1. Vascular Dementia (VaD) Processing speed, executive function impairment, insight, mood Multi-infarct dementia Subcortical vascular disease

2. Diffuse Lewy Body Dementia Prominent visual hallucinations Parkinsonism (gait, balance, rigidity, bradykinesia- rest tremor less common) Falls or gait difficulties Fluctuations in cognition/attention PDD- executive and visuospatial dysfunction MSA- “Shy-Drager”

3. Frontotemporal Dementia Younger onset- 50-60s Behavioral variant- R frontal Primary Progressive Aphasias- L frontal or L temporal Other tauopathies- PSP, CBS

4. Treatment Disclaimer Although there is currently no way to cure Alzheimer's disease or stop its progression, we are making encouraging advances in Alzheimer's treatment, including medications and non-drug approaches to improve symptom management.

5. Cognition Enhancing Drugs Cholinergic Agents (AChEI) - Donepezil/Aricept -Rivastigmine/Exelon -Galantamine/Razadyne NMDA Antagonist -Memantine/Namenda http://www.thefix.com/content/performanc e-enhancing-smart-drugs-olympics8838

6. Acetylcholinesterase Inhibitors Mechanism of Action: Inhibits centrally-acting acetylcholinesterase, making more acetylcholine available This compensates in part for degenerating cholinergic neurons that regulate memory

7. FDA Approved Uses of AChEI Mild/Moderate AD Moderate AD Severe AD- for rivastigmine and donepezil only Parkinson’s disease-related dementia- rivastigmine only

8. Off Label Uses VaD DLB, MSA Tauopathies

9. AChEI side effects Diarrhea Urination Miosis/muscle weakness Bronchorrhea Bradycardia Emesis Lacrimation Salivation/sweating Muscle Cramps Insomnia/ incontinence Nausea Diarrhea

10. What about Namenda and Namenda XR (memantine)? ● regulates glutamate in the brain ● key role in processing information ● may delay the worsening of symptoms ● may allow patients to maintain daily functions FDA approved as an addition to AChEI in mod/sev AD only FDA approved as an addition to AChEI in mod/sev AD only

11. Off Label Use Anecdotally helpful in PPA Trial and error

12. Behavioral Symptoms Insomnia Weight loss Home Safety Agitation Wandering Repetitive vocalizations

13. Weight Loss Possible causes Forgetting to eat Inability to prepare and eat foods Impaired olfaction and taste Behavior problems (restlessness, etc) Depression Comorbid medical illness Medications (esp ACh-I, Antidepressants) Inflammatory abnormalities (anorexia, procatabolic state) Wang et al, J Neurol 2004, 251:314-320; Aziz NA et al, J Neurol 2008

14. Strategies Diet- liberalize it! No special diets! Environment Eat with others Pleasant, quiet setting Music may help Tamura BK et al. Nutrition and the Institutionalized Elderly. 2007

15. More Weight Loss Strategies Food Modifications Single items, presented one at a time Contrast color of food with the dish Make food and setting look attractive Make food portable for those who are restless Sweet, hot/cold, juicy Eating Schedule AD pts ate more at breakfast than other meals Frequent, small meals Tamura BK et al. Nutrition and the Institutionalized Elderly. 2007

16. Behavioral Therapy Nonpharmacologic intervention Antidepressants Antipsychotics if necessary

17. Exercise! Image from bodbot.com

18. Benefits of Exercise Image from bodbot.com

19. Nonpharmacological Strategies Advise caregiver(s) to: 1) Use scheduled toileting and prompted toileting for incontinence. 2) Offer graded assistance (as little help as possible to perform ADLs), role modeling, cueing, and positive reinforcement to increase independence. 3) Avoid adversarial debates; try to redirect conversation instead. 4) Maintain a calm demeanor. 5) Use services of caregiver support groups.

20. Depression in dementia Seen in up to 40% of AD patients; may precede onset of AD Signs include sadness, loss of interest in usual activities, anxiety, and irritability Suspect if patient stops eating or withdraws May cause acceleration of decline if untreated Recreational programs and activity therapies have shown positive results

21. Apathy v. depression in dementia High prevalence and persistence throughout course of AD Causes more impairment in Activities of Daily Living than expected for cognitive status High overlap with depressive symptoms but lacks depressive mood, guilt, and hopelessness

22. Agitation or aggression- What is it? Seen in up to 80% of patients with Alzheimer’s disease A leading cause of nursing-home admission

23. Agitation- What do you do? Identify context of behavior (is it harmful to patient or others?) Identify environmental triggers (eg, overstimulation, unfamiliar surroundings, frustrating interactions) Exclude underlying physical discomfort (eg, pain or hunger)

24. Psychosis in dementia Seen in about 20% of Alzheimer’s disease (AD) patients Delusions may be paranoid (eg, people stealing things, spouse unfaithful) Hallucinations (~11% of patients) are more commonly visual

25. Psychosis- what do you do? Determine whether delusions or hallucinations are interfering with function

26. Black box warning on antipsychotics in dementia [US Boxed Warning]: Elderly patients with dementia-related psychosis treated with antipsychotics are at an increased risk of death compared to placebo. cardiovascular or infectious (eg, pneumonia) quetiapine has a lower propensity to cause extrapyramidal side effects * risperidone not as sedating for daytime use * APA, [Rabins 2007]

27. Resources for managing dementia Elder law attorney for will, advanced directives, conservatorship, estate planning Community: neighbors & friends, aging & mental health networks, adult day care, respite care, home-health agency Organizations: Alzheimer’s Association, Alzheimer’s of Central Alabama Services: Meals-on-Wheels, senior citizen centers, home care services

28. Educational Websites Alzheimer’s of Central Alabama- support groups and daycare programs- http://alzca.org/http://alzca.org/ Alzheimer’s Association- advocacy and research info- http://www.alz.org/ http://www.alz.org/ AlzOnline- patient and caregiver education- http://alzonline.phhp.ufl.edu/ http://alzonline.phhp.ufl.edu/ Association for Frontotemporal Degeneration- theaftd.org Lewy Body Dementia Association- http://www.lbda.org/http://www.lbda.org/ The MSA Coalition- https://www.multiplesystematrophy.org/https://www.multiplesystematrophy.org/ www.uab.edu/alzheimers