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DEMENTIA

matthias
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DEMENTIA

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  1. IS A LOSS OF INTELLECTUAL FUNCTION. IT IS A BROAD TERM USED TO DESCRIBE A CONDITION WHERE A PERSON EXHIBITS IMPAIRMENTS IN HIGHER CORTICAL FUNCTIONS (language, orientation, perception, agnosias, aprexias, etc), IMPAIRMENTS IN SHORT-TERM MEMORY, WITH OR WITHOUT BEHAVIORAL /PERSONALITY CHANGE IN THE SETTING OF A NORMAL LEVEL OF CONCIOUSNESS. DEMENTIA

  2. INCIDENCE: About 1-2%/year (Individuals 65 years or greater) AGE RELATED: 60-69 yrs.: 0.13% 70-79 yrs.: 0.74% >80 yrs.: 2.17% DEMENTIA

  3. PREVALENCE: About 4.5-50% (Individuals 65 years or greater) AGE RELATED: 60-64 yrs.: about 1% 65-75 yrs.: about 5-9% 75-85 yrs.: about 10-15% >85 yrs.: about 50% OVERALL: 4-5 Million: ALABAMA 79,000 DEMENTIA

  4. 1 in 8 people (13%) have AD ½ million cases/yr by 2010; 1 million/yr by 2050 1 case every 77 sec.; by 2050 1 every 33 sec. Fifth case of death in people older than 60 Morality rate increased by 45% between 2000 and 2005, while it decreased for heart disease, stroke, prostate and breast cancer OTHER FACTS ABOUT ALZHEIMER’S DISEASE

  5. Direct cost to Medicare/Medicaid and indirect costs to businesses with employees who are caregivers was $148 billion annually. In 2000, Medicare cost for AD was 3 time higher than for other illnesses ($13,000 vs $4,500) In 2007, 10 million Americans 18 yrs and older provided 8.4 billion hrs. of unpaid care ($89 million), 4 times what Medicare pays for nursing home care OTHER FACTS ABOUT ALZHEIMER’S DISEASE

  6. DIAGNOSIS • MANAGE • EDUCATE • RECOGNIZE DEMENTIAPHYSICIAN’S OBLIGATION

  7. HISTORY OF MEMORY PROBLEM • DOCUMENTATION OF MEMORY PROBLEM • NEUROLOGICAL EXAMINATION DEMENTIAMAKING THE DIAGNOSIS

  8. MINI-MENTAL STATE EXAM • CATEGORY GENERATION • MATH • REASONING • LANGUAGE • SPATIAL ABILITIES DEMENTIACOGNITIVE IMPAIRMENT

  9. MINI-MENTAL STATE EXAM • ORIENTATION: 10 POINTS • IMMEDIATE RECALL: 3 POINTS • ATTENTION: 5 POINTS • DELAYED RECALL: 3 POINTS • HIGHER COGNITIVE FUNCTION: 9 POINTS DEMENTIACOGNITIVE IMPAIRMENT

  10. MINI-MENTAL STATE EXAM • CATEGORY GENERATION • MATH • REASONING • LANGUAGE • SPATIAL ABILITIES DEMENTIACOGNITIVE IMPAIRMENT

  11. DEMENTIAPOTENTIALLY REVERSIBLE CAUSES • STRUCTURAL BRAIN LESIONS • METABOLIC DISORDERS • CNS INFECTIONS • PSYCHIATRIC ILLNESSES • SUBSTANCE ABUSE • MEDICATIONS

  12. ALZHEIMER’S DISEASE • DIFFUSE LEWY BODY DISEASE • FRONTO-TEMPEROL DEMENTIA • PARKINSON’S DISEASE • VIRAL AND PRION INFECTION • MULTIPLE STROKES • OTHER DEMENTIAIRREVERSIBLE CAUSES

  13. BLOOD COUNTS & CHEMISTRIES • THYROID PANEL, B12, RPR • CRANIAL IMAGING (CT/MRI) • ?PET/SPECT • NEUROPSYCH. TESTING • ?LP? • PSYCHIATRIC EVALUATION DEMENTIALABORATORY EVALUATION

  14. MRI OF AD Figure 2. MRI in(a) normal, (b) mild Alzheimer's disease, and (c) moderate Alzheimer's disease subjects, showing medial temporal atrophy, which is worse on the left in subject (b).

  15. PETSCAN AD

  16. SHORT TERM MEMORY LOSS • LANGUAGE DIFFICULTY (naming) • PSYCHIATRIC DISTURBANCES (irritability/personality change) • PRESERVATION OF SOCIAL GRACES • SUPERIFCIALLY APPEAR NORMAL ALZHEIMER’S DISEASEEARLY PHASE

  17. INREASING INTELLECTUAL FAILURE • INCREASING APRAXIAS • SOCIAL WITHDRAWAL • INCREASING MEMORY PROBLEMS • INCREASING LANGUAGE PROBLEMS • SPATIAL & VISUAL AGNOSIAS • BEHAVIORAL PROBLEMS ALZHEIMER’S DISEASEMIDDLE PHASE

  18. LOSS OF RECOGNITON OF SELF & ENVIRONMENT • CHAIR/BED BOUND • DOUBLY INCONTINENT • FEEDING DIFFICULTIES • MUTE ALZHEIMER’S DISEASELATE PHASE

  19. DOMINANT HEMISPHERE: APHASIA WORD FINDING & HESISTENCY PARAPHASIAS & NEOLOGISMS • NON-DOMINANT HEMISPHERE: DRESSING APRAXIA VISUAL AGNOSIAS CONSTRUCTIONAL APRAXIA ALZHEIMER’S DISEASEATYPICAL PRESENTATIONS

  20. PARKINSONISM • SEIZURES • MYOCLONUS ALZHEIMER’S DISEASEOTHER SIGNS & SYMPTOMS

  21. DEFINITE: Requires Clinical and Brain tissue • PROBABLE: 6 Month Hx of Cognitive Decline; STM loss; Loss in at least 2 other Cognitive Domains; Functional Impairment at Work or Home; No other Illness know to cause Dementia • POSSIBLE: Atypical Presentation or Progression; Only 1 Cognitive Domain affected; Other illness known to cause Dementia but not felt to be the cause (i.e. B12 deficiency) ALZHEIMER’S DISEASECRITERIA FOR DIAGNOSIS

  22. VULNERABLE AREAS Hippocampus Association Cortex Amygdala Nucleus Basalis Locus Cerulerous Raphe Nuclei ALZHEIMER’S DISEASEPATHOLOGICAL CHANGES

  23. NEUROFIBILLARY TANGLE • NEURITIC PLAQUE • AMYLOID PROTEINS ALZHEIMER’S DISEASEMICROSCOPIC PATH.

  24. APP METABOLISM

  25. AMYLOID HYPOTHEISIS • NEUROFIBILLARY TANGLE HYPOTHESIS • F REE-RADICAL MECHANISMS • INFLAMMATORY MECHANISMS • CHOLINERGIC LOSS • CHOLESTREROL/ STATINS? ALZHEIMER’S DISEASEPATHOLOGICAL MECHANISMS

  26. AGE 1% Population over Age 65 5% at Age 65 20-50% at Age 80 and Over • FAMILY HISTORY Autosomal Dominant Transmission Increased Risk for 1O Relatives • DOWN’S SYNDROME All get Pathological Changes of AD ; 30-50% develop Dementia ALZHEIMER’S DISEASERISK FACTORS

  27. GENDER More women than men: 1.5-2 w/m • EDUCATIONAL LEVEL Lower education greater risk • VASCULAR RISK FACTORS Heart Healthy is Brain Healthy i.e. Hypertension and elevated Cholesterol are Risks for AD ALZHEIMER’S DISEASERISK FACTORS

  28. AUTOSOMAL DOMINANT TRANSMISSON • EARLY ONSET : <65 YEARS CHROMOSOME 1: Volga Germans; Presenilin 2 CHROMOSOME 14: 70%; Presenilin 1 CHROMOSOME 21: 5-10% • LATE ONSET: >65 YEARS CHROMOSOME 19 families ALZHEIMER’S DISEASEGENETICS

  29. APOLIPOPROTEIN E (Apo-E) 3 isoforms E1,2 & 3; E4 found in 50% of AD and only 10% of normals; Chromosome 19 • MUTATIONS IN APP CHROMOSOME 21: Variety of point mutations ALZHEIMER’S DISEASEGENETICS

  30. CHOLINESTERASE INHIBITORS Aricept (Donepezil) Exelon (Rivastigimine) Razadyne IR , ER (Reminyl; Galantamine) • NMDA RECEPTOR INHIBITORS Namenda (Memantine) ALZHEIMER’S DISEASEMEDICATIONS

  31. IDENTITY OF CAREGIVERS Spouse Adult Childern • SPECIAL STRESS Spouse : may be older in ill health; role reversals; increased work Adult Childern: often working; own family; childern ALZHEIMER’S DISEASECAREGIVERS

  32. AD CAREGIVERS SPEND 69-100 HRS/WK PROVIDING CARE • AD CAREGIVER REPORT MORE: 40 % MORE MD VISITS 70% MORE PRESCRIBED DRUGS MORE HOSPITALIZATIONS • 50% AT RISK FOR DEPRESSION ALZHEIMER’S DISEASECAREGIVER BURDEN

  33. DENIAL • OVER INVOLVEMENT • ANGER • GUILT • ACCEPTANCE ALZHEIMER’S DISEASECAREGIVER ADJUSTMENT

  34. RECOGNIZE CAREGIVERS STRESS • ACKNOWLEDGE CAREGIVERS’ FEELINGS • REFER TO SUPPORT GROUPS • REFER TO PROFESSIONALS • PROVIDE EDUCATION • BE AVAILABLE ALZHEIMER’S DISEASEPROFESSIONAL RESPONSIBILITIES

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