Normal Aging, Brain Injury and Alzheimer’s Disease Annual Conference for Professionals in Brain Injury April 11, 2013

Presenters Jean Wood, Minnesota Board on Aging Mark Kinde, Minnesota Department of Health Michelle Barclay, Alzheimer’s Association

Overview of Session Normal brain changes with age Brain injuries in older adults – Prevalence, causes and comorbidities Alzheimer’s Disease and other dementias – Prevalence, identification and management Falls prevention to reduce risk for brain injury – community interventions

Demographics of Aging The baby boomers started turning 60 in According to the 2010 Census - In 2010, there were 683,000 Minnesotans age 65 and older. in 2030, there will be 1.3 million Minnesotans age 65 and older. The 85+ population is the fastest growing.

Normal Brain Changes with Aging Brain and spinal cord lose nerve cells and weight. Nerve cells may transmit messages more slowly. Reduced or lost reflexes or sensation may occur in some people. Some slight slowing of thought, memory and thinking is natural.

Brain Injury Epidemiology, MN When & where do brain injuries happen? To whom? What are the leading causes? What other illnesses or injuries occur in conjunction with brain injury? What do we know about outcomes? How much do brain injuries cost? Who pays?

ED TBI by age-group N Year

Hospitalized TBI by age-group N Year

ED TBI by gender N Year

Hospitalized TBI by gender N Year

Seasonal incidence of TBI seen in the ED Year N

Seasonal incidence of hospitalized TBI

What causes unintentional TBI? (ED treated) N Year

What causes unintentional TBI? (Hospitalized) N Year

Where do brain injuries happen? (ED TBI) N Year

Where do brain injuries happen? (Hospitalized TBI) N Year

Co-morbidity: ED treated TBI

Co-morbidity Hospitalized TBI

What about drugs & alcohol? ED Treated Hospitalized

Is income related to brain injury? (Median Income by Zip) ED TreatedHospitalized

Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death on CDC WONDER Online Database, released Data are from the Multiple Cause of Death Files, , as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at on Feb 13, :58:52 PMhttp://wonder.cdc.gov/mcd-icd10.html TBI Mortality by year, Minnesota, 55+

ALZHEIMER’S DISEASE AND RELATED DEMENTIA

Dementia is a loss of mental function in two or more areas such as language, memory, or judgment severe enough to impact daily life. 23 Alzheimer’s disease is the most common cause of dementia.

Dementia

25 Causes of Dementia in People 71+ Adams, 2002

Alzheimer’s Prevalence with Age Hebert et al (42%) years (1.6%) years (19%)

Alzheimer’s Disease Risk Factors  Age  Family history  Patients with a 1 st degree relative have a 10-30% increased chance of developing AD (van Duijn 1991)  Genetic factors  Mild Cognitive Impairment (MCI)  Vascular risk factors  Head injury  Amyloid in the brain (PET Scan)

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Progression of Alzheimer’s Disease  Early Stage: years in duration  Middle Stage: years in duration  Late Stage: years in duration

Early Stage AD  Symptoms Interfere with everyday functioning  Forgetfulness  Trouble with time/sequence relationships  More mental energy needed to process  Trouble multi-tasking  Writes reminders, but loses them  Personality changes  Shows up at the wrong time or day  Changes in appearance  Preference for familiar things

Middle Stage AD  Fluctuating disorientation  Diminished insight  Learning new things becomes difficult  Restricted interest in activities  Declining recognition of acquaintances, distant relatives, then more sig. relationships  Mood and behavioral changes  Functional declines  Alterations in sleep and appetite  Wandering

Late Stage AD  Severe disorientation to time and place  No short term memory  Long-term memory fragments  Loss of speech  Difficulty walking  Loss of bladder/bowel control  No longer recognizes family members  Inability to survive without total care

Alzheimer’s Disease: Course, Prevention, Treatment Strategies 35 INTERVENTION Primary Prevention Secondary Prevention Treatment CLINICAL STATE Normal Pre- symptomatic AD Mild Cognitive Impairment AD Numbers of people ??? 20 to 60 mil 10 to 15 mil 5.3mil BRAIN PATHOLOGIC STATE No disease No symptoms Early AD brain changes No symptoms AD brain changes Mild symptoms Mild, moderate or severe impairment STRATEGIES Identify at-risk Prevent AD Prevent or delay emergence of symptoms Stimulate memory Slow progression Treat cognition Treat behaviors Slow progression DISEASE PROGRESSION

ALZHEIMER’S DISEASE IMPACT

Nearly 90,000 Minnesotans have Alzheimer’s disease million Americans have the disease.

Number of people over 65 with AD in MN Change% increase 88,00094, ,00022,00025% Alzheimer’s Association Facts & Figures Report 2012

39 Alzheimer’s disease is the sixth leading cause of death in the United States. AD is the fifth leading cause of death for those aged 65 and older.

% change in leading causes of death: Alzheimer’s Association Facts & Figures Report 2012

41 Nearly 240,000 Minnesotans are caregivers for someone with Alzheimer’s disease. Seventy percent of people with Alzheimer’s disease live at home.

Economic Value of Caregiving in MN 42 Number of ADRD Caregivers Hours of Unpaid Care Economic Value of Unpaid Care 237,441270,397,947$3,225,847,510 Alzheimer’s Association Facts & Figures Report 2011

Age of Alzheimer’s Family Caregivers 43 *Average age = 52 years Alzheimer’s Association Facts & Figures Report 2012

Impact on the Caregiver’s Health  33% of Alzheimer’s family caregivers have symptoms of depression  Alzheimer’s family caregivers are more likely than non- caregivers to:  Report that their health is fair to poor.  Have high levels of stress hormones, reduced immune function, slow wound healing, new hypertension and new coronary heart disease. 44

45 People with Alzheimer’s disease are high users of healthcare and long-term care services. Total cost was three times higher for Medicare beneficiaries age 65+ with AD in 2004.

Average Medicare payments per person for beneficiaries age 65+ with and without ADRDs in 2008 (2011 dollars) 46 Alzheimer’s Association Facts & Figures Report 2012

47 More than seventy thousand Minnesota nursing home residents have cognitive impairment.

48 Current data suggests that less than 35% of people with Alzheimer’s and other dementias have a diagnosis of the condition in their medical record. Boise et al., 2004, Boustani et al., 2005, Ganguli et al., 2004, Valcour et al., 2000

Impact of Co-Existing Medical Conditions: Percentage of Medicare beneficiaries 65+ with ADRD and a co- existing medical condition in Alzheimer’s Association Facts & Figures Report 2012

COMMUNITY INTERVENTIONS TO IMPROVE IDENTIFICATION & MANAGEMENT OF AD

Benefits of Early Identification  Rule out other causes of cognitive impairment  Start treatment early  Better manage co-existing conditions  Understand the symptoms and how to manage them  Make decisions and future plans  Build a support system  Lower anxiety  Avoid crisis-driven care  Participate in clinical trials or other research 51

Provider Practice Tools  Cognitive Impairment ID Flow Chart  Dementia Work-Up / Provider Checklist  Intervention Checklist

Early Intervention  Goal 1: Educate about medications  Goal 2: Reduce excess disability  Treat conditions that worsen symptoms or lead to poor outcomes (depression, uncontrolled diabetes or blood pressure, etc.)  Make safety part of the plan  Goal 3: Educate about the disease, common pitfalls, and actions that lead to success  Taking Action Workbook  Goal 4: Encourage lifestyle changes that may reduce disease symptoms or slow symptom progression  Living Well Workbook

Medical Interventions: Cognitive & Behavioral Symptoms  Cholinesterase Inhibitors (early- late) - Cognex ®, Aricept ® / Donepezil, Exelon ®, Razadyne ® Side Effects: nausea, vomiting, increased bowel frequency  Glutomate blocker (NMDA receptor antagonist: mid/late) - Namenda ®  Goal: to maintain function and reduce impact of symptoms

Medical Treatment – Co-morbid Conditions and Behavioral Symptoms  Co-morbid medical conditions  Diabetes, cholesterol, blood pressure, sleep dysregulation  Psychiatric / Behavioral Symptoms  Depression  Anxiety  Aggression / Agitation  Hyper-sexuality

Reducing Excess Disability  Treat conditions that worsen symptoms or lead to poor outcomes  Depression  Co-existing medical conditions (diabetes, blood pressure, sleep dysregulation)  Stop smoking, limit alcohol  Address Safety Issues  Medication management  Fall risk  Home modification / simplification  Driving assessment  Gun safety  Financial safety  Medical emergency  Employment Issues, when applicable

57 Early Stage Current Services in Minnesota Medical Evaluation / Diagnosis / Pharmacological Treatment* Research / Clinical Trials* Care Coaching / Consultation Information / Education Early Stage Support Groups* Engagement Programs (arts, social, creativity)* Exercise / Nutrition / Cognitive Habilitation* Home Care / Companion Services* Assisted Living Medic Alert Safe Return ® * limited availability

58 Middle Stage Current Services in Minnesota Medical Evaluation / Diagnosis / Pharmacological Treatment Research / Clinical Trials* Care Coaching / Consultation / Counseling Information / Education Caregiver Support Groups* Adult Day Services* Meals on Wheels* Home Care / Home Health Care / Respite Services* Medic Alert Safe Return ® Assisted Living / Nursing Facility * limited availability

59 Late Stage Current Services in Minnesota Medical Evaluation / Diagnosis / Pharmacological Treatment Care Coaching / Consultation / Counseling Information / Education Caregiver Support Groups* Adult Day Services* Meals on Wheels* Home Care / Home Health Care / Respite Services* Medic Alert Safe Return ® Assisted Living / Nursing Facility Hospice* * limited availability

60 Minnesota Resources Telephone / Internet Resources Alzheimer’s Association alz.org/mnnd Senior LinkAge Line MinnesotaHelp.info ACT on Alzheimer’s ACTonAlz.org

Falls in Older Adults Falls are the leading cause of injury for children and for adults 35-years and older. Falls and fall-related injuries among adults over age 65 are on the rise. MN ranks 5 th among states in number of fall- related deaths.

Proven Steps to Reduce Fall Risk Ask fall risk screening questions of the adults you work with. Refer individuals at risk for falls to their physician for a comprehensive assessment. Know your community resources. Connect individuals to the resources that can help them take steps to reduce their risks.

Contact Information Jean Wood, Minnesota Board on Aging , Mark Kinde, Minnesota Department of Health , Michelle Barclay, Alzheimer’s Association ,