Screening, evaluation and Introduction treatment of dementia in the - - PDF document

10/10/2017 1

Screening, evaluation and treatment of dementia in the elderly Asian population

Aimee Kao, MD, PhD Associate Professor of Neurology UCSF Asian Health Symposium 2017.10.05

No disclosures

Outline of talk

• Introduction
• Dementia definition and syndromes
• Case study
• Special issues in the Asian community
• UCSF Chinese Outreach Clinics

Why is dementia important?

• Rapidly aging population
• Alzheimer Disease is the 6th leading

cause of death in the U.S.

• 5.4 million individuals affected
• 1 in 8 Americans aged 65 and older is affected by

Alzheimer’s Disease

• In 2013, Americans provided provided 17.7 billion

hours of unpaid care to people with AD and other dementias

• In 2014, AD cost Medicare and Medicaid ~$150 billion

Alzheimer's & Dementia: 2015 11:332-384

Percentage change in cause of death 2000 to 2013

Public health impact of deaths from Alzheimer’s disease

10/10/2017 2

• Recent studies suggest rates of dementia in

Chinese are comparable to those in U.S.

• 8% in Hong Kong
• 10% in China
• ~11% in US
• Asians in US, average annual rate:
• 15.2 per 1,000 for Asian‐Americans (included Japanese)
• 19.3 per 1,000 for Caucasians
• Little data comparing dementia in Asians vs. other

Americans

Sources: Fei et al., Alz Dis Assoc Disord, 2009; Lam et al., Int Psychogeriatr, 2008; Mayeda et al. Alzheimers Dement, 2016; 2000 U.S. Census Data; 2009 American Community Survey Data

Rates of dementia in Asian Americans

What is dementia?

Pre‐frontal: Executive function and behavior Temporal: Memory Parietal/temporal: Language and visuospatial Frontal and subcortical: Motor

• An acquired, progressive, persistent

impairment in cognition or behavior

• Involves 1 or more

cognitive domains

• Sufficient to cause a

decline from a previous level of functioning

• Dementia is no

longer a diagnosis of exclusion

Risk and protective factors

Risk Factors

• Increased age
• Vascular disease
• Genetics (ie ApoE4)
• Head injury
• Lower education
• Chronic inflammation

Protective Factors

• Physical exercise
• Social engagement
• Mental activity
• Education

Careful phenotyping of dementias is critical for appropriate treatment

Courtesy Howard Rosen Adapted from Plassman et al., 2007

• Lewy Body Disease
• Frontotemporal dementia
• Progressive supranuclear palsy
• Corticobasal degeneration
• Multiple system atrophy
• Amyotrophic lateral sclerosis
• Triplet repeat disease

(ie Huntington’s Disease)

• Paraneoplastic disorders
• Hashimoto’s encephalopathy
• CNS lymphoma
• Rapidly progressive dementias

(ie Creutzfeld‐Jakob disease)

10/10/2017 3 The Mini Mental Status Exam (MMSE) for dementia screening

• Very good screening tool
• Can be administered rapidly (<5

min) and reproducibly

• Covers basic cognitive domains

(memory, language, visuospatial, executive, motor)

• Normal is ≥29/30 (as long as ‐1

is from word memory)

Case Study: A 76 yo Chinese‐American woman with forgetfulness

• CC: “My memory is not as good as it used to be, but overall it’s fine.”
• HPI: (from patient and informant)

‐ Over last 2 years, has forgotten to take her pills and missed appointments ‐ Family is concerned about her riding buses in the city by herself as she got lost and was missing for several hours. ‐ Has had several falls in the last 1‐2 years ‐ Family worries that she is depressed

• PMH: Hypertension, hyperlipidemia
• Neurological exam:

‐ Socially intact but with a paucity of spontaneous speech ‐ Cogwheel rigidity in arms L>R (parkinsonism) ‐ Gait instability

• MMSE: 21/30 missing points for orientation, memory, copy of pentagons

Depression as a sx? Fall risk Executive, memory and visuospatial Insight?

What is the diagnosis?

• A. Normal aging
• B. Alzheimer Disease (AD)
• C. Vascular dementia (VaD)
• D. Alzheimer Disease + Vascular dementia

Answer: It depends on the MRI

For vascular dementia, look on T2 or FLAIR sequences for… Periventricular white matter (PVWM) changes (FLAIR image) Lacunar infarcts

10/10/2017 4 In AD, look for hippocampal atrophy

Normal hippocampus Atrophy of hippocampus

Alzheimer Disease (AD)

• 1st symptom: Difficulty encoding new memories

(due to hippocampal atrophy)

• Will spread to include other cognitive domains
• Usually social graces and motor functions are

spared until late in disease

AD symptoms mirror its spreads through connected neuronal circuits

Early Middle Late

• 1st symptom: Difficulty retrieving

memories (sub-cortical pattern of memory impairment)

• Stepwise progression
• Oftentimes accompanied by

executive dysfunction, parkinsonism, psychiatric disturbance (paranoia, hallucinations)

• Vascular dementia is distinct from stroke

Vascular Dementia (VaD)

Example of sub‐cortical fibers

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Diagnosis of vascular dementia

• Can be difficult
• Symptoms and impairments similar to AD
• Research shows that physicians don’t always agree
• Presence of PVWM changes on MRI does not rule
• ut AD
• Absence of PVWM changes makes AD more likely
• Problems with balance and walking are more

common in early vascular dementia

• Differs from stroke in non‐acute onset and

progressive impairment without recovery over time

Amyloid imaging is an early biomarker for AD

Amyloid Plaques N S NH11CH3 HO

PET Imaging + Pittsburgh Compound B (PIB)

Courtesy of William Klunk, UCB

• PIB binds fibrillar amyloid in a

reversible fashion

• Helpful in distinguishing AD from
• ther dementias
• Can help to predict who will convert

from MCI to AD

• Is not a screening tool for

asymptomatic individuals

Amyloid is Also Detectable in Normal Older Adults

Rabinovici and Jagust

15%-30% of cognitively normal older adults are Aβ- PET+ More common in ApoE4+ and

• lder age

Treatment of AD and VaD are similar

• Acetylcholinesterase inhibitor (ie donepezil)
• SSRI for depression and/or irritability
• Exercise regimen +/‐ physical therapy
• Home safety evaluation to prevent falls, accidents
• Planning for the future
• Caregiver support

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AD and VaD: Take home points

• By age 90, >50% of individuals have AD plaques

and tangles, so overlap syndromes are common

• Loss of insight is common in dementia affecting

frontal lobes

• Depression can be a presenting symptom of a

neurodegenerative disorder

Special considerations in an Asian population

• Because of family support, presentation to

healthcare tends to be later in disease

• Family interviews may need to be conducted

separately out of respect to affected individual

• Potential stigma against psychiatric disorders can

make the diagnosis of co‐existent depression challenging

• Compliance with medications, especially anti‐

depressants, may be an issue

Chinese Outreach Clinics 華人外展計劃診所

Chinatown Public Health Center 華城公共衛生局 Chinese Hospital 東華醫院

Thursdays

AM PM

Goals of Chinese Outreach Program

• Address the under‐

representation of Asian Americans in dementia research

• Establish outreach to overcome

geographical, resource and transportation barriers

• Conduct community lectures to

provide dementia education in appropriate cultural context

10/10/2017 7 UCSF Chinese Outreach Team 外展團隊

Multilingual and multicultural staff

• Dr. Howard Rosen (Neurologist) 羅森醫師，神經內科
• English
• 英文
• Dr. Richard Tsai (Neurologist) 蔡孟鈞醫師，神經內科
• Mandarin, English
• 國語，英文
• Marian Tse (Clinical Outreach Coordinator) 謝譚敏兒， 研

究助理

• Cantonese, Toishanese, Mandarin, English
• 廣東話，台山話，國語，英文
• Contact info:

Phone 415/476‐1692 Fax 415/476‐0213 Email Marian.Tse@ucsf.edu

UCSF Sandler Neurosciences Center Thank you

• UCSF Chinese Outreach Program：
• UCSF創立華人外展計劃：
• Address the underrepresentation of Chinese Americans in

dementia research

• 針對華人在失智症/老人癡呆症研究領域代表性不足
• Establish outreach clinics to overcome geographical, resource and

transportation barriers.

• 創立華人社區診所，客服地理，資源，交通困難
• Conduct community lectures to provide dementia education in

appropriate cultural context.

• 為華裔美國人提供語言，文化適當的失智症/老人癡呆症教育

與支持

Purpose of Chinese Outreach Program 華人外展計劃宗旨