Dementia and Aging Steven Huege, M.D Assistant Professor of Clinical Psychiatry Perelman School of Medicine at the University of Pennsylvania

Dementia and Aging Contrary to popular belief: Dementia and Memory loss are not part of normal aging Cognitive processing does slow down, but progressive short term memory loss is not normal and warrants a thorough work-up

Dementia Syndrome characterized by a deterioration of cognitive ability from a previous level leading to impairment in functioning. Can have many causes – Infectious (HIV, syphilis) – Toxic/Metabolic (Cu, Pb, ETOH, Folate, B12 deficiency) – Neurodegenerative/Vascular (Alzheimer’s, Parkinson’s, Lewy Body, FTD, Prion) – “Structural” (Normal Pressure Hydrocephalus, Tumor)

Prevalence of Dementia Major health problem, especially as population ages 3-11% of community-dwelling adults age >65 have dementia 20-50% age >85 have dementia In 2000, 4.5 million people had Alzheimer’s

Population with Alzheimer’s in U.S Alzheimer’s Association

Alzheimer’s Dementia Major health problem, especially as population ages 3-11% of community-dwelling adults age >65 have dementia 20-50% age >85 have dementia In 2000, 4.5 million people had Alzheimer’s

NIA: Updated criteria for Dementia 1.Interfere with the ability to function at work or at usual activities 2.Represent a decline from previous levels of functioning and performing 3.Are not explained by delirium or major psychiatric disorder 4.Cognitive impairment is detected and diagnosed through a combination of (A) history-taking (B) an objective cognitive assessment 5.The cognitive or behavioral impairment involves a minimum of two of the following domains: I.Impaired ability to acquire and remember new information II.Impaired reasoning and handling of complex tasks, poor judgment. III.Impaired visuospatial abilities IV.Impaired language V.Changes in personality, behavior, or comportment

NIA: Alzheimer’s Criteria Meets criteria for dementia + A.Insidious onset. Symptoms have a gradual onset over months to years B.Clear-cut history of worsening of cognition by report or observation C.The initial and most prominent cognitive deficits are evident on history and examination in one of the following categories. a. Amnestic presentation b. Nonamnestic presentations: i. Language presentation ii. Visuospatial presentation: The most prominent deficits are in spatial cognition, including object agnosia, impaired face recognition, simultanagnosia, and alexia iii. Executive dysfunction: The most prominent deficits are impaired reasoning, judgment, and problem solving

Pathology of Alzheimer’s Senile (Amyloid) Plaques – Extracellular – Result from accumulation of proteins and an inflammatory reaction around deposits of β- amyloid Neurofibrillary Tangles – Intracellular – Aggregates of hyperphosphorylated microtubular protein tau

Tangles and Plaques ladulab.anat.uic.edu/images/ADstain.jpg

Symptoms of Alzheimer's at various stages of illness Mild Moderate Severe

Mild AD MMSE 20 Memory complaints-cardinal symptom! Decreased knowledge of current events Difficulty performing complex tasks Impaired concentration Less able to manage travel, finances Disorientation Word finding difficulty Pt may not be aware of deficits

Moderate MMSE 15 Inability to recall address, names of family members Some disorientation Still retain major biographical info about self Initially able to toilet, feed, but may become more impaired as illness progresses Worsening language and apraxia

Severe MMSE <5 Minimal verbal ability Incontinent Unable to perform even basic ADL’s Immobile Completely dependent on others for all aspects of care

Mild Cognitive Impairment (MCI) Memory Impairment beyond normal limits Performance < 1.5 SD on memory testing No major impairment in functioning Able to carry out all ADL’s 70% of pts with MCI will progress to dementia

Biomarkers for Alzheimer’s Dementia Sperling, et.al. 2011

Neuropsychiatric Symptoms of AD Based on Scores on MPI > 4, Lyketsos, C. JAMA 2002 SymptomMCI %AD% Delusions238 Hallucinations418 Agitation1553 Depression2058 Anxiety1635 Disinhibition125 Irritability2445 Sleep2872 Eating2057 Aberrant Motor Activity743 Apathy2097

Pharmacological Treatments Cholinesterase inhibitors Memantine Antidepressants/Antipsychotics None are disease modifying, preventative or curative Symptomatic treatments only

Survival by Dementia Type Fitzpatrick, et.al 2005

Conclusion Dementia can be thought of a “biopsychosocial” illness. The cognitive impairment from dementia requires pt, caregivers, and physicians to address all aspects of pt’s life.