What Does Alzheimer’s Look Like?

1. What Does Alzheimer’s Look Like? James K. Cooper, MD Clinical Professor of Medicine Division of Geriatrics and Palliative Care George Washington University Medical Center Washington, DC

2. This talk is not sponsored by any pharmaceutical or other corporation.The speaker is on the staff of the George Washington University Medical Center. He has no financial interests in any product or other facility that may be mentioned.

3. Images here are presented for single, non-commercial, private, educational purposes. Further reproduction is prohibited.

5. Outline • I. Ballpark (Orientation) • The game • The clubs • Our Players • II. A Person with Alzheimer’s • III. Issues

6. Outline • I. Ballpark (Orientation) • The game • The clubs • Our Players • II. A Person with Alzheimer’s • III. Issues

7. Dementia is • Condition of decreased cognitive (brain) function • Progressive • New • Will cause memory loss • Not caused by other conditions • Depression • Metabolic/nutritional abnormalities • ‘Medical’ conditions (heart failure, lung disease) • [“secondary dementias”]

8. Morris Kantor,1934 b. Minsk, Russia

9. Outline • I Ballpark • The game • The clubs • Our Players • II A Person with Alzheimer’s • III Issues

10. Different Dementias • Alzheimer’s • Vascular • Lewy body • Frontotemporal lobe • Traumatic Brain Injury • Parkinson’s Disease • Alcohol • CADASIL • HIV

11. Alzheimer’s • Recent (Short Term) Memory • Age 65+ • Other Symptoms Late • Characteristic brain changes Amyloid plaques; tangles; in the hippocampus Rita Hayworth/ Scottie/ Floyd Patterson/ Ronald Reagan/ Dr. G Jones [IVF]/ Charlton Heston/ ADM Stockdale/ Charles Bronson /

12. Dementia Types – Alzheimer’s

15. Vascular Dementia

16. Age 65: Lord of Admiralty; Prime Minister Age 79: Nobel Prize, Literature Age 84: finishes History of English Speaking People Winston Churchill

17. Dementia types - Vascular Vascular Dementia Loss of brain functions due to the accumulation of small strokes or other cell loss due to inadequate blood flow Difficulty with decisions firstThen ↓ short term memory

18. The Nun Study. Brain Pathology: 61 had amyloid plaques and tangles (signs of Alzheimer’s)Some also had additional vascular disease How many of the 61 Nuns had Alzheimer’s dementia? Vascular lesions % Dementia None 57%Large infarcts 75%Lacunar infarcts 93% The presence of brain amyloid may not be enough to cause Alzheimer Disease. (JAMA 1997; 277: 813)

19. “Mixed Dementia” May be the most common form of dementia in the USA

20. Dementia Types – Lewy Body Dementia with Lewy Bodies (DLB) • Brief periods of confusion • Visuospatial dysfunction • Incoordination or abnormal muscle control: Falls • Sleep disorder: central regulation of consciousness • Hallucinations Memory may be OK …a tau protein abnormalityGuy M. Arch Neurology 58:1803

23. Dementia Types – Frontotemporal Lobe Personality change Loss of social inhibition Apathy (not depression) Memory May be OK

25. Alcohol Related Dementia • Normal thiamine, no vitamin deficiencies • May be noticed years after drinking stopped • Characterized by pre-frontal, frontal lobe signs: poor decision making; retained semantic and ST memory; loss of personal geographic place skills • Variable course, often very slow loss

26. 3-point stance

27. Blast injuries

29. Traumatic Brain Injury—predicted to lead to a surge of new dementia cases

30. Mild Cognitive Impairment • Not Dementia • . • . • – May Improve • . • . • . • – No medication is useful • . • . a.k.a. Cognitive Impairment, No Dementia (CIND) Schőlzel-Dorenbos: JAGS 2006;54:180 Photo: Crestis Panagiotou, ANA via Euro Pressphoto Agency

31. Different Dementias • Alzheimer’s • Vascular • Lewy body • Frontotemporal lobe • Traumatic Brain Injury • Parkinson’s Disease • Alcohol • CADASIL • HIV • (Mild Cognitive Impairment)[not dementia]_

32. Does Mr. Pickles need to be tested??Would Mr. Pickles benefit from treatment??

33. Diagnosis History Physical Exam Lab studies Brain imaging Neurobehavioral testing

34. Diagnosis –Neurobehavioral Testing As quickly as you can, please tell me the color of the ink for each word on the next slide.

35. BlueGreenRedVioletYellowOrangeBlack

36. BLUE GREEN RED YELLOW

37. Outline • I Ballpark • The game • The clubs • Our Players • II A Person with Alzheimer’s • III Issues

38. MD Patient

39. Entrepreneurs Medicare,other Insurers Residential facilities Pharmaceutical Industry Research Community Social Support Services FDA Behavioral Treatment Medications Family/Caregiver MD Person Advocacy Groups

40. Outline • I Ballpark • The game • The clubs • Our Players • II A Person with Alzheimer’s • III Issues

41. A Person with Alzheimer’s– Early AD-8 (a screening test) Judgment, e.g., finances Less interest in hobbies Repeats questions, statements, stories Trouble learning to use gadgets, computer, DVD Forgets month or year Trouble handling complex financial affairs, e.g., taxes, investments Trouble remembering appointments Daily problems with thinking or memory

44. A Person with Alzheimer’s– Early Feelings Depressed Angry “Dizzy” Disoriented Shrinking personal world

45. A Person with Alzheimer’s– Early Other Signs Misperceptions Misidentifications Delusions Hallucinations

47. A Person with Alzheimer’s– Early “Of course it upsets me. I was a reporter. I deal with facts. She says things that aren’t true.” --Retired reporter whose wife has Alzheimer’s dementia

48. A Person with Alzheimer’s– Later Cognitive Performance Scale

49. Outline • I Ballpark • The game • The clubs • Our Players • II A Person with Alzheimer’s • III Issues

50. Issues When to Start/Stop Medications How to Protect Financial Resources Is the coalition of NIH,Big Pharma, & Academic Researchers In the public’s best interest? How to Diagnose Alzheimer’s (and biomarkers) What to do with Mild Cognitive Impairment Terminal Care Pacemakers Feeding tubes How should we prepare for the expected increase in dementia from traumatic brain injuries? Who determines reimbursement for (and controls) medications and long term care?