Memory Loss, and Alzheimer’s: Leadership Summit Biloxi, Mississippi October 11 -13, 2018 Memory Loss, and Alzheimer’s: What we need to know Monica W. Parker, MD

Questions we will discuss today 1) Are Dementia and Alzheimer’s the same thing? 2) What Is Mild Cognitive Impairment? 3) How do we diagnose Alzheimer’s Disease? 4) Can we prevent Alzheimer’s ? 5) Is research Safe?

Alzheimer’s Disease is Expensive Dementia costs more to American society than heart disease and cancer – and is now the most expensive disease in the United States –  Average, annual, per-person Medicaid spending on seniors with Alzheimer’s disease or another dementia is 19 times higher than average per-senior Medicaid spending on those without Alzheimer’s 75% of Alzheimer’s patients end up in a nursing home by age 80 51% of AD patients rely on Medicaid Georgia Medicaid - $2 billion just on long term nursing care for seniors in 2010 Source: HealthPayer Intelligence

Social and Economic Costs of AD AD is the 4th leading cause of death for AA 65+in the US.1 Annual healthcare costs in US is $226 billion costs $217 billion in unpaid caregiving.1 Annual costs for health care, long-term care, and hospice care for patients with AD and other dementias are expected to increase to more than $1 trillion in 2050.1 AD appears to be the most costly illness in the United States, even more so than cancer and heart disease.2 Alzheimer’s Association, 2015 (www.alz.org/facts/downloads/facts_figures_2015.pdf). 2. Hurd MD et al. N Engl J Med. 2013;368:1326-1334.

The Alzheimer’s Disease Epidemic US Population > 85 years old (in millions) . . . 5.5 million today . . . nearly 50% over age 85 have AD . . . . . . 70 million baby boomers turning 65 – ~10,000 per day thru 2030

Prevalence of Dementia

Figure 3. Age-adjusted death rates for Alzheimer’s disease, by Hispanic origin, race for non-Hispanic population, and sex: United States, 2010 http://www.cdc.gov/nchs/data/databriefs/db116_fig3.png) NOTE: Death rates for Hispanic origin should be interpreted with caution because of inconsistencies in reporting Hispanic origin on the death certificate as compared with censuses, surveys, and birth certificates. SOURCE: National Vital Statistics System, Mortality.

Medicare Beneficiaries 50% of all Medicare recipients have ADRD 92% of patients with ADRD have at least 1 chronic disease Medicare recipients with ADRD have four or more chronic diseases High blood pressure, Diabetes, High cholesterol, Heart Disease, Chronic Kidney Disease, Anemia, Rheumatoid Arthritis, Depression, COPD, Heart Failure

What Is Dementia or NCD? Dementia or Neurocognitive Disorders(NCD), are NOT NORMAL in aging! Two or more brain functions are affected Symptoms and behaviors interfere with normal social or occupational function No effective treatment Symptoms may overlap with delirium, a treatable medical problem ( infection, dehydration, meds)

Neurocognitive Disorders in DSM-5: Impairment Across 6 Key Domains Symptoms Complex attention Ability to attend to and process multiple stimuli Executive function Ability to plan, organize, and complete tasks/projects Learning and memory Acquiring, manipulating, and remembering items, facts, words and their meanings, events, people, procedures, skills, etc. Perceptual-motor Identification and manipulation of figures, maps and items; motor tasks; recognition of faces and colors Language Expressive and receptive language skills Social cognition Socially appropriate behaviors and decision-making; empathy APA. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013. Alzheimers Summit.Los Angeles.091615

What is Mild Cognitive Impairment? An Acquired condition that may affect only ONE higher brain function. Cognitive impairment does NOT interfere with normal activities Symptoms are mild and persistent Earliest detectable stage of illness may NOT result in dementia

Frequency of Dementia Disorders LB,CTE,HIV,ETOH Frontotemporal (FTD) Alzheimer’s Disease 52% Parkinson’s Disease Vascular 17% AD + Vascular 14%

Dementia Symptoms Memory Loss Repetition of words, stories, phrases Loss of bowel and bladder function Inability to independently dress, groom, toilet, feed or manage finances or meals Gait instability- falls Personality Changes- belligerent, apathy Psychoses- paranoia

Dementia Behaviors Wandering Personality Changes- irritability Paranoia- fear, suspicion Hallucinations Unusual Spending/Buying Compulsive Behaviors Driving Difficulties-accidents, getting lost

How do you Address Behaviors? See a Doctor! A careful medical evaluation is required to look for treatable causes Address problems with a trained professional ( MD, elder attorney, Occupational therapist) to manage finance, health, behavior problems Enroll in caregiving training classes and support groups

Risk Factors for Brain Dysfunction Advanced Age Medication Interactions Genetics/Gender Chemotherapy Stroke and CVD benzodiazepines Atrial Fibrillation Sleep Disorders Heart Failure Diabetes Hypertension High Cholesterol Thyroid Disease Mood Disorders Head Trauma Depression Substance Abuse B, D, Folate ETOH, tobacco Vitamin Deficiencies

Factors that Protect the Brain Education Formal training, music, language Exercise Moderate aerobic Anti-inflammatory drugs Aspirin, ibuprofen, antioxidants Statins-protect against CVD risk Red wines Social Engagement Preventing Hearing Loss Treating Depression Managing chronic diseases: HTn; T2DM;CVD Getting enough Sleep Maintaining Healthy Body Weight Mediteranean or Heart Heathy Diet

Alzheimer’s Pathology

Brain Autopsy Specimens

Stages of Dementia Diseases End-stage cognition Dependent Poor quality of life Profound loss of abilities Behavioral problems Increasing burden Worsening memory Functional limitations Needing more support Isolated memory Independent Excellent quality of life Cognition Preclinical Stage Mild Dementia Moderate Severe Age 45 50 55 60 65 70 75 80 85 Mild Cognitive Impairment

Annual Wellness Visit (AWV) Age 65 and annually (www.medicare.gov) No CO-PAY Allows review of preventive health measures Immunizations Preventive examination review Vision Cancer( mammograms, lung,colonoscopy) Hearing Diabetes, cholesterol,anemia screening Dementia/depression screening

How is dementia diagnosed? Comprehensive Medical Exam Medication review medical history and diagnoses Thyroid, diabetes, syphilis, diabetes, vitamin tests Brain Imaging – MRI, Amyloid Pet Scan Neuropsychologic Testing Spinal Fluid examination via Lumbar Puncture for AB and tau protein precursors

Treatment There is no known cure for brain degenerative disease.

Medications for Symptoms Cholinesterase inhibitors Aricept –donepezil Razadyne (galantamine) Exelon(rivastigmine) NMDA Antagonists Namenda- Memantine Antidepressants to manage mood/sleep Zoloft, Citalopram, Lexapro, Trazodone, Mirtazepine Antipsychotics to manage psychosis Risperdal; Seroquel; Geodon Exelon

Alzheimer’s Research The NINDS reports US volunteers for Alzheimer’s and NCD research studies are: 70% European American 12% African American 8% Asian American 10% Hispanic 53% Female 44% Male

Research Inclusion is a Civil Right The Revitalization Act of 1993 requires that women and minorities be included in all clinical research studies funded by NIH because: -Disease prevalence varies by population - -Treatment for chronic diseases may not be as effective for minority persons as for those of European descent

Institutional Review Boards Are regulatory agencies at each institution that reviews studies before they are allowed to proceed. They ensure safety ethical conduct of research investigation Protection of personal privacy Informed consent for voluntary participation

Summary Dementia is NOT a normal part of aging Persons 65+ need an Annual Wellness Visit (AWV) Allows yearly screen for memory and mood Medications, chronic diseases, mood disorders may cause symptoms of dementia There is no drug available to cure dementia Lifestyle changes and control of chronic disease can prevent brain dysfunction Research is ongoing. Effective treatments require the participation of all people

Websites www.alzu.org Tutorial about the disease www.alz.org Resources forcaregivers www.alzheimers.gov resources for care, diagnosis, caregiving, education and training, research trials