Age (Year) - LeadingAge Colorado

Different Types of Dementia Not Everyone has Alzheimer’s Haleh Nekoorad-Long, M.D. Geriatric Psychiatrist AltaVita Memory Care Centre www.AltaVitaLiving.com 303-300-3700

MILD COGNITIVE IMPAIRMENT • Impaired memory, but otherwise functioning well and do not meet clinical criteria for dementia • May be the earliest sign of evolving AD

• Neuropsychological testing helpful • Rule out any organic (Medical) causes • The sooner diagnosis, the better outcome with treatment

Meaning of Dementia • • • • • •

Impairment in short-term and long-term memory Impairment in abstract thinking or reasoning Impairment in Judgment Personality changes Apraxia (forgetting how to do things) Aphasia (difficulty with speech)

Types of Dementia • Alzheimer’s Disease(55-65%) • Vascular Dementia(10-15%) • Dementia with Lewy Bodies(15-20%): parkinsonian, visual hallucination, fluctuating level of confusion • Parkinson’s Disease with Dementia: about 40% risk after 8-10 years of living with Parkinson’s disease. • Frontotemporal Lobe Dementias(5-8%) : Personality changes, hypersexuality, aphasia (speech)

ALL OTHER CAUSES OF DEMENTIA(19%) • Frontal-Temporal Dementia (10%) • Chronic Alcohol Use • B12 Vitamin Deficiency • Infectious Disease (Neurosyphilis, HIV) • Neoplastic (Meningiomas, Brain tumors) • Other Degenerative Diseases (Huntington’s, Parkinson’s, CJD or mad cow disease, Progressive Supranuclear Palsy, etc.)

Alzheimer's Disease • Alzheimer disease was first described in 1907 by Dr. Alois Alzheimer. • From its original status as a rare disease, Alzheimer disease has become one of the most common diseases in the aging population, ranking as the sixth most common cause of death. • The incidence of Alzheimer disease is strongly related to age

ALZHEIMER’S TYPE • Age is number one risk factor

• Family History (increases risk by 3-4 times) • Head Trauma • Female sex

• Gradual presentation (10 years on average) • Memory impaired early in the course • Psychiatric symptoms is common (50%): Depression, Apathy, Agitation, Aggression, Psychosis, Delusions, Pacing, Wandering, Hoarding, Sleep problems

Prevalence of Alzheimer Disease (AD) in the US Prevalence (%)

50 40 30

16%

20 10

0 • • • • •

32%

8%

1%

2%

4%

60-65

65-70

70-75

>65 years: 10% >85 years: 32%-47% 68% are women Today: ~4 million have AD 2050: >14 million will have AD

75-80

80-85

>85

Age (Year)

(Clinical Neuroscience Research Associates (©CNRA, 2000). Available at: www.therubins.com.)

Amyloid Plaques and Neurofibrillary Tangles in Alzheimer’s Disease and Normal Aging Plaques

Alzheimer’ s

Tangles Courtesy of Harry Vinters, MD.

Normal

Positron Emission Tomography (PET) Studies of Glucose Metabolism (FDG)

Normal

Early Alzheimer's Late Alzheimer's

Child

VASCULAR DEMENTIA • Cerebrovascular disease (CVD)/ Strokes/Mini-strokes • Focal signs (weakness on one side, facial droop) • Abnormal brain imaging

• Relationship between dementia and CVD • Onset within 3 months of stroke • Abrupt onset, stepwise decline

• Mixed Alzheimer’s disease and CVD common

VASCULAR DEMENTIA RISK FACTORS • Age • History of Vascular Disease: Strokes, Heart Attacks • Smoking • Hypertension • Diabetes • High Cholesterol • Atrial Fibrillation

LEWY BODY DEMENTIA Dementia (more severe executive dysfunction and visuospatial disturbances than AD) •Two of three of the following: •Parkinsonism (motor symptoms) •Visual hallucinations •Sleep disorders (Acting out dreams) •Fluctuating cognition •Lewy bodies in brain (limbic and neocortex) •Cholinergic deficit •Dopaminergic deficit

PARKINSON'S DISEASE WITH DEMENTIA • Parkinson’s Disease Diagnosis before Dementia • Bradykinesia (slow movements) • Rigidity • Tremors • Response to dopaminergic treatment (Levodopa/Carbidopa)

• 40% develop dementia after 8-10 years • Cortical Lewy bodies and cholinergic deficit

FRONTOTEMPORAL LOBE DEMENTIA (56%) • Frontal lobe dysfunctions: Personality change, labile mood, agitation, hypersexuality • Speech difficulties: Apraxia, naming, fluency, expressive aphasia, echolalia (repeating your words)

• Usually memory is effected at later stages in the disease • Abnormal brain imaging • No great studies about treatment options, but symptom control with psychotropic medications

Dementia Work Up • Physical and Neurological Exam • Labs including: B12, Folate, TSH, UA, CBC, CMP, syphilis& HIV (if indicated) • Brain Imaging: PET, MRI, CT • Neuropsychiatric Testing if not sure of diagnosis • Question Alcohol or Pain Medication Use • Depression and Anxiety Screen • Insomnia/Apnea work up (if indicated) • Rule Out Delirium

Definition of Delirium • 30-50% of Ill Geriatric patients become delirious at some point during their hospital stay • Rapid Onset (hours to days) • Brief Duration (days to weeks), Transient • Alternating level of consciousness, altered attention (sundowning) • Disorientation, Disorganization, Memory Impairment • Psychosis, Irritability • Disruption of the sleep-wake cycle

Delirium Suspects • In Demented Patients #1 cause is UTI • Many other medical problems can cause it • Dehydration, Pneumonia, Flu, Constipation, CNS infections, Post-Stroke, Hypoxemia, Hypo-or Hyperglycemia, Thyroid disease • Drugs: Benadryl, Pain Meds, Lithium, Sinemet, Anesthesia (Post-Surgery), Alcohol, Benzos • Drug withdrawal: Alcohol, Benzos, Opioids

GENETIC FACTORS • New Studies show 22 gene variants has been linked to late-onset Alzheimer's disease, including one called Apolipoprotein E-e4 (APOE-e4) which appeared to have the strongest impact on risk. • Recent studies have also associated poor sleep habits to buildups of brain plaques and people who eat foods high in copper content appear to have higher incidences of Alzheimer's disease.

Genetic Testing Not Recommended, YET! • For sporadic or familial late-onset Alzheimer disease, the ApoE 4 gene has been associated with a high risk of the disease; however, it does not provide sufficient sensitivity or specificity for diagnosis, and its use as a diagnostic marker is not recommended. • If positive, it indicates you are at higher risk, but not guarantee that you will develop the disease.

Reasons for Delayed Diagnosis • • • • •

Normal aging Insidious onset/course Other medical illness/depression Lack of routine screening Denial

Memory Meds • Do not prolong life • Improve quality of life, prolong self-sufficiency • Improved cognition and functioning after one year compared to patients who were never on ACHEIs • Slowing in deterioration • Benefit declines as more cholinergic neurons are lost – Start treatment early

• Decreased risk of Nursing Home Placement

MEMORY ENHANCING MEDS • ACHEI’s ( Acetyl Cholinesterase Inhibitors) Aricept(Donepazil): Tablets Disintegrating tablets for patients that can’t swallow Razadyne(Galantamine): Capsules Exelon(Rivastagmine): Capsules and Patches for people that can’t tolerate capsules secondary to G.I. side effects. • NMDA: Namenda(Memantine)

TREATMENT EXPECTATIONS • With memory meds, clinical success is measured by: Improvement No Change Less than expected decline

Behavioral Problems • • • • • • • •

Depression / Tearfulness Anxiety Isolation Agitation / Irritability Psychosis, Visual or Auditory Hallucination Disturbed Sleep Pattern Poor Appetite Inappropriate sexual comments or behavior

DEPRESSION AND ANXIETY TREATMENT • Antidpressants: • SSRI’s: Zoloft, Prozac, Paxil, Celexa, Lexapro, Luvox, Vybriid, Brintallix • SNRI: Effexor, Cymbalta, Pristiq, Fetzima • Remeron: Used often because it increases appetite and improves sleep patterns. • Wellbutrin: can cause anxiety since it is an stimulating antidepressant

DEPRESSION VS. APATHY • Apathy is lack of feeling, emotion, interest, or concern. Not sad… • Patient with apathy is not concerned, but family and staff notice isolation.

• Antidepressants not very effective, at times Ritalin more effective.

INSOMNIA • Treatment is effective and needed since the insomnia will effect the caregiver • Melatonin can be effective • Trazadone can be effective • Be careful with medications such as Ambien, Lunesta • Stay away from OTC sleeping aids such as Tylenol P.M. and Advil P.M. since they have Benadryl which can cause increased confusion the next day!

PARANOIA AND PSYCHOSIS • Can be difficult to treat • No FDA approved treatments, and antipsychotics have black box warning for elder with dementia • Antipsychotics can be effective to decrease agitation, psychosis, and help insomnia • Not comfortable for the patient to feel fear and agitation

POSSIBLE ANTIPSYCHOTICS •

ALL antipsychotics have “black box warning” for use in elderly with dementia

•

Seroquel(Quetipine)

•

Zyprexa(olanzapine)

•

Abilify(no generic)

•

Risperdal(risperidone)

•

Latuda

•

Stay away from Haldol if possible given side effects of unstable gait, tremors, swallowing difficulties)

Nonpharmacological Management • Safety: – “Child Proofing” the home (OT Eval) – Driving (Driving Test) – Limit financial responsibilities

• Serenity: – Maintain a calm and peaceful atmosphere • Dimmed lighting • Peaceful music

Nonpharmacological Management (cont.) • Structure: – Regular Routines – Keeping things familiar – Memory Book (OT Eval)

• Sanity of Caregivers – Day care center (Homestead) – Respite Care

Caregiver Burden • Financial costs to caregivers – Direct costs (eg, medical care): $12,000 per year – Indirect costs (eg, unpaid, informal care): $35,000 per year

• Psychological costs to caregivers – >80% report high levels of stress – ~50% report depression

Sources: www.alzheimers.org/unravel.txt www.alz.org/caregiver/guide/coping/stress.htm

Signs of Stress in Caregivers • • • • •

Anger Anxiety Denial Depression Exhaustion

• • • • •

Health problems Irritability Lack of concentration Sleeplessness Social withdrawal

Alzheimer’s Association. Caregiver stress. Available at: http://www.alz.org/hc/counseling/stress.htm.

REASONS FOR PLACEMENT • Disease Severity • Loss of Functional abilities(urine or bowel incontinence) • Behavior problems( paranoia, agitation, wandering)

Alzheimer’s Association Resources

• • • •

Contact center Safe Return Clearinghouse Multicultural outreach

1-800-272-3900 www.alz.org

Wandering Behavior • 4%-26% of SNF patients wander • Up to 59% of patients who reside in a community wander • If not located within 24 hours, 46% will die of hypothermia or dehydration • No one can predict when wandering will occur

Safe Return Bracelet • Registrant and caregiver ID products • National information and photo database • 24-hour, toll-free crisis line

• Fax alert notification system • Local chapter support • Wandering behavior information and training

AltaVita Memory Care Centre • Assisted Living Community for the memory impaired • Respite Care and Day Care programs to help stimulate cognition and decrease isolation • Licensed facility to use LTC insurance if available

HOME LIKE ENVIRONMENT

HALEH NEKOORAD-LONG, M.D., ALTAVITA MEMORY CARE CENTRE

NEIGHBORHOOD CONCEPT

HALEH NEKOORAD-LONG, M.D., ALTAVITA MEMORY CARE CENTRE

AltaVita Memory Care Centre

Call for information 303-300-3700 Come by for a tour Check us online WWW.AltaVitaLiving.com