Healthy Aging and Reducing the Risk of Alzheimer’s disease in People with Down syndrome

Elizabeth Head, Ph.D.Department of Pharmacology & Nutritional SciencesSanders-Brown Center on AgingUniversity of KentuckyLexington, KYElizabeth.head@uky.edu

Overview

� What is Alzheimer’s disease

� The link between Down syndrome and

Alzheimer’s Disease

� Treatments – pharmacological

� Treatments – managing behavioral changes

� Prevention

� Take home message

Alzheimer’s Disease in USA

3

Alzheimer disease in

Canada

5%The percentage of the Canadian Institutes of Health Research’s budget invested in dementia research

45%The greater your risk of developing dementia if you smoke

65%Of those diagnosed with dementia over the age of 65 are women

16,000The number of Canadians under the age of 65 living with dementia

25,000The number of new cases of dementia diagnosed every year

56,000The number of Canadians with dementia being cared for in hospitals even though this is not an ideal location for care

564,000Canadians are currently living with dementia

937,000The number of Canadians who will be living with the disease in 15 years

1.1 millionThe number of Canadians affected directly or indirectly by the disease

$10.4 billionThe annual cost to Canadians to care for those living with dementia

Auguste D� On Nov. 25, 1901 51 year old

female, Auguste D., of Frankfurt, Germany presented to Dr. Alzheimer.

� She had a cluster of clinical symptoms including: – Aphasia – Disorientation – Unpredictable behavior – Paranoia – Auditory hallucinations – Pronounced psychosocial impairment

http://hod.kcms.msu.edu/timeline.php?y=1901-1906

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Clinical Diagnosis of Dementia� Possible - absence of neurologic,

psychiatric or systemic disorder but with a dementia syndrome

� Probable – dementia, deficits in 2 or more areas of cognition, progressive worsening, absence of other brain diseases that may cause the dementia, supported by impaired activities of daily living, family history

� Definite – clinical criteria and neuropathologic evidence

� This can be challenging to diagnose for people with Down syndrome

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Final diagnosis – only post mortem

www.alz.org

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Alzheimer Disease – Two Hallmarks

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Beta-amyloid plaques Neurofibrillary tangles

What is the link between Down syndrome and Alzheimer’s disease?

LeJeune and Gautier, 1959**

Down syndrome

J. Langdon Down - 1887

Causes of DS

� full triplication of chromosome 21 (95%)

� translocation - piece of chromosome 21 is triplicated (may be on another chromosome -3-4%)***

� mosaicism - some but not all cells of the body contain 3 chromosomes (1-2%)

How does the extra copy of chromosome 21 in DS lead to higher risk for AD with age?

2001

Chromosome 21

200 known genes

– 300-400

predicted

Smallest

chromosome

1.5% of total DNA

APP – Alzheimer’s disease

Amyloid precursor protein (APP), and Alzheimer’s disease

http://www.rienstraclinic.com/newsletter/2006/November/

We can see plaques in the brain

Figure of PiB imaging from:Handen et al., (2012) Imaging brain amyloid in nondemented young adults with Down syndrome using Pittsburgh compound B. Alzheimers Dementia, Vol. 8: 496-501

© 2015 American Academy of Neurology. Published by American Academy of Neurology. 2

Plaques increase with age in Down syndrome

Age dependence of brain [beta]-amyloid

deposition in Down syndrome: An

[18F]florbetaben PET study.

Jennings, Danna; Seibyl, John; Sabbagh,

Marwan; Lai, Florence; Hopkins, William;

Bullich, Santi; Gimenez, Monica;

Reininger, Cornelia; Putz, Barbara;

Stephens, Andrew; MD, PhD; Catafau,

Ana; MD, PhD; Marek, Ken

Neurology. 84(5):500-507, February 3,

2015.

DOI: 10.1212/WNL.0000000000001212

What is the age of onset of AD neuropathology in Down syndrome?

Mann et al., 1993

Virtually all adults with DS over the age of 40 years have sufficient neuropathology for AD (Struwe, 1929; Jarvis, 1948) – including plaques and tangles

***but wait there is more and its good news ***

Copyright © 2008 The Royal College of Psychiatrists

SCHUPF, N. et al. The British Journal of Psychiatry 2002;180:405-410

Not everyone with Down syndrome develops dementia!

http://www.uky.edu/DSAging/

The goals of the UKY aging study

� Find out what the earliest signs of dementia may

be (more accurate diagnosis)

� Earlier we catch signs of dementia – the sooner

we can start an intervention

� Which treatment and importantly, when?

� What measures should we make when we are

planning clinical trials dedicated to people with

Down syndrome to prevent Alzheimer’s

disease?

UKY Down syndrome and Aging Study

� The goal of this study is to follow people with Down syndrome over 25 years of age as they get older (n=80)

� We are measuring learning and memory every year

� Participants are seen by a neurologist every year

� MR imaging is acquired annually� Blood is taken annually� The study will be for 5 (and now 5

more) years� Some have consented to autopsy� Autopsy studies on archived brain

tissues

Neuropsychological MeasuresCognitive

� Kauffman Brief Intelligence Test

� Severe Impairment Battery� Brief Praxis Test� Fuld Object Memory

Evaluation� Peabody Picture Vocabulary

Test� Children’s memory Scale: Dot

Locations� Category Verbal Fluency� Beery Visual Motor Integration� WISC-R Block Design

Behavioral/Functional

� Vineland Adaptive Behavior Scale

� Behavioral Rating of Executive Functions

� Dementia Questionnaire for Mentally Retarded Persons

� Adaptive Behavioral Assessment System

� Reiss Screen & Neuropsychiatric Inventory

Current Cohort Demographics

As of August 2017 we have had two autopsies

DMR = Dementia Questionnaire for Persons with Mental Retardation (higher score = poorer performance)

Last Clinical Consensus Diagnosis

Not Demented (n=37)

Questionable Dementia (n=13)

Demented(n=24)

Total (n=74)

Age (Mean in yrs. ±sd)

40.2±9.8 45.8±9.3 57.5±5.7 46.8±11.4

% Female 62.2 61.5 70.8 64.9

DMR Total 7.7±8.1 33.0±15.6 53.0±12.4 38.3±32.7

Treatment of Dementia for People with Down syndrome

From Mario D. Garrett PhD

Treatments at a glance for AD

Generic Brand Approved For Side Effects

donepezil Aricept All stages Nausea, vomiting, loss of appetite and

increased frequency of bowel movements.

galantamine Razadyne Mild to moderate Nausea, vomiting, loss of appetite and

increased frequency of bowel movements.

memantine Namenda Moderate to

severe

Headache, constipation, confusion and

dizziness.

rivastigmine Exelon Mild to moderate Nausea, vomiting, loss of appetite and

increased frequency of bowel movements.

memantine

+ donepezil

Namzaric Moderate to

severe

Nausea, vomiting, loss of appetite,

increased frequency of bowel movements,

headache, constipation, confusion and

dizziness.

http://www.alz.org/alzheimers_disease_standard_prescriptions.asp

Drugs approved for use to treat AD in DS (as of 2017)

� Memantine just failed in a clinical trial in demented adults with DS, no improvement but no increase in adverse effects

� Donepezil - studies small and show modest or no effect with high adverse events (2009), recent 2011 study in women suggests improvement, 2015 review suggests no improvement and more adverse effects

� Exelon – one small study of rivastigmine patch n=10 (2012)

� Galantamine – no studies

� Tacrine – no studies

Overall

� “Due to the low quality of the body of evidence in this review, it is difficult to draw conclusions about the effectiveness of any pharmacological intervention for cognitive decline in people with Down syndrome.” Livingstone et al., 2015.

Potential Behavioral Issues� Early stages of AD

� Irritability

� Anxiety

� Depression

� Later stages of AD

� Anger

� Agitation, general emotional distress

� Aggression, physical or verbal outbursts

� Restlessness

� Hallucinations and/or delusions

� Sleep disturbances

28 http://www.channel4.com/news/more-people-with-downs-syndrome-developing-dementia

Managing Behavioral Issues

� Identify triggering situations

� Moving

� Changes in familiar environment or caregiver

� Misperceived threats

� Being asked to bathe or change clothes

� Identify medical conditions that may be contributing

� Drug side effects or interactions (rivastigmine, mematine)

� Infections (UTI, full bladder, constipation, too hot too cold)

� Hearing or vision

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Managing Behavioral Issues

� Non-drug approaches

� Modify the environment to make the patient feel more at ease and comfortable

� Coping tips for caregivers (encourage caregiver support)

� Monitor personal comfort

� Avoid being confrontational

� Redirect attention

� Calm environment

� Rest

� Provide a security object

� Acknowledge requests

� Look for reasons behind behavior

� Don’t take the behavior personally!

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Managing Behavioral Issues

� Pharmacological Approaches

� Target a specific symptom (e.g. depression, may help someone sleep better)

� Start with low doses and monitor

� Commonly used medications

� Antidepressants (low mood and irritability)

� Anxiolytics (anxiety, restlessness, verbally disruptive behavior)

� Anti-psychotics (hallucinations, delusions, aggression, etc) –extreme caution is advised when using this class of medication because some may lead to increased stroke and death.

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Sleep disturbances

� OSA Dr. Edgin

� Difficulty sleeping (may be disruptive to caregiver)

� Daytime napping and shifts in sleep/wake cycle (sundowning –restlessness or agitation in the early evening)

� Depression may be a major contributor to sleep problems

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http://www.sleepapnoeablog.com/do

wns-syndrome-is-high-risk-for-sleep-

apnoea-volunteers-needed-for-new-

study/

Managing Sleep Disturbances

� Non pharmacological

� Maintain regular schedule

� Bed is only for sleeping – if awake – get out of bed

� Safety lights

� Regular exercise

� Cholinesterase inhibitors – try to give in am not pm

� Treat pain

� Temperature

� Discourage TV if awake

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Managing Sleep Disturbances

� Pharmacological

� Must be very careful with using sleep-inducing medications

� Start with low doses and slowly increase if needed

� Increased risk of falls and fractures

� Increased confusion

� Examples

� Tricyclic antidepressants

� Benzodiazepines

� “sleeping pills” – zolpidem, zaleplon, chloral hydrate

� “atypical” antipsychotics – risperidone for example

� Classic antipsychotices – older – e.g. haloperidol

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How can we prevent Alzheimer’s disease in people

with Down syndrome?

Cornell hosts Camp PALS NY for adults with Down syndrome

Control co-occuring illnesses as

these are risk factors for dementia

� Stay on top of hypothyroidism treatment (Framingham study – high and low TSH in women = increased risk)

� Vitamin deficiencies (e.g. vitamin D, B)

� Diabetes

� Epilepsy

� Sleep apnea

� Psychiatric conditions (e.g. Depression or anxiety)

� Cardiovascular??

Lifestyle factors we can modify

� Obesity, type II diabetes – raises risk for AD

� Poor cardiovascular function – can lead to blood

vessels in the brain not working well

� Poor sleep – Dr. Edgin – Obstructive sleep

apnea can lead to losses in brain volume in

regions important for memory in the brain

� Others are being identified

Prevention –

Healthy Diet

� Fruits and vegetables are high in antioxidants –better than supplements

� Mediterranean diet – lots of fish, nuts and healthy oils, fruits and vegetables – very nice evidence of protection from AD

� A healthy diet can reduce obesity and associated risk factors

http://www.medicinenet.com/mediterranean_diet/article.htm

Antioxidants

� Some of the genes on chromosome 21 that are overexpressed lead to oxidative damage to a greater extent in Down syndrome

� Antioxidant supplements –clinical data?

� The importance of well controlled clinical trials

Prevention - Exercise

� Reduces risks associated with obesity and cardiovascular function

� Can help the brain grow new neurons!

� Stimulates the brain to make growth factors to support healthy cells

� How much? What kinds?

http://www.dailymail.co.uk/news/article-2407982/Meet-Downs-Syndrome-man-thats-elite-athlete--regularly-lifting-non-impaired-competitors.html

Prevention – Cognitive Exercises

� The more active your brain is –helps neurons to make more connections

� Leads to growing new neurons

� Leads to growth factors being released in the brain to make existing neurons happier and healthier

� The more connections you have, the more “damage” you can absorb

Prevention – Social Activities

� People with very active social lives, lots of friends tend to be more protected against AD

� Why? Social activity engages the brain and the more active your brain, the more neurons are stimulated to make connections and stay healthy

The future for treating Alzheimer’s disease in people with Down syndrome

� Several clinical trials are going on in sporadic AD including new drugs and vaccines

� We have to be careful about thinking these same drugs or vaccines might be directly applicable to people with Down syndrome without testing them directly

Clinicaltrials.gov

� Search of Down syndrome

� 46 studies ongoing

� 2 are dedicated to aging (ACI-24 vaccine) and

observational

� 6 are dedicated to Alzheimer disease and

cognitive decline (nicotine, memantine,

observational)

� Other AD trials, most people with DS are

excluded

Summary

� People with DS are at a higher risk for AD with

an earlier age of onset but NOT EVERYONE

DEVELOPS DEMENTIA

� Current treatments for Alzheimer’s disease

include both pharmacological and

nonpharmacological interventions

� Prevention approaches are very promising and

include modifying lifestyle risk factors

� New treatments are in the pipeline

Take home messages

� A healthy diet – lots of fruits and vegetables

� Exercise – make it fun! Dancing counts ☺

� Make friends – and then make more friends and keep visiting with friends

� Play (board games, computer games), learn new things (music, drawing, cooking), take classes

� Make sure you are getting lots of good sleep

� All of these reduce your risk factors

� Prevention is more powerful than treating a disease

Be active and

proactive!

Advocate and self-

advocate for more

research to help us

find ways to

improve health in

aging people with

Down syndrome

Volunteer ☺

Be positive!!

Thank you!

Resources

Dr. Julie Moran - www.ndss.org

https://niad-project.org/

http://www.uky.edu/DSAging/

https://www.nia.nih.gov/research/abc-ds

https://dsconnect.nih.gov/