Alzheimer’s Dementia “A Psychiatrist’s Perspective”

2. Alzheimer’s Dementia“A Psychiatrist’s Perspective” Juan R. Jaramillo, M.D. Pathways October 22, 2002

3. Alzheimer’s DementiaIntroduction • Alois Alzheimer 1907 • “a peculiar disease of the cerebral cortex” • Brain atrophy • Characteristic microscopic lesions---plaques and tangles

8. Alzheimer’s DementiaIntroduction • Best care is offered by multidisciplinary team • Physicians, social workers, lawyers, psychologists, recreational therapists, chaplains and, especially… • Nurses and relatives • Ideally a Board Certified Psychiatrist

9. Alzheimer’s DiseaseIntroduction • Psychiatric symptoms are common • Their approach is a “juggling act” • Palliative care…still • Evidence-based please ! • “Quality of Life” as a guiding principle

10. Alzheimer’s DementiaEpidemiology • Responsible for 60-70% of dementia cases • Risk increases with age • 1 % at age 60, risk doubles every 5 years • Other risk factors: low educational level, h/o head trauma, h/o depression, ?? women, genetics

13. Alzheimer’s DementiaGenetics • Chromosome 21---amyloid precursor protein (APP) gene • Chromosome 14---presenilin 1 gene • Chromosome 1-----presenilin 2 gene • Chromosome 12---late onset dementia

14. Alzheimer’s DementiaGenetics • Most cases are not familial but “sporadic” • But still with a genetic component • Apolipoprotein E---epsilon 4 allele-----chromosome 19 • Risk increases for those with a first degree relative that has it

16. Alzheimer’s DementiaPathophysiology • Neuronal loss, amyloid angiopathy • Medial temporal lobe most affected • Temporal parietal areas and frontal lobes • Amyloid beta peptide (a normal protein) overproducedorinefficiently cleared • All these are present in the normal old age brain

17. Alzheimer’s DementiaClinical Features • Typically after age 50, but most cases in 8th and 9th decades • Insidious and gradually progressive decline in mental abilities • Memory, job performance, poor tolerance to routine disruption • MMSE declines by 3 or points per year

18. Alzheimer’s DementiaClinical Features • Independent tasks become more difficult • Hygiene may suffer • Delusional beliefs may develop • Same for hallucinations • Behavior problems

19. Alzheimer’s DementiaClinical Features • Frequency of Behaviors Apathy---------------72 % Agitation-------------60 Anxiety---------------48 Irritability------------42 Depression-----------38 Disinhibition---------36 Nighttime behavior---24 Delusions-------------22 Hallucinations--------10

20. Alzheimer’s DementiaDiagnosis • Clinical diagnosis can be accurate • Family’s insight is essential • DSM-IV TR Criteria • Memory plus 1 (or more) of *Aphasia *Apraxia *Agnosia *Executive functioning

21. Alzheimer’s DementiaDiagnosis (DSM-IV TR) • “Significant impairment” • Gradual onset and continuing cognitive decline • “Not due to something else” • Early vs. Late • Brain imaging (CT or MRI) not diagnostic

24. Alzheimer’s DementiaDiagnosis • Most important “something-elses” *Medications *Medical conditions (NPH, brain tumors) * Other psychiatric conditions *Benign forgetfulness *Mild Cognitive Impairment *Other dementias (Lewy Body, Vascular)

29. Alzheimer’s DementiaDiagnosis • Diagnostic testing *Mini Mental Status Examination---bedside test. Takes 10 minutes. 24 (or less) out of 30 points=Dementia *Dementia Rating Scale *Alzheimer’s Disease Assessment Scale (ADAS-cog) *Neuropsychiatric Inventory *Apathy Evaluation Scale

30. Alzheimer’s DementiaPsychiatric Complaints • Cognitive • Behavioral • Psychiatric

31. Alzheimer’s Dementia1. Cognitive Problems • Cholinesterase Inhibitors Donepezil (5 to 10 mg/day). Then Galantamine. Then Rivastigmine ?. • Promising: Memantine. • Others: Vit E ?, Estrogen (women), Ginkgo Biloba ?,Aspirin ?,Selegiline, Folic Acid ?

33. Alzheimer’s DementiaOther treatments “likely to be beneficial” • Ginko Biloba ???? Also for patients with mild cognitive impairment. 40 mg three times a day. Careful with interactions • Selegiline 5 mg twice a day • Reality Orientation

34. Alzheimer’s DementiaOther treatments “unlikely to be beneficial” • Estrogen---”should not be used” (AAN) • Aspirin---”unknown” • Vitamin E---some groups use it--2.000 units per day, in combination with Donepezil

35. Alzheimer’s Dementia2. Depression • Present in about 20 to 30 % of patients • Difficult to diagnose ! • All antidepressants may work---SSRI’s should be tried first---Citalopram especially, Venlafaxine and others are OK • Start low, but full doses often needed • Treatment can have a big impact on Quality of Life

36. Alzheimer’s Dementia3. Delusions • False, “unbreakable” ideas • May occur in any stage • Not confabulations • Very amenable to treatment a) Medications-----Risperidone * Olanzapine, Quetiapine b) Reassurance, benign disinterest

37. Alzheimer’s Dementia4. Hallucinations • Relatively rare • Not illusions • If present and strong, often times unresponsive • Antipsychotics-----Risperidone Olanzapine and Quetiapine • Low doses and short term !

38. Alzheimer’s Dementia5. Dangerous, careless behaviors • Driving, handling equipment, wandering • Wandering promotes institutionalization • Anxiolytics (Lorazepam) or antipsychotics (Risperidone) • ? Daily vigorous exercise • ? Badges, armbands

39. Alzheimer’s Dementia6. Restlessness, agitation, hostility • The most frequent behavioral problems that the psychiatrist is consulted for • r/o medical reasons • Reality orientation, creativeness, humanness • Medications---”trial and error”, avoid “prn’s”, start with low doses • Multiple classes of medications (cont.)

40. Alzheimer’s Dementia6. Restlessness, agitation, hostility • Price is paid in side effects • Consider hospitalization • Geropsych unit • As disease gets more advanced, behavior problems diminish

41. Alzheimer’s Dementia7. Overelated, intrusive behavior • History of bipolarity is frequent • Neuroleptics (Risperidone) and Benzodiazepines (Lorazepam) • Maybe even mood stabilizers (Lithium, Valproate, Trileptal)

42. Alzheimer’s Dementia8. Insomnia and daytime somnolence • Usually difficult to treat • ? Medical causes • May use medications * Aspirin, Tylenol, Benadryl *Trazodone *Chloral Hydrate * Temazepam • Chronic severe insomnia is major problem

43. Alzheimer’s Dementia9. Repetitive screaming and crying out • Difficult to treat • Try non-medical options first----isolation, activity, one to one, soothing music • Medication---trial and error---multiple classes

44. Alzheimer’s Dementia10. Inappropriate sexual behavior • Most often in men • Behavioral techniques---privacy v.s. limit-setting • Hormonal therapy---medroxyprogesterone injections

45. Alzheimer’s Dementia11. General regression and refusal to eat • Often times these patients seem to be in no distress • ? Stimulants (Pemoline, MPH) ? Nutritional supplements • Trying too hard may make matters worse • Avoid tube feeding

46. Alzheimer’s DementiaBehavioral Modification • To reduce urinary incontinence • To increase functional independence • To decrease problem behaviors • For eating and activities of daily living

48. Alzheimer’s DementiaMedical-Legal Issues • CELA---Certified Elder Law Attorney • The 4 basic documents *Living Will *Durable Power of Attorney for Health Care *Durable Financial Power of Attorney *Last Will

49. Alzheimer’s DementiaImpact on Caregivers • Women are 81% of caregivers • 20% of caregivers stop working • 69-100 hours/week spent in care giving • Caregivers are more likely to make more physician visits, take more medication, have a higher incidence of depression, more likely to be hospitalized

50. Alzheimer’s DementiaImpact on Caregivers • Education programs for family caregivers (short term and long term) • Education for staff in long term care facilities • Support groups • Respite