Different Strokes for Different Folks: Variable Approaches to Different Forms of Dementia

1. Different Strokes for Different Folks: Variable Approaches to Different Forms of Dementia Julie Feil, MSW, LCSW The Memory Center Affinity Health System

2. The Goals of The Memory Center • We see individuals of all ages with all forms of memory loss in various stages. • To identify and provide treatment options for those with memory disorders • To advocate for early detection!

3. Why is the Diagnosis Important? It allows us to identify what form of memory problem we are dealing with. This results in: • More focused education and support- appropriate to family and individual • More accurate and effective pharmaceutical treatment modality choice • Increased awareness for families and individual • Rule out treatable causes of dementia

4. It is like Stopping a Rolling Truck!

5. Barriers to Obtaining a Diagnosis • Belief that it is “Just normal aging” • Stigma attached to “Alzheimer’s Disease” • Fear • Lack of Insight into Problem • Denial • Embarrassment

6. Determining the Diagnosis Appointment includes: • The Neurological or Medical Examination • The Neuropsychological Testing • The Psychosocial Evaluation

7. Possible Diagnosis’ • Alzheimer’s Disease • Mild Cognitive Impairment • Probable Lewy Body Dementia • Vascular Dementia • Frontotemporal Dementia • Normal Pressure Hydrocephelus • Sleep Apnea • Pseudodementia- Depression • Epilepsy • Parkinson’s Disease Plus • Alcohol Related Dementia

8. Imaging Studies • Extremely helpful tool in diagnosing which particular type of memory disorder is likely present. A trained physician can now identify classic Alzheimer’s Disease with 98% certainty.

9. Alzheimer’s Disease

10. What is Alzheimer’s Disease? • The most common cause of dementia • Irreversible, progressive disease • Affects the brain by destroying neurons – first in the hippocampus (memory area of the brain) then spreading to other areas • Neuron degeneration is felt to be from plaques consisting of beta amyloid proteins that are deposited and tangles in nerve cells

11. Is it in the Water? • “Why are so many people ‘getting it’ “ is a common question. • We do not know the exact cause nor do we have a cure. Latest research is focusing on diet and lipids. • This is a disease that, predominantly affects those > 65. • As we are living longer, the prevalence is thus higher.

12. Neuropsychological Testing • Following testing, individuals with MCI show an isolated memory loss. Those with Alzheimer’s Disease show a pattern of increased difficulty with memory, categorical fluency, orientation, and emerging problems in construction and calculations.

13. Exercise • Name as many animals as you can in 1 minute • Measures catagorical fluency • Individuals with some form of progressive memory disorder will score less than 12 and should be evaluated. • A better predictor of Alzheimer’s disease or MCI than the Mini Mental and can easily be used quickly as a screen in doctor’s offices

14. Mild Cognitive Impairment • Being researched as a likely “pre-cursor” to Alzheimer’s Disease- consists of mild memory loss that appears progressive in nature • It is crucial that these individuals are assessed as early preventative interventions are showing promise in delaying the onset or “conversion” to Alzheimer’s Disease!

15. Assessment Questions • Short term memory loss? • Financial management • Repetitive questions? • Depression? Anxiety? • Misplacing items or hiding items? • Orientation to person, place and time • Change in ability to perform hobbies or household tasks? • Occupational issues?

16. Depression Screen It is also important to address depression using a depression screening tool such as the Geriatric Depression Scale or Beck Depression Inventory. Why? Studies suggest between 20 and 30% of dementia patients in early stages develop Major Depressive Disorder and between 30-40% in middle stages. Not uncommon, depressive symptoms need to be monitored closely on a frequent basis and treated appropriately.

17. Characteristics - Early • Short term memory loss and asking questions repeatedly are often the first signs • Inability to complete familiar tasks • Difficulty learning and retaining new information • Misplacing items, often in inappropriate places • A growing awareness of subtle changes may cause depression and frustration.

18. Moderate • Forgetting to turn off stoves, appliances • Emerging safety concerns • Problems with calculations and financial management • Inappropriate in public • More problems communicating, reading, writing

19. Severe • Severe loss of memory • May be unable to recognize loved ones • More hallucinations or delusions • Void of emotion • Needs assistance with all personal cares • Difficulty chewing or swallowing.

20. Treatments • Cholinesterase Inhibitors are being used to slow the progression with good success: • Aricept • Razadyne • Exelon Other medication often used in conjunction with cholinesterase inhibitors (NMDA receptor antagonist) • Namenda

21. Key Psychosocial Issues Individuals and families coping with Alzheimer’s Disease require ongoing support as the disease progresses. A referral to the local Alzheimer’s Association is recommended for ongoing needs Although there is “staging” documented and many follow the pattern loosely, everyone has a unique, individual experience.

22. Supportive Approaches • Care partners have various thresholds in terms of their ability to manage the care of someone with progressive Alzheimer’s Disease. • Goal is to tackle each symptom as it emerges and seek manageable solutions • Behavior issues are often signs of unmet, unexpressed needs. • Important to increase activity level and provide cognitive “exercise” as well as physical and social activity.

23. The Alzheimer’s Association • Excellent organization for all types of memory disorders • Provide support, education, advocacy and programming encompassing all aspects of the disease to individuals and their care partners.

24. Other Resources for Individuals and Care Partners • Adult Day Centers • Home health agencies • Respite care • Transportation resources • Care consultants • Assisted living options • County Departments on Aging / Benefit Specialists • Aging and Disability Resource Centers • Elder Law Attorney

25. Support Groups • Support groups are very valuable and take many forms. Groups exist for: • MCI patients • Early onset Alzheimer’s disease • Care partners (spouses, family, etc) • Adult Children of people with Alzheimer’s Disease • Early stage Alzheimer’s Disease

26. Key Resources • Books and Magazines: • The 36 Hour Day – Mace and Rabins • A Dignified Life: The Best Friend’s Approach to Alzheimer’s Care – Bell and Troxel • Reminiscence magazine (Reiman Public.) • Aging with Grace - Snowdon • Learning to Speak Alzheimer’s - Coste • Mayo Clinic on Alzheimer’s Disease - Peterson

27. Resources continued: • Websites: • www.alz.org – The Alzheimer’s Assoc. • www.alzheimers.org - Alzheimer’s Disease Education and Referral Center • www.alzstore.com – The Alzheimer’s Store • www.cwag.org – Coalition of WI Aging Groups • www.dhfs.state.wi.us/aging/dementia - WI Bureau of Aging & Long Term Care Resources • www.mayoclinic.com – Mayo Clinic Health Info

28. Lewy Body Dementia

29. Lewy Body Dementia • A progressive brain disease and second leading cause of dementia in elderly. (20% of all dementia cases) • Appears to affect men more than women • Consists of protein deposits or “lewy bodies” that are widespread throughout the brain. Often the memory area looks fine on imaging. • Cognitive decline occurs prior to or concurrent with parkinsonian features • Earlier age of onset than Alzheimer’s

30. Characteristics • A probable Lewy Body Disease is defined when one meets 2 out of the 3 symptoms: • Fluctuating Cognition with clear variations in alertness. • Recurrent visual hallucinations that are very detailed • Parkinsonism – muscle stiffness and rigid, slowed movements

31. Other Suggestive Features • REM sleep disorders – vivid dreams, purposeful and sometimes violent movements • Severe sensitivity to neuroleptics (medications for psychiatric symptoms) • Abnormal depth perception – problems in visuospatial skills • Mood lability, depression, aggression

32. Neuropsychological Testing • Individuals with LBD have difficulty in the following areas of cognitive thinking: • Orientation • Construction • Perception • Memory

33. Hooper Visual Organization Test • 30 “puzzle” pictures • Indicator of visuospatial skills and posterior functioning. • Shows how we perceive and make sense of the world around us. • Often a good predictor of whether or not someone should be retested for driving abilities.

34. Hooper Visual Organization Example

35. Answer: LIGHTHOUSE

36. Clock Draw Example • Goal- To draw the face of a clock, put the numbers in the correct positions, and indicate the time at 11:10.

37. Key Psychosocial Issues Families and affected person may be dealing early on with safety issues involving the physical issues, hallucinations, and misperceptions (often leading to trouble with driving). Also, the inconsistency of symptoms and confusion, creates stress as the family never quite knows what is coming next. Loved one may not recognize family or home at an earlier stage.

38. Assessment Questions • Sleep disturbance? • Gait disturbance / Falls? • Appears socially withdrawn at times • Variable symptoms? • Hallucinations? • Disorientation? • Suspiciousness? • Wandering? • Apparent slowed processing verbally and physically • Other behavior problems or aggression?

39. Supportive Approaches • Families struggle with misperceptions- benefit from support of others in same situation (support groups). Care partners need respite! • Often occurs at a younger age- grieve loss of retirement plans, etc. • Individual often very insecure without loved one • More rapid course than AD • Physical and communication issues in addition to cognitive

40. Common Interventions • Due to Parkinsonism, individual is at a higher fall risk. Need to adapt environment and consider a Physical therapy evaluation • Misperceptions! Eg. May perceive that a black rug is a hole, or texture change represents a different height/level. Occupational therapist evaluation, adjusting home environment, adjusting lighting and visual cues • Wandering Risk – easily disorientated- Obtain Safe Return • Driving Issues – becomes lost or does not recognize once familiar landmarks. Driver evaluation and subsequent referral to transportation resources suggested

41. Treatments for LBD • Cholinesterase inhibitors (medications approved for Alzheimer’s Disease) tend to work even better for people with LBD • Parkinson’s Disease medications often help with the symptoms related to movement • It is important to diagnose LBD as some antipsychotic medications given for hallucinations can cause severe reactions in patients with this disease. (eg. Haldol)

42. Key Resources • The Alzheimer’s Association • The Lewy Body Dementia Association • Websites: • www.lewybodydementia.org LBD Assoc. • www.zarcrom.com/users/alzheimers/odem/od-d.html Directory of other Dementias • www.alz.org – The Alzheimer’s Assoc.

43. The Frontotemporal Dementias

44. Frontotemporal Dementias • Neurodegenerative changes in the frontal and temporal lobes of the brain • Several types depending on which areas show damage – eg. Picks disease (involves only frontal lobes) • Occurs between the ages of 35 and 75 years (younger than AD and LBD) Some forms are genetic. • Many early research programs are focusing on the frontotemporal dementias and “possible” reversible causes

45. Characteristics There is generally an early loss of personal awareness and sometimes an increase in social disinhibition and mood swings. Depression is common Often diagnosed at an earlier age, therefore occupational problems may exist. Family members are usually quite frustrated and require special counseling or support More rapid progression

46. The Frontal Lobe - the Gatekeeper • People who suffer from the FTDs may exhibit inappropriate behaviors in public, be less inhibited, may show mood swings, or may become quite the opposite- more depressed, apathetic and socially withdrawn.

47. Neuropsychological Testing • Frontal area involves the “doing” part of the brain- executive functioning thus testing shows difficulties in the areas of: • Behavior • Reasoning and Judgment • Planning • Initiation

48. Neuropsychological testing continued… • Temporal Area involves speech and language thus testing reveals difficulty with • Naming • Comprehension • Word finding • Speech (aphasia often noted)

49. Example – Boston Naming Test

50. Key Psychosocial Issues • Loss of Insight: Often people with frontotemporal dementias do not have insight into their difficulties. This makes it more challenging for families to provide care and that care is occasionally met with resistance • Compulsive behaviors • Lack of empathy for others- Often the care partner desires an acknowledgement for their hard work that never comes.