Alzheimer’s Disease

1. John Stoukides MD Chief, Division of Geriatrics and Palliative Medicine Roger Williams Medical Center Providence, R.I. Alzheimer’s Disease

2. The Far Reaching Impact of AD • Patient • 4 million affected • Increasing with aging population • 70% live at home • Family • Loss of productivity of caregivers • Painful process • Significant incidence of depression and medical illness • Society • $100 Billion / year

3. Impact of Alzheimer’s Disease on Caregivers • More than 70% of patients with Alzheimer’s disease live at home, and almost 75% of home care is provided by family and friends1 • 46% to 59% of caregivers reported depression, according to various studies2,3 1. Alzheimer’s Association. Available at: http://www.alz.org. Accessed October 7, 2004. 2. Gallagher D et al. Gerontologist. 1989;29:449-456. 3. Cohen D et al. Behavior, Health and Aging. 1990;1:171-182.

4. ALZHEIMER’SANNUAL COST TO U.S. • Heart Disease $ 183 Billion • Diabetes 112 • Cancer109 • Stroke 45 • Pulmonary Disease 24 • Pneumonic Influenza 22 • Chronic Liver Disease 9 • HIV/AIDS 7 Alzheimer’s110 Alzheimer’s average cost to each family is $25,000/ year and 100 hours/week.

7. Dementia - Definition • An unusual loss of mental function • Acquired, persistent impairment in multiple areas of intellectual function not due to delirium. • A symptom of many diseases, not a diagnosis

8. Differential Diagnosis of Dementia AD and Lewy body dementias Vascular dementias Multi-infarct dementia Binswanger’s disease Lewy body dementias Parkinson’s disease Diffuse Lewy body disease Lewy body variant of AD Other dementias Frontal lobe dementia Creutzfeldt-Jakob disease Corticobasal degeneration Progressive supranuclear palsy Many others Vascular dementias and Alzheimer’s disease (AD) AD 5% 10% 65% 8% 7% 5% Adapted with permission from Zurad E. Drug Benefit Trends. 2001;13:27-40.

9. Alzheimer’s Brain Normal Brain

10. Beginning Symptoms of AD • Progressive memory loss • recent events including time and place • Difficulty with complex tasks • Inability to use reasoning strategies • Problems finding words • Disorientation to location and direction • Have difficulty reorienting them selves to recent event • Depression

11. Mid-Stage Alzheimer’s Disease • Requires assistance with activities of daily living • Language and communications degrade • Impaired judgment • Emotional instability • Psychiatric instability • Personal hygiene decreases • Inappropriate responses • Unaware of surroundings • Trouble distinguishing people - familiar vs. strangers • Are mostly unaware of their cognitive loss

12. Late Stage Alzheimer’s Disease • Agitation, depression, delusions diminish • Need for tranquilizers lessened • Brain activity severely disrupted • Vulnerable to seizures, aspirations and pneumonia • Motor skills deteriorate • Lose ability to • Walk • Communicate • Chew and swallow • Assume fetal position • Ultimate outcome - death

13. MILD MODERATE SEVERE ADVANCED RESISTIVENESS INCONTINENCE MOTOR IMPAIRMENT BEDFAST MUTE NO MEMORY I N D E P E N D E N C E DRIVING MEMORY PERSONALITY SPATIAL DISORIENTATION EATING PROBLEMS ? INSTITUTIONALIZATION RECURRENT INFECTIONS APHASIA APRAXIA CONFUSION AGITATION INSOMNIA ? † TIME

14. Delirium in the Elderly • Acute decline in attention and cognition • Potentially life threatening • Preventable in most cases • Accounts for 49% of all hospital days in pts over 65 • Complicates 20% of all hospital admissions • Precipitating factor in most hospitalizations • Associated with very high mortality rate • Is a medical emergency

15. Clinical Features • Acute onset • Fluctuating course • Inattention(difficulty focusing, sustaining attention, maintaining conversation) • Disorganized thinking (disorganized or incoherent speech rambling or irrelevant or illogical) • Altered level of consciousness • Cognitive deficits • Perceptual disturbances

16. Psychomotor changes • Hyperactive Delirium: agitation, hyper-vigilance, inappropriate excitement and perceptual disturbances • Hypoactive Delirium: reduced motor activity, inattentive, easily distracted and unable to sustain a train of thought.

17. Additional Features Various Emotional Disturbance • Fear • Depression • Euphoria • perplexity

18. Baseline Characteristics Vulnerability • Advanced age • Organic Brain disease (stroke, dementia, PD) • Acute Medical Illness • Sensory Impairment • Diminished ADL’s (activities of daily living) • Polypharmacy • Alcohol Use • Medication misuse • Toxin ingestion

19. Precipitating Factors • Addition of more than three medications to medical regimen • Infection • Dehydration • Immobility (restraints) • Malnutrition • Temperature extremes

20. Examples of symptoms • You ask the person for his phone number after probing it is clear he doesn’t know it • Memory impairment • During the interview the person dozes off while you are asking questions • Alerted level of consciousness (lethargy) • As you ask a question the person keeps repeating the answer from a previous question • inattention

21. Examples of symptoms • The person is in a restaurant for breakfast and angrily says “why the F%@$ are they giving me eggs for dinner” • Disorientation • Person startles easily at any sound or touch, eyes open wide • ALOC vigalant • You ask why the person is stopped is sitting in their car and he says “I’ve gotta get to the yellow brick road” • Disorganized thinking

22. Examples of symptoms • As you interview the person she keeps looking at the corner then blurts out “what is that man doing there” • Perceptual disturbance (visual hallucinations) • As you begin the interview the person is looking around the room. You call her name and touch her she momentarily looks at you then starts looking around again • Inattention

23. Examples of symptoms • You introduce yourself and he says what are you doing in my home • Disorientation • You walk into the room and the person says “lucy where have you been, You said you’d be right back” • Disorientation • During the encounter the person is continuously fidgeting, dressing and undressing himself • Psychomotor agitation

24. Examples of symptoms • Between questions the person is carrying on a conversation with her husband who is not present • Perceptual disturbance (auditory hallucinations) • You ask the person if she is able to call a family member and she says “it depends on the type of party I’m at: I need a comb” • Disorganized thinking • The person remains motionless in a chair and performs tasks very slowly • Psychomotor retardation

25. Helping Patients with Troublesome Behaviors • Patients with significant cognitive impairment in most cases can not be reality oriented • Patients with agitation should be considered acutely medically ill until proven otherwise • Pacify and re-direct is usually best approach

26. Conclusion • Alzheimer’s disease is a extremely common and unfortunately incurable condition in the elderly • It has a slow steady progression, acute changes in it’s course frequently represent an acute medical illness • Alzheimer’s patients have an inability to accurately report reality or be reoriented to their current situation • Confronting an Alzheimer’s patient will frequently escalate the unwanted behaviors.