DEMENTIA
Disclaimer Speaker’s Bureau • Pfizer • Eli Lilly • Janssen • Sunovion
“Fun” facts about Dementia before we start u AD is 6 th Leading cause of death in the US; 5 th for those 65 and older u Women make up a larger share (2/3) of Alzheimer’s (AD) patients than men u Lifetime risk is 20% for women and 10% for men at age 45 u AA and Hispanics are morel likely to have AD as likely as Whites. LOWEST FOR ASIAN-AMERICANS! The Japanese have the lowest. u Negative socio-economic characteristics maybe increase for those groups
More “fun” facts u In the US, 15.8% of age 60 and older have MCI u The oldest member of the Baby Boom generation (1946- 1964) just turned 72 in 2018 u Decline in the age-specific risk of AD and other dementias in the past 25 years u BUT a dramatic increase is expected in the TOTAL NUMBER of cases u A worldwide trend showing an increase in OBESITY and DIABETES can potentially reverse the declining trend u In low- and middle-income countries, such as the Philippines, there is no evidence that the risk for AD and other dementias has been declining
Last “fun” facts u $232 Billion expense in 2017 and $277 Billion in2018 u Costs extend to family caregivers’ increased risk for emotional distress and negative mental and physical health outcomes u With the identification of biomarkers in recent years, our understanding of AD has changed
NEURO-COGNITIVE DISORDERS (NCD) Acquired and represents decline from previous level of functioning Mild NCD aka Mild Cognitive Moderate NCD aka DEMENTIA Impairment (MCI or MCD) u Significant decline u Substantial impairment u Moderate decline u 2 or more cognitive domains u Modest impairment Attention, Learning/Executive Function, Memory, u u Does not interfere with Language, Emotion, Visuospatial Function/Motor & Action independence u Interferes with independence u +/- Behavioral Disturbance u +/- Behavioral Disturbance u Mild, Moderate or Severe
Possible Reversible Causes of NCD u Depression u Delirium u Substance or Medication Induced > Alcohol > Medication Mismanagement > Anticholinergics > Benzodiazepines BENADRYL, Parkinson’s Rx, Antipsychotics, Ditropan > Ativan, Xanax, Clonazepam, Vaiium u > Statins > Medication Mismanagement u Hypothyroidism, Vit B12 Deficiency, Neuro-syphillis u Normal Pressure Hydrocephalus (NPH), Subdural Hematoma, Brain Tumor u Sensory Impairment, especially hearing
DEPRESSION u Associated with an increased risk of Alzheimer’s Disease u Depression and other neuropsychiatric symptoms often emerge during the preclinical phase of AD – a period marked by the accumulation of deposits of fibrillar amyloid and pathological tau u Cognitively normal older adults with worsening anxiety had higher levels of amyloid beta, a brain protein implicated in AD
LINK BETWEEN DEPRESSION AND DEMENTIA u Those with MCI were 2.6 times more likely to have a history of depression u Those with AD were 3.77 times more likely to have had depression
DEPRESSION WITH ANXIETY u When compared with other symptoms of depression, ANXIETY SYMPTOMS increased over time in those with higher amyloid beta levels in the brain u Anxiety may be a manifestation of the disease process BUT it may also be a DISEASE-POTENTIATING FACTOR
ANTI-DEPRESSANT MEDICATION u The antidepressant SSRI Citalopram and Sertraline decrease amyloid-Beta generation and plaque load. u SSRI was associated with delayed dementia onset and increased longevity in patients with Down Syndrome, who have a high risk of AD
ANTI-DEPRESSANT MEDICATIONS u Long-term treatment of depression (more than 4 years, even after the depressive symptoms have resolved) with SSRI of those with MCI was associated with a delay of approximately 3 years in progression of Alzheimer’s u SSRI cannot stop the AD pathology u Non-SSRI antidepressants were associated with a higher risk of progression from MCI to AD
DELIRIUM (vs Dementia) u Disturbance in ATTENTION or AWARENESS + another deficit u Develops over short period of time and tends to fluctuate u Direct physiological consequence of something else u Hyperactive (easy to Dx) or hypoactive (easy to miss) types u Can be reversible – SIGNIFICANT CAUSE OF MORBIDITY AND MORTALITY during acute hospital admission
SENSORY IMPAIRMENT- HEARING LOSS u Age-related hearing loss linked to impaired performance across cognitive domains and increased risk for Dementia diagnosis u Underlying PSYCHOSOCIAL MECHANISM of diminished hearing leading to increased risk for depression
SENSORY IMPAIRMENT – HEARING LOSS u Underlying NEUROBIOLOGICAL MECHANISM of diminished hearing leading to increased risk for depression u DECREASE COGNITIVE PERFORMANCE and INCREASE DEPRESSION RISK by u Reducing cognitive reserve u Increasing executive dysfunction u Disrupting normative emotion reactivity and regulation
What does it mean to have “Dementia?” u COGNITIVE IMPAIRMENT u Learning and Memory u Executive Function u Language Skills u ETC u FUNCTIONAL IMPAIRMENT u Instrumental Activities of Daily Living (IADLs) u Activities of Daily Living (ADL)
Diagnosis of Dementia u Is cognitive impairment present u Is there anything I can fix? u Time will tell – Is this dementia? If so, what is the etiology?
Basic Work-Up for Dementia u Clinical Evaluation u Hx – Cognitive & Functional (collaborative informant) u Cognitive Testing – MMSE or Montreal Cognitive Assessment u Neurological Exam – Focal S/Sx, Parkinsonism u Review of Current Rx and Substance Use u Laboratory Studies (TSH, B12, Syphillis) u Brain Imaging – CT Scan or MRI, possibly PET Scan u Others as clinically indicated – Lyme’s, EEG
Dementia in the Elderly u Alzheimer’s Disease 65% u Frontotemporal Lobar Degeneration 10% u Vascular Dementia 10% u Lewy Body Dementia 5% u Other/Mixed 10% u Substance/Medication Use, HIV Infection, Prior Disease, Parkinson’s Disease, Huntington’s Disease, Other Medical Conditions These numbers vary widely u
ALZHEIMER’S DISEASE u Primary deficit is the decline in memory and learning – short- term, episodic u Executive Dysfunction can occur early on u Insidious onset and gradually progressive decline u Cause is multifactorial; <5% is genetic; plaques and tangles in the brain u Greatest risk factor is advancing age; also family history and genetics (ApoE3 allele) u Neurological exam unremarkable in mild to moderate stages u AD is a LIFE-LIMITING ILLNESS that lasts 8-12 years on average
ALZHEIMER’S DISEASE u Cognitive Impairment u Amnesia (partial or total loss of memory) u Aphasia (loss of ability to understand or express speech) u Apraxia (inability to perform purposeful actions) u Agnosia (inability to interpret sensations and to recognize things) u Executive Dysfunction u No evidence of neurological disease, metabolic etiology, substance-induced, or delirium u Significant functional impairment in IADLs or ADLs
Early Stage of AD - Mild u Short-term memory is poor u Expressive language and naming are affected u Executive function is impaired u Trouble with IADLs (higher level activities) u Some activities are taken over by others u Need gentle reminders and supervision u Close family and friends can notice
What does early AD typically look like? COGNITIVELY FUNCTIONALLY u Short-term memory loss u Forget conversations u Word-finding difficulties u Forget dates, miss appointments u Trouble with reasoning u Misplace items frequently u Becoming lost or disoriented u Trouble with finances u Get lost while driving
Stages of AD – Moderate (Middle) u Long-term memory becomes affected u Decision-making is harder (limit to 2 choices) u Speech comprehension is difficult u “Praxis” (doing things) is more impaired u ADLs are affected (personal care) u Need cuing, set-up and assistance u Incontinence develops in the 2 nd half u Gait disturbance with falls u Becomes more obvious to others
Stages of AD – Severe (Late) u All cognitive domains are affected u “Gnosis” (recognizing people) is affected u Very basic information is lost, including one’s name u Become unable to walk, talk, feed oneself u Fully dependent on others for care u Neurological changes and abnormalities u Swallowing becomes affected
FRONTO-TEMPORAL DEMENTIA (FTD) u Age of onset: 40-65 u Behavioral variant – Pick’s Disease (Frontal Lobe) u Language variant – Primary Progressive Aphasia or Semantic Dementia (Temporal Lobe) u Relative sparing of learning, memory, and perceptual motor function u Several different gene mutations have been identified u Most cases without family history u Can be associated with Motor Neuron Disease (ALS)
VASCULAR DEMENTIA u Presence of sufficient cerebrovascular disease u Prominent deficits in complex attention and frontal executive function u Symptoms vary u Thinking is more affected than memory u Temporally related to cerebrovascular events u Can occur suddenly (pot-stroke) or step-wise (series of strokes) u Exam may show focal deficits and gait disturbance u Risk Factors: Age, Hx of MI, CVA, TIA, Atherosclerosis, Hyperlipidemia, HTN, DM, Smoking, A-fib
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