Dementia

1. Dementia Leke Ogunmefun, MD Clinical Assistant Professor Department of Psychiatry University of Maryland School of Medicine

3. The BRAIN

4. Types of Dementia Alzheimers’ Dementia – Commonest type of dementia. Unknown cause, may occur in families, gradual onset Vascular Dementia – Caused by changes in blood supply to the brain. Hypertension, stroke, diabetes and high cholesterol may contribute to this Lewy-body Dementia – Dementia and Parkinson’s disease

5. Dementia Subtypes Dementia secondary to Gen. Med. Cond. Syphilis CJD – Mad cow disease HIV Head Trauma with severe memory loss Mixed

6. Treatable causes Less than 5% of a sample of dementia cases have a potentially treatable cause. These include: Hypothyroidism Vitamin B1 (thiamine) deficiency Vitamin B12, Vitamin A deficiency Depressive pseudodementia (note: dementia and depression can coexist in many patients and can be difficult to differentiate.) Normal pressure hydrocephalus Tumor

7. Alzheimer’s Disease Purpose: To introduce Alzheimer’s disease and the discovery of senile plaques and neurofibrillary tangles. Key Points: Frau Auguste D. was brought by her husband to Dr Alois Alzheimer at a German mental asylum. The husband complained that she had changed drastically over the last few years, that she had become insanely jealous, had severe memory loss, fits of screaming, and hallucinations. He no longer recognized the woman he was married to. Upon her death, Dr Alois Alzheimer examined her brain and observed abundant senile plaques and strange neurofibrillary formations in the cerebral cortex, which he determined were responsible for her dementia. As we now know, senile plaques, made up of insoluble amyloid beta fragments, and neurofibrillary tangles of hyperphosphorylated tau are the hallmarks of Alzheimer’s disease.Purpose: To introduce Alzheimer’s disease and the discovery of senile plaques and neurofibrillary tangles. Key Points: Frau Auguste D. was brought by her husband to Dr Alois Alzheimer at a German mental asylum. The husband complained that she had changed drastically over the last few years, that she had become insanely jealous, had severe memory loss, fits of screaming, and hallucinations. He no longer recognized the woman he was married to. Upon her death, Dr Alois Alzheimer examined her brain and observed abundant senile plaques and strange neurofibrillary formations in the cerebral cortex, which he determined were responsible for her dementia. As we now know, senile plaques, made up of insoluble amyloid beta fragments, and neurofibrillary tangles of hyperphosphorylated tau are the hallmarks of Alzheimer’s disease.

8. Forecast of Alzheimer’s Disease Prevalence in the U.S. Purpose: To illustrate the increasing prevalence of AD in the United States. Key Points: Projected prevalence of AD for 3 separate age groups is shown based on disease estimates for the U.S. population in 1980 and population projections from the U.S. Bureau of the Census. Alzheimer’s disease is projected to quadruple to 16 million by the year 2050 (the upper limit for the projected number). The numbers on the slide represent the estimated middle series. Prevalence is expected to increase in every age group, with the most dramatic increase in those age 85 and above.Purpose: To illustrate the increasing prevalence of AD in the United States. Key Points: Projected prevalence of AD for 3 separate age groups is shown based on disease estimates for the U.S. population in 1980 and population projections from the U.S. Bureau of the Census. Alzheimer’s disease is projected to quadruple to 16 million by the year 2050 (the upper limit for the projected number). The numbers on the slide represent the estimated middle series. Prevalence is expected to increase in every age group, with the most dramatic increase in those age 85 and above.

9. Normal Brain vs Severe Alzheimer’s Disease Brain Purpose: To demonstrate the differences in cross-sections of brain at autopsy between a normal brain and an AD brain in the severe stage.   Key Points: There is a cascade of events that kill brain cells and result in loss of neuronal connectiveness. The loss shows up in a variety of ways. The above images are cross-sections of brains at autopsy. One is a normal brain, and the other is of a brain affected with severe AD.Purpose: To demonstrate the differences in cross-sections of brain at autopsy between a normal brain and an AD brain in the severe stage.   Key Points: There is a cascade of events that kill brain cells and result in loss of neuronal connectiveness. The loss shows up in a variety of ways. The above images are cross-sections of brains at autopsy. One is a normal brain, and the other is of a brain affected with severe AD.

10. Dementia and Depression Patients with mild dementia are almost always depressed. >80% Elderly depressed patients are sometimes misdiagnosed as Alzheimer’s dementia. Demented patients do poorly in testing due to cognitive decline despite excellent motivation. Depressed patients do poorly in testing due to decline in motivation despite excellent cognitive skills. Both illnesses are under-diagnosed and under-treated.

11. Real Symptoms Memory loss- Recent >Remote initially Poor night time sleep Excessive daytime sleepiness Wandering Irritable mood because of forgetfulness Speech impairment Suspiciousness (Paranoia) Auditory and/or visual hallucinations Physical combativeness Weight loss DEPRESSION

12. Fronto-temporal Dementia

13. Symptoms of Dementia Marked loss of memory for recent events -losing items -getting lost in familiar places -Missing appointments -Trouble with cooking, paying bills, driving -Can’t understand books, movies or news items

14. Symptoms of Dementia Substitution of approximate phrases ("Where is the thing for sweeping?" for ‘broom’) Misidentifying people (Confusing sister with [deceased] mother) Use of empty phrases ("You know", "That thing") Difficulty inhibiting behavior

15. Behavior Disturbance Wandering, especially at night Physical combativeness Argumentative with care provider Refusing medications Dangerousness- Leaving stove on, forgetting to turn off faucets, getting lost Delusions resulting in suspiciousness of care provider, calling the police, bizarre acts Disturbed sleep-wake cycle Incontinence- Bowel and or bladder *** DRIVING

16. Diagnostic Tools MMSE – at doctor’s office – scored /30 Clock Drawing Animal naming in one minute Other tests may be done by the doctor or specialist

17. Normal Memory Problems Occasional memory problems attributable to age-related forgetfulness Normal finding or misleading info after age 45 Forgetting keys or where you parked Incidental occurrence of misplacing items Declining mental performance which can be explained by age, stress or medical condition. Bereavement and depression

18. Normal Brain in Section

21. Dementia Brain in Section

22. Dementia Treatment Start early in treatment and continue indefinitely Target specific areas: Cognition, Behavior and/or Function Cholinesterase inhibitors indicated for mild to moderate disease NMDA indicated for moderate to severe They can and should be combined

23. Treatment of Dementia Cholinesterase inhibitors: -Aricept -Exelon -Razadyne ER NMDA receptor antagonist: -Namenda ****These medications DO NOT improve memory, they only SLOW the decline****

24. Initial Practical Approaches Housing: One level, < 3steps; few, large furniture; low bed or floor mattress; burglar alarm turned on at all times Healthy finger foods and microwave Electric stove preferred; with controlled access to fusebox Telephone with large numbers and letters Orientation cues: LARGE calendar, names and pictures of patient and loved ones

25. QUESTIONS ?????????? THE END