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

2. 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

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

4. 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

5. 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

6. 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!

7. 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

8. 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

9. 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

10. Diagnosing AD
Definite AD - Histopathological evidence (requires autopsy)
- Course and examination characteristic of AD
Probable AD - Deficits in > 2 areas of cognition
- Onset (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

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

12. AD Pathology
Amyloid plaques (Ab)

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

14. 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

15. 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

16. 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)

17. 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

18. 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

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

20. 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

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

22. 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

23. 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

24. 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

25. 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

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

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

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

30. 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.

31. 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

32. 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…

33. Memory

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

35. Understanding

36. 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

37. Talking

38. 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

39. Impulse Control

40. 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

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

42. Positive Physical Approach

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

44. Use empathy & Go with the flow
Reality Orientation
Telling Lies

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

46. Hand-Under-Hand Assistance

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

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

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