ACT on Alzheimer’s Disease Curriculum Module I: Disease Description

Disease Description These slides are based on the Module I: Disease Description text Please refer to the text for all citations, references and acknowledgments

Module I: Learning Objectives Upon completion of this module the student should: Gain understanding of normal aging and cognitive functioning. List potential causes of dementia and memory loss. Identify the impact that Alzheimer’s disease and other dementias have on the human brain and functioning. Demonstrate knowledge of Alzheimer’s disease including: stages and categories, symptoms, diagnosis, risk factors, and disease duration.

Normal Aging

Normal Aging Intelligence remains intact Principal changes in “normal” aging: General slowing of cognitive performance Decrease in mental flexibility Solving new problems with old solutions Mild word-finding difficulties Names of places, objects, people Mild decrease in working memory Manipulating information mentally (working a math problem in your head) “Senior moments”

Normal Aging Independence in daily activities preserved Complains about memory but provides considerable detail re: instances of forgetfulness Patient often more concerned than close family Recent memory intact for important events Normal performance on mental status exam

Description of Dementia

Dementia is NOT normal aging What is Dementia? A chronic and persistent disorder caused by a brain disease or injury that produces a decline in memory and intellect from some previously higher level of functioning severe enough to interfere with everyday life. Dementia is NOT normal aging Dementia is a syndrome, a collection of signs and symptoms occurring together, not the name for a single disorder

Dementia Alzheimer’s Disease Brain tumor Pick’s disease Vascular dementia Lewy Body Disease Alzheimer’s Disease

Causes of Dementia According to Adams (2002), the causes of dementia in people 71 years and older are: Alzheimer’s disease is the leading cause of dementia, accounting for 70% or more of cases. [need to resolve which slide to use, this one or the next one]

Alzheimer’s Disease Alzheimer’s disease is the most common form of dementia, accounting for 60-80% of all cases Symptoms of Alzheimer’s disease include: Early stage symptoms may include difficulty remembering names and recent events Mid-stage symptoms may include deficits that impact language and visuospatial function Later stages include impaired judgment, confusion and difficulty walking, talking and swallowing

Vascular Dementia Vascular dementia (VD) was previously known as multi-infarct or post-stroke dementia VD is rarely the primary cause of dementia (5-10% of all cases) VD frequently overlaps with Alzheimer’s disease Clinical manifestations can be divided into cortical and subcortical syndromes

Vascular Dementia For cortical syndromes, the presenting symptoms vary to the original stroke location For subcortical syndromes, presenting symptoms include focal motor signs, gait disturbance, and personality changes, and cognitive changes including mild memory deficit

Other Forms of Dementia While Alzheimer’s disease and Vascular Dementia account for the vast majority of dementia cases, there are other forms of dementia: Lewy Body dementia Mixed dementia Parkinson’s disease Frontotemporal lobar dementia Creutzfeldt-Jakob disease Normal pressure Hydrocephalus

Memory Loss In addition to dementia, memory loss can result from a variety of conditions: Vascular (stroke, hypoxic injury after cardiac arrest) Infectious diseases (Herpes simplex, HIV) Toxic (alcoholism, medication overdose) Autoimmune Metabolic (B12 deficiency, electrolyte imbalance)

Memory Loss Other non-dementia conditions that may cause memory loss: Neoplastic (brain tumor) Traumatic (traumatic brain injury) Endocrine (Hypothyroidism) Episodic (seizure, migraine) Neurodegenerative (Huntington’s Disease)

Neuroanatomy of Memory Loss Memory is divided into the following memory systems: Episodic memory: remember last minutes to years, this type of memory is most commonly impacted by Alzheimer’s disease Working memory: type of memory lasting seconds, impacted by vascular dementia Semantic memory: consists of factual information Procedural memory: driving a car or riding a bike

Alzheimer’s Disease

Alzheimer’s Disease Is: A progressive, degenerative, neurological disease of the brain A steady decline in memory and cognitive functioning severe enough to interfere with everyday life Related to specific chemical and structural changes in the brain NOT reversible What is Alzheimer’s disease? Alzheimer’s disease was first identified in 1906 by Alois Alzheimer a German physician. He had a female patient who was described by the caregivers in the sanitarium where she lived as becoming more child-like as she aged. When she passed away Dr. Alzheimer’ did an autopsy and found in her brain the markers of Alzheimer’s disease: plaques and tangles. Alzheimer’s disease is a progressive, degenerative, neurological disease of the brain. There is a steady decline in memory and intellectual functioning that is severe enough to interfere with a person’s everyday life. Alzheimer’s disease is the most common form of dementia. We will be discussing other forms of dementia in an upcoming slide. Alzheimer’s disease is not reversible.

What does Alzheimer’s Look Like? Neurofibrillary tangles Amyloid plaques Decrease in chemicals that facilitate memory Cell death Many changes occur in the brain as a result of Alzheimer’s disease. There is a presence of plaques and tangles. Although, it was believed for many years that the plaques and tangles caused the many symptoms of Alzheimer’s, there is now research that indicates that although these are present, there may be other prior processes which play an integral role in the progression of Alzheimer’s disease which begin before these biomarkers are evident. Neurofibrillary Tangles are caused by abnormal processing of a protein called tau. As Alzheimer’s develops, the tau protein changes chemically. These proteins unravel and clump together. Plaques: dead and dying nerve terminal cluster around abnormal fragments of amyloid proteins and interfere with the transmission of impulses Also, acetylcholine (important chemical messenger) production is decreased (caused by the enzyme acetylcholinesterase). This makes nerve receptors less receptive to impulses. Degeneration of the hippocampus: This area of the brain is responsible for learning and new memories Analogy: (This illustration may/may not be used depending on the audience.) So what is going on in the brain of a person with Alzheimer’s disease? Alzheimer’s disease affects memory and learning If I asked you what day it is today and you told me ______. My brain will take that piece of information, capture it and make it into a memory. Hopefully then, I will remember that date all day. The way thoughts travel through the brain can be compared to a train. Let’s say the people in (Insert Any Town in Your Region) do not know what date it is. They ask the people in (Insert a town close to the first town you chose) and they tell them today is (Have the group tell you again what day it is). In the brain of a person without Alzheimer’s disease the “train” or thought, goes from the point of entry to where our brain stores that memory. On a blank overhead/whiteboard draw a train with today’s date in one of the boxcars and then draw a line from one town to another In the brain of a person with Alzheimer’s disease there are neurofibrillary tangles which are twisted filaments that occur as abnormal structures in the brain blocking that memory’s storage. On the same overhead/whiteboard take a pen and draw (see example) a line from the town you started in and draw the line all over the page to illustrate the track being twisted and turned It takes much longer for the information to get from point A to point B in the brain when the “track” is twisted. There are also plaques in the brain of person with Alzheimer’s disease. These are dead and dying nerve terminals that cluster around abnormal fragments of amyloid proteins and interfere with the transmission of impulses. On the overhead/whiteboard add “boulders” on the twisted track to illustrate the plaques (see example) So now the thought is traveling all over the brain, taking much longer to get where it needs to go and has to push through the plaques that slow it down even more and in some cases will stop the thought completely. Acetylcholine production is decreased as well in the brain of a person with Alzheimer’s disease. This makes nerve receptors less receptive to impulses. This is like the train that is carrying the thought through the brain gradually running out of fuel. On the overhead/whiteboard add puffs coming out of the steam stack on the train carrying today’s date (see example) There is also a degeneration of the hippocampus. This is the area of the brain responsible for learning and new memories. This is like the conductor getting off the train. The train now has no one to give it direction. On the overhead/whiteboard draw a conductor next to the train (see example) This is why repetition happens to people with Alzheimer’s disease. The part of their brain that takes information and makes it a memory is dying so every time they ask you a question and you give them an answer it is the first time they have heard the information. Unfortunately, no matter how many time they will never “learn” the answer. Imagine if you didn’t know what day it is or what time it was? How would you know where you were supposed to be or what you were supposed to be doing? Now imagine feeling that way everyday. Another possible analogy: Imagine a brain as a lawn with millions of healthy blades of grass. Then in the center of the lawn creeping charlie begins to grow. It gradually grows and wraps around each blade of grass slowly strangling and eventually killing each one. Ultimately it will grow to cover and kill the entire lawn. (This analogy is similar to AD because the process gradually begins and then works its way throughout the brain.)

Impact of Alzheimer’s on Brain Size Image appears courtesy of Dr. Richard E. Powers, Director of the Alabama Bureau of Geriatric Psychiatry, alzbrain.org

Symptoms of Alzheimer’s Disease Memory loss that disrupts daily life Challenges in planning or solving problems Difficulty completing familiar tasks Confusion with time or place Trouble understanding visual images or spatial relationships

Symptoms of Alzheimer’s Disease New problems with words in speaking or writing Misplacing things or losing the ability to retrace steps Decreased or poor judgment Withdrawal from work or social activities Changes in mood and personality

Categories of Alzheimer’s Disease The severity of Alzheimer’s disease can be broken down into three categories: Mild cognitive decline Moderate cognitive decline Severe cognitive decline

Categories of Alzheimer’s Disease Mild cognitive decline includes three stages: Stage 1: no impairment, normal function Stage 2: very mild cognitive decline, occasional memory lapses; may be normal aging or the earliest signs of Alzheimer’s disease Stage 3: mild cognitive decline, early-stage Alzheimer’s may be diagnosed at this stage; family and friends may begin to notice changes

Categories of Alzheimer’s Disease Moderate cognitive decline includes two stages: Stage 4: moderate cognitive decline (mild or early-stage Alzheimer’s disease); careful medical interview should discover clear-cut symptoms Stage 5: moderately severe cognitive decline (moderate or mid-stage Alzheimer’s disease); individuals begin to need help with day-to-day activities

Categories of Alzheimer’s Disease Severe cognitive decline includes two stages: Stage 6: Severe cognitive decline (moderately-severe or mid-stage Alzheimer’s disease), memory loss worsens, changes in personality and individuals may need help with daily activities Stage 7: Very severe cognitive decline (severe or late-stage Alzheimer’s disease), individuals lose the ability to respond to their environment and need help with much of daily personal care

Diagnosis of Alzheimer’s Disease Diagnosis of Alzheimer’s disease is commonly made by an individual’s primary care physician or neurologist. Steps in the diagnosis process include: Getting a family and medical history Family members provide input Conducts cognitive test and physical and neurologic exams May include MRI or CT scans to detect changes in the brain

A Modern Diagnosis of Alzheimer’s In 2011, the National Institute on Aging (NIA) recommended new diagnostic criteria and guidelines for Alzheimer’s disease The new criteria and guidelines update, refine and broaden the guidelines published in 1984 Three new stages of Alzheimer’s disease were proposed in 2011 to replace the prior stages that were developed in 1984

Three Stages of Alzheimer’s Preclinical Alzheimer’s disease Mild Cognitive Impairment (MCI) due to Alzheimer’s disease Dementia due to Alzheimer’s disease These are new stages

Preclinical Alzheimer’s Disease Measurable changes in the brain that indicate signs of disease, but no development of symptoms Alzheimer’s disease changes in the brain 20 years before symptoms occur Additional biomarker research is needed before this stage of Alzheimer’s disease can be diagnosed

MCI due to Alzheimer’s disease Individuals with MCI have mild but measurable changes in thinking abilities 10-20% of people over 65 years of age have MCI We do not know why some people with MCI develop dementia and others do not

Dementia due to Alzheimer’s Disease This stage encompasses all stages of Alzheimer’s disease as they are listed in the previous stage descriptions from mild / early stage to severe / late-stage This stage is characterized by memory, thinking and behavioral symptoms that impair a person’s ability to function in daily life

Causes of Alzheimer’s Disease The cause or causes of Alzheimer’s disease are not yet known Experts believe that Alzheimer’s develops as a result of multiple factors, rather than a single cause These factors include a variety of changes in the brain Accumulation of the protein-amyloid outside neurons Accumulation of the protein tau inside neurons Genetic mutation is a known cause of Alzheimer’s disease

Risk factors for Alzheimer’s Most people with Alzheimer’s are over the age of 65. In addition to advancing age, other risk factors include: Family history Apolipoprotein E-ε4 (APOE-ε4) Mild Cognitive Impairment (MCI) Cardiovascular disease risk factors Social engagement and diet Head trauma and traumatic brain injury (TBI) Lack of education

Alzheimer’s Disease Duration Studies indicate that people age 65 and older with Alzheimer’s disease survive a median of three to eight years after a diagnosis, yet some live as long as 20 years On average a person with Alzheimer’s will spend more years (40% of the total number of years with Alzheimer’s) in the most severe stage of the disease than in any other stage Alzheimer’s disease is the sixth leading cause of death in the United States