition of Dementia

An acquired complex of intellectual deterioration which affects at least two areas of cognitive function.

A syndrome, not a diagnosis. In the past, commonly referred to as

senility or “hardening of the arteries”

Cognitive FunctionsCognitive Functions

Memory Orientation Language Judgement

Perception Attention Ability to perform

tasks in sequence

Dementia = Brain failureDementia = Brain failure

Two basic types 1) Reversible dementias 2) Irreversible dementias

All dementias are treatable to a degree

Reversible DementiasReversible Dementias

Intoxications Infections Metabolic

disorders Major depression

Brain tumors Head injuries Normal pressure

hydrocephalus

Irreversible DementiasIrreversible Dementias

Alzheimer’s disease Multi-infarct or

vascular dementia Parkinson’s disease Lewy Body disease

Creutzfeldt-Jakob disease

Pick’s disease Huntington’s

disease AIDS dementia

complex Progressive aphasia

Diagnostic Evaluation of DementiaDiagnostic Evaluation of Dementia History from patient

and relative or friend Clinical exam Blood work: CBC,

Chem profile, Thyroid function tests, Syphilis serology, Vit B12, Folate

Brain scan, CT or MRI

If indicated: - Psychological testing - HIV - Brain biopsy - SPECT or PET scan - Lumbar puncture - EEG

Criteria for Probable Alzheimer’s DiseaseCriteria for Probable Alzheimer’s Disease Dementia established

by clinical and neuropsychological examination

Deficits in at least two areas of cognition

Progressive worsening of memory and other cognitive functions

No disturbances of consciousness

Onset between ages 40 and 90

Absence of other disorders to account for dementia

Prevalence of Alzheimer’s DiseasePrevalence of Alzheimer’s Disease More than 4 million Americans plus their

families Number doubles every 5 years after age

65 Estimated cost of $100 billion annually Numbers may triple by 2050

Prevalence of Alzheimer’s Disease by AgePrevalence of Alzheimer’s Disease by Age

0

10

20

30

40

50

%

65-74 75-84 85+

65-74

75-84

85+

SOURCE: Evans, D.A. et al. (1989). Journal of the American Medical Association. Vol. 262: 2251-2256.

Stages of Alzheimer’s diseaseStages of Alzheimer’s disease

FunctionFunction Early StageEarly StageMemory Routine loss of recent memory

Language Mild aphasia (word finding difficulty)

Orientation Seeks familiar and avoids unfamiliar

Motor Some difficulty writing and using objects

Mood and behavior Apathy & depression

Activities of Needs reminders with some ADL’s

daily living (ADL)

FunctionFunction Middle StageMiddle StageMemory Chronic, recent memory loss

Language Moderate aphasia

Orientation May get lost at times, even inside the home

Motor Repetitive actions, apraxia

Mood and behavior Possible mood and behavioral disturbances

Activities of Needs reminders and help with

daily living (ADL) most ADL’s

Stages of Alzheimer’s diseaseStages of Alzheimer’s disease

FunctionFunction Late StageLate StageMemory Mixes up past and present

Language Expressive and receptive aphasia

Orientation Misidentifies familiar persons and places

Motor Bradykinesia, at risk for falls

Mood and behavior Greater incidence of mood and behavioral disturbances

Activities of Needs reminders with all ADL’s

daily living (ADL)

Stages of Alzheimer’s diseaseStages of Alzheimer’s disease

FunctionFunction Terminal StageTerminal StageMemory No apparent link to past or present

Language Mute or few incoherent words

Orientation Oblivious to surroundings

Motor Little spontaneous movement, dysphagia, myoclonus, seizures

Mood and behavior Completely passive

Activities of Requires total care

daily living (ADL)

Stages of Alzheimer’s diseaseStages of Alzheimer’s disease

Alzheimer’s Disease & Brain Changes Alzheimer’s Disease & Brain Changes Loss of brain cells and mass Neurofibrillary tangles Neuritic plaques Change in blood flow & glucose

utilization

NeurotransmittersNeurotransmitters

Facilitate communication among nerve cells

Acetylcholine production & other neurotransmitters reduced in Alzheimer’s disease

Communication between nerve cells disrupted

Nerve cells die

Definite Risk Factors for Alzheimer’s DiseaseDefinite Risk Factors for Alzheimer’s Disease Increasing age Family history; genetics Female gender Down Syndrome

Genes Linked to Alzheimer’s Genes Linked to Alzheimer’s DiseaseDiseaseChromosome Type Age of Onset % of Cases Gene 21 Autosomal 45-65 < 1% APP (Amyloid

Dominant precursor protein)

14 Autosomal 28-62 < 1% Presenilin 1

Dominant

1 Autosomal 45-65 < 1% Presenilin 2

Dominant

19 Risk Factor > 60 > 50% ApoE 4

12 Risk factor > 70 ? A2M

Source: Marx, J., (1998, July 24) Science, Vol. 281, 509.

Possible Risk Factors for ADPossible Risk Factors for AD Environmental toxins Low formal education & occupational

attainment Previous head trauma Cerebrovascular disease

Strategies for Medical Treatment ofAlzheimer’s Disease

Strategies for Medical Treatment ofAlzheimer’s Disease Prevention of disease Delay onset Slow rate of progression Treat primary symptoms (cognitive) Treat secondary symptoms (behavioral)

Tacrine (COGNEXTM) Tacrine (COGNEXTM)

Approved for treatment of AD in 1993 Intended for use with mildly &

moderately impaired patients Limited benefit for a limited duration in a

minority of patients High risk of adverse effects Rarely prescribed today

Donepezil (ARICEPTTM) Donepezil (ARICEPTTM)

Approved for treatment of AD in 1996 Intended for use with mildly & moderately

impaired patients Improvement or stability in almost half of

patients during clinical trials; long-term effects unknown

Minimal adverse effects, usually at higher dose Dosage 5 mg or 10 mg tablet once at night

Rivastigmine (EXELONTM)Rivastigmine (EXELONTM)

Approved in 2000 for treatment of mild to moderate AD

Improvement or stability in a majority of patients during clinical trials who had highest dose

Benefits and minimal adverse effects tied to increasing dosage

Galantamine (REMINYLTM)Galantamine (REMINYLTM)

Approved in 2001 for treatment of mild to moderate AD

Twice daily dosage starting at 4 mg tablets each, increasing to 8 mg at 4 weeks, then to a maximum of 12 mg after 4 more weeks

Increasing dosage tied to greater benefit and more side effects

Potential Treatments/ PreventionPotential Treatments/ Prevention Non-steroidal anti-inflammatory drugs

(NSAIDs) Antioxident agents Estrogen Alternative medicine Others???

Directions for ResearchDirections for Research

Further identify risk factors & underlying biological causes

Improve diagnostic tools Develop better drugs Improve approaches to care Reduce caregiver distress

Care of Persons with Alzheimer’s diseaseCare of Persons with Alzheimer’s disease Create a supportive atmosphere Structure appropriate activities & routine Design “dementia friendly” environments Facilitate peer groups (for emotional

support & shared activities)

Help for Family CaregiversHelp for Family Caregivers

Offer education, training and consultation Promote respite services, e.g., adult day

care, companion Offer individual and family counseling Encourage participation in support groups