Dementia & Alzheimer’s Disease What’s the Latest???

Where did we start? Alzheimer’s first diagnosed in 1907 OBS – organic brain syndrome - common term 60’s ‘Hardening of the arteries’ & senility seemed ‘normal’ Psychiatric illness – mentally ill – 60’s-80’s Drugs and restraints – 60’s-80’s De-institutionalization - nursing homes – 70’s-80’s Diagnosis of Alzheimer’s on autopsy only – till 90’s Little could be done once diagnosed – until the 90’s Families - ‘do the best you can’ – 60’s – 90’s

Over the past 5-10 years research and knowledge has increased dramatically

Where are we NOW… Over 90-95% accuracy on diagnosis Early diagnosis - best treatment & planning Drugs can help delay symptoms Strategies to improve care & quality of life 4 ½ million people in the US – 300% increase 70-80 known causes of ‘dementia’ Some causes are reversible We can reduce our risks New info each week

How Can You Help? Encourage Durable PoA discussions early and with everyone – before its needed Encourage caregivers to write down concerns ahead of visits Screen for changes in cognition & function Make referrals to support systems Encourage brain health

Help Caregivers Appreciate… By managing their own behaviors, actions, words & reactions they can change the outcome of interactions. It’s the relationship that is MOST critical, NOT the outcome of one encounter Let health care providers be the ‘Bad GUYS’ It’s a marathon & they will need help!

SO… What is Dementia? It is NOT part of normal aging! It is a disease! It is more than just forgetfulness - which is part of normal aging It makes independent life impossible

Aging Changes in Cognition… Normal aging changes = more forgetful & slower to learn MCI – Mild Cognitive Impairment = 1 problem area Immediate recall, word finding & complex problem solving problems (½ of these folks will develop dementia in 5 yrs) Dementia = Chronic thinking problems in > 2 areas Delirium =Rapid changes in thinking & alertness (seek medical help immediately ) Depression = chronic unless treated, poor quality , I “don’t know”, “I just can’t” responses, no pleasure can look like agitation & confusion

DEMENTIA Alzheimer’s Disease Early onset Normal onset Lewy Body Dementia Other Dementias Metabolic Drugs/toxic White matter disease Mass effects Depression Infections Parkinson’s Vascular (Multi-infarct) Dementia Alzheimer’s Disease Early onset Normal onset Fronto- Temporal Lobe Dementias

Diagnosing AD Definite AD - Histopathological evidence (requires autopsy) - Course and examination characteristic of AD Probable AD - Deficits in > 2 areas of cognition - Onset 40-90 (usually > 65); progressive course - Other causes excluded Possible AD - Deficit in only 1 area of cognition - Atypical course - Other dementia causes present Unlikely AD - Sudden onset - Focal signs - Seizures or gait disturbance early in course

What happens with Alzheimer’s Disease? Two processes Cells are shrinking & dying Cells are producing less chemical to send messages

AD Pathology Amyloid plaques (Ab)

Normal Brain Cells Neurotransmitters (AChE)– being sent – message being communicated to the next cell

Normal Brain Cells Once the message is sent, then enzymes lock onto the messenger chemicals and take them out of circulation so a new message can be sent

Brain Cells with Alzheimer’s Less neurotransmitter Further to go to get to the next cell plaques tangles Enzymes (AChE inhibitors) – get to them BEFORE they deliver their message

What do Alzheimer’s drugs DO? Alzheimer’s drugs provide FAKE messenger chemicals that distract the enzymes. They attach to the Fake AChE & the message can get thru Aricept, Exelon, Reminyl (Razadyne)

One New Drug Memantine - Namenda from Europe - 10 years of research coming this year to the US different effect moderates glutamate absorption - May show language, movement, interest, participation improvement Can use it with AChE inhibitors… two actions Keeps the cell from getting so much glutamate in it

Vascular Dementia Nerve cells are OK Blood supply is damaged no oxygen gets to the cell no nutrients get to the cell Then … the nerve cells die

Vascular Damage Healthy cell with oxygen and nourishment No message Dead nerve cell - no blood supply No message

Early - Get good long term care insurance! Then - check out the possibility that something IS WRONG See someone who is interested in DEMENTIA and ALZHEIMER”S DISEASE Consider a specialist… Neurologist, geriatrician, gero-psychiatrist

Key Issues Early Diagnosis Medications & Treatment Legal Issues Financial Issues Care Options & Funding Family Support & Education Staff Support and Education

Early Diagnosis Failure to ID Early Detection safety issues family disasters $$$ disasters mis-diagnosis untreated problems fear & stress panic Early Detection drugs work better personal planning decision making $$$ planning treat the treatable counseling & support

What Should be DONE… Neuropsychological testing – screening for cognitive changes A thorough physical & medical history Blood work A neurological exam A good history from the person and the family of the ‘problem’ A complete medication review A CAT scan or MRI (atypical Alzheimer’s – PET scan) FOLLOW-UP and counseling or at least a referral

Intervention & Programming to: physical activity mental activity social activity spiritual involvement well-being and self-worth minimize ‘risky’, challenging, or ‘dangerous behaviors reduce anxiety or distress

Latest Thinking About Prevention… Help… Mental activity Aerobic activity Vitamin E (low dose) & C Heart Smart Diet Omega 3 fatty acids (fish, canola, flaxseed oils) Lower weight Not smoking Enough sleep De-stressing Moderate alcohol intake Help… Keeping iron in limits Keeping homocysteine ‘right’ – Vitamin B’s Monitor thyroid function Staying socially active Getting depression treated Control diabetes better Control hypertension better Statins (if needed) Protect your head - prevent head injuries

The person’s brain is dying Brain Failure The person’s brain is dying

New Imaging Technology for AD 67 yo NL 79 yo AD PET scan Amyloid detection Nordberg Lancet Neurology 2004

PET and Aging PET Scan of 80-Year-Old Brain ADEAR, 2003

Positron Emission Tomography (PET) Alzheimer’s Disease Progression vs Positron Emission Tomography (PET) Alzheimer’s Disease Progression vs. Normal Brains Early Alzheimer’s Late Alzheimer’s Normal Child G. Small, UCLA School of Medicine.

Alzheimer’s: a window of opportunity Reiman et al PNAS 2004 FDG-PET 20-39 year olds (~30) e4 carriers vs controls Purple: AD pts Blue: young carriers Prevention Delayed progression

Brain atrophy the brain actually shrinks cells wither then die abilities are lost with Alzheimer’s area of loss are fairly predictable … as is the progression BUT the experience is individual…

Memory

Memory Loss Losses Preserved abilities Immediate recall Attention to selected info Recent events Relationships Preserved abilities Long ago memories Confabulation! Emotional memories Motor memories

Understanding

Understanding Losses Can’t interpret information Can’t make sense of words Gets off target Preserved abilities Can get facial expression Hears tone of voice Can get some non-verbals

Talking

Language Losses Preserved abilities Can’t find the right words Word Salad Vague language Single phrases Sounds & vocalizing Can’t make needs known Preserved abilities singing automatic speech Swearing/sex words/forbidden words

Impulse Control

Impulse & Emotional Control Losses becomes labile & extreme think it - say it want it - do it see it - use it Preserved desire to be respected desire to be in control regret after action

It all starts with your approach! How can we help… better? It all starts with your approach!

Positive Physical Approach

How you talk… How you say it… What you say… How you respond…

Use empathy & Go with the flow Reality Orientation Telling Lies

How you help… Sight or Visual cues Verbal or Auditory cues Touch or Tactile cues

Hand-Under-Hand Assistance

People with dementia Are doing The BEST they can! Believe - People with dementia Are doing The BEST they can!

Remember who has the healthy brain! So WHAT should we do??? Remember who has the healthy brain!

Being ‘right’ doesn’t necessarily translate into a good outcome the person with dementia OR the caregiver