Alzheimer's and Other Dementias

1. Alzheimer's and Other Dementias Henry Pacheco, M.D. Medicine & Public Health Director National Hispanic Council on Aging (NHCOA) Washington, DC National Hispanic Council on Aging (NHCOA) Working to improve the lives of Hispanic older adults, their families, and caregivers

2. Learning Objectives • To provide an overview of dementias with focus on Alzheimer’s Disease • To describe risk factors, signs and symptoms and progression of Alzheimer's Disease • To describe some diagnostic and treatment challenges for primary care providers (PCPs) • To understand the importance of focusing on the caregivers of people with Alzheimer’s

3. What is Dementia? “Dementia is a general term for a decline in mental ability severe enough to interfere with daily life.” ( ALZ Assoc, 2012) • Not a specific disease • Describes a collection of symptoms • Caused by many disorders that affect the brain • Results in impaired intellectual functioning • Interferes with normal activities and social relationships. • Loss of cognitive abilities, personality changes, agitation, delusions, loss of emotional control, behavioral problems, inability to solve daily problems.

4. Types of Dementia • Alzheimer's Disease – 60-80% of all dementias • Vascular Dementia -10%-20% • Dementia with Lewy Bodies (DLB) – 5%- 10% • Mixed Dementia • Parkinson's Disease • Fronto-Temporal Lobar Dementia (FTLD) 15%- 25% • Creutzfelt-Jacob Disease • Normal Pressure Hydrocephalus

5. Alzheimer's Disease What is Alzheimer’s Disease (AD)? It is an irreversible, progressive and fatal neuro-degenerative brain disease. Characteristics: 1)Loss of memory, (inability to learn new and recall old information), and 2) Decline or loss of one or more of the following: • Language (aphasia) • Purposeful action (apraxia) • Recognition (agnosia) • Executive function (think abstractly, judgment) Interference with social or occupational functions of daily life DSM-IV Criteria for Diagnosis of Alzheimer's

6. The Impact of Alzheimer's Disease and the Aging of the Population • 5.4 million people in the US have AD • 11 to 16 million adults 65+ projected to have AD by 2050 in US • 24 million with AD worldwide • AD is the most common form of dementia • Mortality secondary to AD is up 20% in the past decade • Cost of caring for people with AD ~ $200 billion a year and growing Source: ALZ Assoc. 2012, NIH, AOA

7. Normal Age-Related Cognitive Decline • Decrease in the rate of information processing, especially non-verbal information • Reduced spontaneous recall • Small decrease in executive skills • Still able to learn new information, but decline in recall Sources: AMA Therapeutic Insight Management of Alz Disease, 2010

8. Potential Causes of Cognitive Impairment • Chronic alcohol or drug abuse • Tumors • Subdural hematoma • Normal pressure hydrocephalus • Metabolic disorders • Hypothyroidism • Hypoglycemia • Certain medication side effects • Medicines interacting • Depression • Psychotic disorders • HIV Dementia • Lyme’s Disease, Syphilis • Hepatic & uremic encephalopathy • Low literacy or language impairment (may appear as cognitive impairment)

9. Alzheimer’s Disease • Older age is primary risk factor: AD incidence doubles every 5 years after age 65 • Family history • Lower educational level • Female • Genetic Risk factors: mutation in 3 genes associated with AD • Amyloid Precursor Protein (APP) • Presenillin -1 (PS1) • Presenillin-2 (PS2) Apo lipoprotein E (APOE) Pathophysiology: • Disorder in B- amyloid metabolism • Extensive B- Amyloid plaque deposits between neurons( possibly no symptoms) • Neurofibrillary tangles (protein Tau), loss of synapse, neuronal death from inflammation (cognitive impairment) • Loss of neurons leading to abnormalities in multiple regions of the brain (neuro degeneration) with loss of neurotransmitters (acetyl choline) Sources: 1)NIH ,2012 , 2) AMA Therapeutic Insight Management of Alz Disease, 2010

10. Inside the Human Brain Neurons • The brain has billions of neurons, each with an axon and many dendrites. • To stay healthy, neurons must communicate with each other, carry out metabolism, and repair themselves. • AD disrupts all three of these essential jobs. Slide 14

11. Symptoms of Alzheimer's • Early: forgetfulness (2-4 years) • Mild cognitive impairment (MCI) between normal forgetfulness of aging and the development of AD • Moderate: (2-10 years) • Change in sleep patterns, delusions, depression, agitation • Difficulties in simple tasks, dressing driving, reading or writing • Forgetting details of current events, losing self-awareness • Argumentative, aggressive behavior, poor judgment • Using the wrong words, mispronouncing, confusing sentences • Withdrawing from social contact • Advanced: (1-4 years) • Fails to understand conversations • Fails to recognize family members • Can’t perform basic activities of daily living( eating, dressing, and bathing), incapacitated • Incontinence , swallowing problems • Death usually from infections such as pneumonia

12. Diagnosis of Alzheimer’s Disease Medical History (hx) Deficits, rate of progression, personality, behavior changes, gait movement problems. Family Hx Any hx. of dementia or neurologic conditions Past Med History Hx. of Hypertension, strokes, diabetes, employment hx (exposure to toxic materials), psychiatric hx., substance abuse Labs Mostly to uncover or rule out treatable medical conditions responsible for cognitive deficits: HCT, TSH, Electrolytes , fasting glucose, Vit. B12 level, folate deficiency, RPR, HIV, ESR. Future Tests ( research) May include bio-markers for AD in cerebro-spinal fluid (CSF,) blood and urine Physical Exam Thorough neurological. exam, sensory deficits, peripheral neuropathy, gait ,etc./ mental status assessment. Any co-morbidities? Neuropsychological cognition testing Early diagnosis of AD is challenging; PCP typically conduct tests such as; Montreal Cognitive Assessment (MoCA), Mini-mental State Exam (MMSE), clock drawing test Mini Cog. Other tests include CT or MRI , PET scans (not routine) may be left to the neurologist, CSF analysis Referrals/consultations Neurologist, social and support services Differential Diagnosis • Treatable causes of cognitive impairment • The differentiation of Mild Cognitive Impairment (MCI) from normal aging and early Alzheimer’s – not always clear • Must distinguish AD from other dementias such as Lewy Body or FTLD because the usual AD medications may have adverse effect on these dementias

13. Importance of Early Diagnosis To allow effective preparation for: • Family & patient counseling • Life style modifications • Diet/aerobic exercise • Control of chronic diseases HTN, diabetes, etc. • Start disease treatment earlier • Early planning for the future (not overwhelm the patient or the family) There are often subtle cognitive impairments in early AD that may go underdiagnosed by PCPs this may be specially the case among African American & Hispanic patients

14. Primary Treatment of Alzheimer’s Non pharmacological • Care planning through the stages • Coordinated care options for patients • Support of care

15. Care Planning For Alzheimer's Patients • While patient still able to understand & communicate effectively • Advance directives, durable power of attorney • Planning for quality of life, driving, etc. • Mental health evaluation • Functional assessments on regular basis • Cognitive assessment on regular follow -ups • Behavioral assessment ( mood, activities, etc.) • Discuss medications • Terminal care

16. Primary Treatment of Alzheimer’sPharmacological For Mild to Moderate A.D. • Cholinesterase Inhibitors (for mild/moderate AD) may for a limited time delay or prevent symptoms. • Aricept® (donepezil) (widely used) • Exelon® (rivastigmine) • Razadyne® (galantamine) • Cognex® (tacrine) (rarely used now) For Moderate to Severe A.D. • Namenda® (memantine) • Aricept

17. The Caregivers • Estimated that 15 million people provide unpaid care for patients with AD • Caregivers are generally older (52+) and female • Spouses (the largest group of caregivers) • Daughters (the sandwich generation) • Family members • Friends, neighbors, members of non-profit organizations • AD represents a very significant emotional, psychological, financial and physical burden for caregivers and their families. • Caregivers are vulnerable to physical, emotional and financial stress • Essential AD care involves providing information and support interventions (psycho-educational, supportive, psychotherapy, etc.) to caregivers Sources: ALZ Assoc. 2012

18. Care Planning For Caregivers • Evaluate understanding of Alzheimer’s Dementia and provide education • Referral to resources: local community and national resources(Alzheimer’s Association, day care, respite programs,) • Evaluation of support system (family, friends) • Coping, stress, depression and potential abuse • Caregiver training (safety precautions at home ) • Keeping a log for Alzheimer’s patient • Placement of Alzheimer’s patient in nursing home

19. Coping with Difficult Behaviors • A presentation by: Thomas Magnuson, M.D. Assistant Professor, Department of Psychiatry, UNMC www.unmc.edu/media/intmed/.../dealingwithdifficultbehaviorsi_.ppt

20. Grants and Funding • Grants.gov • Provides current funding information from NIH, CDC, FDA AHQR • Grants • www.grantWatch.com • Alzheimer’s Foundation

21. Bibliography • National Institute of health/National Institute on Aging • National Institutes of Health. US DHHS. Alzheimer's Disease Education & Referral (ADEAR) Center. Alzheimer's Disease Fact Sheet. Bethesda, MD: National Institutes of Health; 2011. NIH Publication 11-6423 • Current Medical Diagnosis & Treatment 2013 • 2010 Progress Report, National Institute on Aging, National Institute of Health & Human Services, Dec 2011 • Alzheimer's Association Facts and Figures 2012

22. Thank You!