Dementia & Alzheimer’s Disease

Dementia syndrome of progressive change in cognitive function

memory loss and at

least one other type of cognitive deficit.

Senile Dementia of the Alzheimer’s Type

one cause of dementiainsidious onset

Cognitive Impairment

a range of disturbances in cognitive functioning. diagnosis depends on assessment of cognitive function

and a complete mental status examination

Dementia, Delirium, Depression

Cognitive Impairment Problem Areas

Attention spanConcentrationIntelligenceJudgmentLearning abilityMemory Orientation

PerceptionProblem solvingPsychomotor abilityReaction timeSocial intactness

Confusion

Non clinical term to describe acute onset of inability to understand cir cumstances without loss of consciousness.

Acute onset is over hours or days.

Normal Aging vs Dementia

Characteristics

Normal aging Alzheimer’s/Dementia

Memory loss Mild forgetfulness (able to use reminders)

Progressive memory loss (gradually unable to use reminders, eventually no ability to learn or recall information)

Thinking (cognitive impairment)

None Progressive loss in thinking skills (the ability to make decisions, to judge, to follow directions)

Paranoia, hallucinations

Some paranoia related to vision & hearing loss (may think others are talking about them)

Function of the illness although symptoms will vary among individuals. Paranoia and hallucinations are more prevalent, especially in the middle stage.

Self-care capacity Usually able to perform all self-care tasks

Progressively unable to care for themselves (eventually requires total assistance)

Dementia

Causes Reversible Irreversible

Dementia

Reversible causes nutritional deficiencies endocrine disorders trauma depression sensory deficits

Reversible Cause Normal Pressure Hydrocephalus

accumulation of cerebrospinal fluid in brain

symptoms mild dementia gait disturbance urinary incontinence

diagnosis: CT scan, ventricular enlargement

treatment: ventriculoperotonial or ventriculoatrial shunting

Irreversible Causes

Arteriosclerosis changes Multiple infarctions Alzheimer’s disease Pick’s disease Parkinson’s disease Huntington’s disease Alcohol abuse

What is Alzheimer’s Disease?

amyloid ß peptide (Aß) that accumulates in the AD brain is deposited within senile plaques and cerebral vessels

Aß accumulation initiates AD pathology

Classic triad of AD pathology

senile plaques containing Aß neurofibrillary tangles (NFTs) widespread neuronal loss in the hippocampus and

select cortical and subcortical areas

Alzheimer’s Disease

Characteristics Memory problems the first sign Language difficulties early in the

illness Attention intact for most of illness Motor and seizure disorders occur late

if at all Slowly but steadily progressive over

10-15 years

Early Warning Signs of AD

Developing memory lossLosing things, repetitive questionsSuspiciousness of othersLess activeTrouble drivingDifficulty with financesSelf-neglects —not eating, bathingIrritability, stubbornness, anxiety

Importance of Early Detection of Alzheimer’s Disease

SafetyFamily understandingEarly education of caregiverAdvanced planningPatient’s family right to knowStabilizing treatments now available

The Challenges

Patients with dementia do not recognize that they need help.

If a patient suspects he/she has a problem can go to great lengths to try and hide it.

Social skills are often preserved in early stages.

Diffuse Lewy Body Dementia

Second most common cause of dementiaName comes from the presence of abnormal lumps which

develop inside nerve cells called Lewy bodies.

Lewy Body Disease

Diffuse Lewy Body Disease Dementia

Early problems with attention, executive function, and visuospacial abilities even preceding memory impairment

Fluctuating cognitive ability (day to day changes)

Visual (93%) and auditory (50%) hallucinations are common and not always troubling to patients

Early Parkinson-like motor abnormalities and falls

Diffuse Lewy Body Disease Dementia

At risk for exaggerated Parkinsonian drug side effects from haloperidol and risperidone

psychosis with dopaminergic drugs

Vascular Dementia

Dementia related to strokesVariety of presenting signs with attention disturbances,

memory loss and changes in social behavior being common

Course is progressive, commonly with a step-wise decline being related to each new stroke

Focal neurologic signs are often presentPatients have other vascular diseases such as DM,

HTN, High Cholesterol and a history of smokingCommonly occurs with Alzheimer’s Disease (10-15%)

Frontotemporal Dementia & Pick’s Disease

Early Behavioral changes: lack of social skills, poor hygiene, sexual disinhibition, constant touching and rearranging objects, putting objects in mouthAge of onset earlier than Alzheimer’sCalculation and visuospacial skills intact until late in illnessSlow and steady progression

Parkinson’s Dementia

Dementia occurs late in the history of Parkinson’s Disease (different pattern than DLBD)

Steadily progressive

Memory Memory problemsproblems

AttentionAttention

CognitionCognitionHallucinatioHallucinationsns

Distress Distress BehaviorBehavior

MotorMotor

ProblemsProblems

AD Early Hallmark

Early Intact attention

Late or never

Late occurring

DLBD Not first symptoms

Early Fluctuating cognition

Early and Common

Parkinson-like Early

VAS Early attention problems

Common Early

PD Precedes dementia by years

Characteristics of Common DementiasCharacteristics of Common Dementias

Stages of Dementia

EarlyEarlyLoss of Recent memoryMild ConfusionMild Communication DifficultiesImpaired JudgmentPersonality and Behavior Changes (e.g., anxious,

withdrawn, depressed, irritable, mellow, sensitive, frustrated, inconsiderate)

Mild Difficulties with ADLs and advanced activities (e.g., driving, managing finances, telephoning, cooking)

The Stages of DementiaMiddleMiddle

Increased Memory Loss

Significant Confusion

Frustration

Moderate to severe communication difficulties

“When do we eat?”

anger and anxiety if unable to express needs

verbal or physical outbursts, such as yelling or throwing furniture

major word finding problems; sentences may not make sense; it may be difficult to understand others; speech may be slow

Stages of Dementia MiddleMiddle

Poor Judgment

Increased personality and behavior problems

Difficulty in completing activities of daily living

inappropriate comments to friends, questions to strangers, or an attempt to undress in a public place

restlessness, fidgeting, pacing, aimless wandering, hallucinations or delusions

bathing, toileting, grooming, dressing.

Symptoms of DementiaMiddleMiddle

loss of impulse control

agnosia

apraxia

perceptual disturbances

yells out when disturbed or strikes out when awoken

unable to recognize a fork

forgets how to use a fork

thinks the person in the mirror is someone else

Stages of DementiaLateLate

Limited memory

Extremely limited ability to perform any activities of daily living including feeding. Loss of bowel and/or bladder control

Limited communication

Increasing vulnerability and frailty

May not recognize family or friends;

May not recognize self in the mirror;

may think spouse is a stranger

Dependent on 24 hour assistance. Often no longer ambulatory.

May be mute or unable to understand words

More susceptible to infections, physical illnesses

More nutritional problems

Stages of DementiaStages of DementiaLateLate

urinary incontinence delusions

hallucinations

inability to control bladder functions

mistakenly accuses a spouse of affairs

sees people or things that are not there

Dementia Diagnostic Criteria

Characterized by multiple cognitive deficits orientation memory judgment abstract thinking problem solving

Fluctuations in moodShallowness of affective range

Dementia Diagnostic Criteria

loss of intellectual abilities-interference with functioning

at least one: impaired abstract thinking impaired judgment personality change disturbed cortical functioning

Dementia Diagnostic Criteria

disturbed cortical functioning aphasia: impaired language apraxia: impaired motor activity agnosia: failure to recognize constructional difficulty

no clouded consciousness

Diagnostic Workup

History: from patient and familyPhysical exam & vital signsMental status examNeurological examCT scan & EEGThyroid function tests

Diagnostic Workup

Serum B12 and folic acidChest Xray, ECGCBC, Urinalysis, Glucose, BUN, serum

albumin, electrolytes, VDRL

Diagnostic Work up

Rule outtreatable causes of cognitive impairmentcommon co-occuring conditions

Brain imaging studies can rule out vascular disease tumor subdural hematoma normal pressure hydrocephalus

Delirium

Diffuse disruption of cognitive statePrevalence

10-30% in the hospitalized medically ill 10-15% hospitalized elders on admission 10-40% elders while in the hospital 60% of nursing home residents over 75 experience

delirium 80% with terminal illness

Delirium

Causes drugs fever dehydration anesthesia sleep deprivation medical problems: CHF, CVA, renal failure,

anemia psychosis tumors

Delirium

Suspect delirium when Prodromal symptoms develop

Anxiety Restlessness Irritability Disorientaion Distractibility Sleep disturbance

Condition changes throughout the day Familiar figures unable to soothe

Delirium

May progress to Stupor Coma Seizures Death

Delirium Diagnostic Criteria

Disturbance of consciousness Reduced clarity of awareness of the environment Reduced ability to focus, sustain, or shift

attention

Delirium Diagnostic Criteria

At least two of the following:1. Perceptual disturbances

Misinterpretations Illusions Hallucinations-usually visual

Delirium Diagnostic Criteria

At least two of the following:1. Speech

Rambling Irrelevant Pressured Incoherent Switching from subject to subject

Delirium Diagnostic Criteria

2. Disorientation3. Short onset-hours to days

Delirium Associated Features

Sleep disturbance Daytime sleepiness Night time agitation Difficulty falling asleep Wakefulness during the night Reversal of day-night sleep cycle

Delirium Associated Features

Disturbed psychomotor behavior Restless Hyperactive Picking at bed clothes Attempting to get out of bed when it is unsafe to do so

Delirium Associated Features

Disturbed psychomotor behavior Sluggishness Lethargy

Delirium Associated Features

Emotional disturbance Anxiety Fear Depression Irritability Anger Euphoria Apathy

Delirium Associated Features

Behaviors accompanying emotional disturbance Screaming Cursing Muttering Moaning

Delirium Treatment

Manage the causative e.g. hypoxia and pain

Comfort measures to calm patient Antipsychotics for psychotic behaviorAtivan for excessive anxiety

Mini Mental State Exam

Standardized, widely used

Assesses orientation, memory and cognitive skills

Scoring 0-30 0 rating- severe

impairment 24-30 rating- normal

rangeUntreated patients

with dementia have an annual decline of 10%

Secondary Dementia

AlcoholismParkinson’s diseaseHuntington’s disease

Depression in Dementia

Harder to diagnose in the older adults especially with dementia.

May not exhibit sadness

Depression in Dementia

Harder to diagnose in the older adults especially with dementia.

May not exhibit sadness

Causes of Depression in Dementia

Psychosocial factors inability to communicate loss of function loss of pleasurable activities loss of home loss of independence loss of relationships

Biological factors

Consequences of Depression in Dementia

Accelerates decline increases memory loss causes delusions causes agitation causes giving up

Excessive disability loss of functional abilities

Clinical Cues of Depression in Dementia

irritability somatic complaints no tears ruminating critical refusing to eat low self-esteem

Supportive Therapy

One to one very helpful Conversation to reduce isolation Exercise

Group approaches can also be effectiveCombination of support and drugs most

effective for major depression

Primary Prevention

Healthy lifestyle preserves cardiovascular health and subsequently brain health