Aging with a Developmental Disability

1
Aging with a Developmental Disability

• Leonard L. Magnani, M.D., Ph.D.
• Alta California Regional Center
• Sacramento

Access, Attitudes, and Aging Community Health
Care for Adults with Developmental
Disabilities September 25, 2007
2
Aging From Birth to Death

• Our concern The life-cycle stage of senescence
  (from the Latin, senesco, to grow old)
• Life span ? life expectancy the span-queens
  live to be 120-126 years. Our life expectancy is
  77-78, an arithmetic mean, that changes as we
  age
• Simply stated, the best way to make it to 80 is
  to first make it to 70 and at 80, your odds go
  up to make 90!
• Life expectancy calculators ask current age, and
  then questions about background, family, life
  style, etc.

3
Effects on Health During the Aging Process

• Normal aging process
• Lifestyle choices
• Genetic effects
• Environment
• An example Japanese women increase their
  risk of breast cancer 10 times if they live in
  the United States for most of their adult life

4
Aging With a Developmental Disability
Effects of the disability and its treatment
Normal effects of aging
Limited access to quality health care
Lack of knowledge about aging for people with DD
Inadequate funding for health care
Person with a Disability
Lifestyle effects
Negative attitudes about people with disabilities
Decreased Quality of Life
5
Aging with a Developmental
Disability1. Review of Systems Head to
Toe Summary 2. Dementia and Alzheimers
6
The Tippy-top The Scalp

• Hair follicles die, hair thins or balding occurs
• More seborrhea and actinic keratoses in those
  with developmental disabilitiesWhy?
• The Theme Increasednot decreasedcare and
  attention is needed for those with disabilities
• a. more brushing and inspection of
  scalp
• b. special shampoos and lotions
• c. hats worn even on warm days

7
Vision Changes of Aging

• Loss of acuity as eye muscles atrophy
• Loss of accommodation (presbyopia)
• Decrease in light transmission
• Changes in color perception (greens, blues,
  violets)
• Decrease in dark adaptation
• Less able to adapt to glare
• Decreased visual field

8
Communication of the Problem What you see is
what you get

• Rubbing eyes
• Squinting
• Shutting or covering one eye
• Tilting or thrusting head forward
• Redness of eye or area around eyes

9
Changes in mechanical behaviors

• Stumbling or stepping on objects
• Hesitancy navigating a step or a curb
• Holding a page or an object up close
• Sitting very near the TV

10
Some Common Eye Diseases Associated with Aging

• Dry eyes - scratchy, irritated
• Blepharitis - red, itchy lids (dont blame
  rubbing)
• Age-related macular degeneration (ARMD)
• Cataracts - gradual clouding of lens
• Diabetic retinopathy - damage to retina that can
  be attenuated with laser coagulation
• Glaucoma gradual tunnel vision, then blindness
• Keratoconus disease of eye surface (cornea)
  this and cataracts are far more common in persons
  with Down Syndrome

11
Types of Senescent Vision Loss

• Loss of central vision
• Blind spot for central field
• Unable to see faces or read letters
• Loss of acuity or clarity
• Caused by macular disease

12
Macular Degeneration (MD)

• Age-related MD is the leading cause of
  irreversible blindness in our country
• Manifests itself as early as age 40 or 45
• Yellowish deposits under retina (drusen) may be
  the earliest signs (cause or effect?)
• Choroidal neovascularization may follow
• About 12 million people in the US have MD and 7-8
  million with drusen are at risk

13
Types of Vision Loss (contd)

• Loss of peripheral vision
• From glaucoma or retinitis pigmentosa
• Affects safe mobility
• Diffuse loss across visual field
• From diabetes, cataracts, keratoconus
• Vision may fluctuate based on amount and
  direction of light

14
Support Strategies for Vision

• Periodic eye exams to check for asymptomatic
  problems or unexplained symptoms
• Modify the environment
• Use high contrast colors, non-glare lighting and
  surfaces, large print avoid highly polished
  floors
• Red, oranges, yellows better than blues, greens,
  violets partial color blindness is very common
• Provide increased lighting, use night lights
• Organize belongings and keep locations consistent
• Keep eyeglasses clean and prevent scratches

15
Another Vision Support Strategy is to Modify the
Activities

• Engage in more daytime activities
• Provide support for night-time activities
• Allow time to adjust to change of light
• Protect the good eye

16
Hearing Changes of Aging

• Loss of auditory nerve cells and fibers
• Reduction of blood supply to auditory nerve
  transmission area
• Thickening of eardrum
• Increased ear wax increases with inactivity
• Presbycusis, the loss of high frequencies like
  those found in speech, is ten times more common
  in Down syndrome
• Decreased tone discrimination localization

17
Types of Hearing Loss

• Conductive
• Problem with the physical conduction of sound
  through the ear structures
• From earwax, infection, head trauma, damage to
  ear drum
• Sensorineural
• Problem with the conduction of the sound signal
  through the nerve to the brain or a problem with
  the processing of the information in the brain
• From head trauma, drugs, diabetes, high blood
  pressure, heredity, kidney failure, coronary
  artery disease, dementia

18
Communicating Hearing Problems Possible
Signs and Symptoms

• Turning TV volume up very high
• Speaking more loudly than necessary
• Inappropriate response to questions
• Confusion in noisy situations
• Isolating or seeming disinterested
• Self injurious behaviors and frustration
• Here we encounter the
• psychological masquerade

19
Psychological Masquerade

• Behavioral changes can mask serious physical
  diseases etiology is not psychological but due
  to a yet undiagnosed and untreated physical
  disease
• Once the physical disease or condition is
  treated, the aberrant behaviors lessen, recede or
  vanish the abnormal psychological behaviors
  (mental illness) have a physical cause that can
  be diagnosed and treated

20
Aging Effects on Mouth and Taste

• Decrease in taste buds
• Sour receptors atrophy in our teens
• Next come sweetness bitter is last to
  go
• Recession of gums
• Thinning of dental enamel
• Loss of teeth
• Sense of thirst diminishes making
• dehydration much more of a risk

21
Oral Abnormalities and Disease

• Decreased saliva from parotid gland atrophy,
  medications or diseases
• Dental caries
• Root caries and abscesses
• Chronic periodontal inflammation
• Sores, especially with dentures
• Infection of mucus membranes
• Cancers

22
Support Strategies for the Aging
(Mature?) Mouth

• Regular dental checkups and good oral hygiene,
  even if no natural teeth remain
• Floss or use a Proxabrush
• Consider battery-powered toothbrush
• Alcohol-free mouth wash
• Increase seasonings of food except for salt

23
Nose and Smell Change with Aging

• Decrease in nerve fibers
• Drying of mucous membranes in the nose
• Decreased sensitivity to odors

24
Support Strategies forChanges in the Nose

• Use of smoke detectors
• Care if using gas stoves or water heaters
• Discard all food after recommended time, and
  frequently check for spoilage
• Assist with awareness of body odor or the
  over-use of fragrances
• Most of taste is smell beef-up the flavors!

25
Skin and Touch in Aging

• Decreased sweat glands, subcutaneous fat,
  peripheral blood supply, elasticity, and skin
  thickness heightened cold intolerance and
  increased risk of heat stroke (? sweating)
• Loss of pigmentation
• Decreased skin cell production and hair growth
• Changes in nail matrix and fungal overgrowth
• Decreased sensation to touch and pain
• In CP, heightened risk of decubitus ulcerations

26
Protecting the Skin

• Minimize use of soap and rinse well remember
  that nothing desiccates the skin more than water
• Dry the skin well and use moisturizers
• Reposition frequently if mobility is limited
• Check skin frequently for problems
• Clearly label hot and cold water and monitor
  water temperatures set water heater on lukewarm
  
• Increased skin dryness and flaking with Down
  syndrome, immobility, and poor nutrition
• Use sun protection and reapply it every 2 hours

27
Aging of the GI System

• Decreased gastric acid secretion as parietal
  cells atrophy, but an even greater decrease in
  prostaglandins and the protective mucus and gel
  layer the net result is more indigestion and
  ulceration, and more H. pylori erosions
• Decreased saliva production may lead to more gum
  disease and trauma
• Decreased smooth muscle tone and slower emptying
  and peristalsis, combine to cause GERD upstairs
  and constipation downstairs

28
GERD is Everywhere!

• Observe for signs of reflux common in CP
• Heartburn, discomfort after meals or at night
• Difficulty or painful swallowing
• Swallowing or excessive salivation when not
  eating drooling above and beyond the baseline
• Coughing during night (think GERD first)
• Hands in mouth and/or induced vomiting
• ?Again, another frequent invitation to the
  psychological
• masquerade

29
Genitourinary Changes are all Accelerated in
Cerebral Palsy

• Bladder capacity and muscle tone decrease
• Kidneys function deteriorates
• Enlargement of prostate is common
• Relaxation of pelvic muscles
• Effects of decreased hormones and/or menopause
  are on the entire body

30
Older Women with Disabilities

• Older women with developmental disabilities
  receive very little gynecological care
• Hip fractures secondary to osteopenia are twice
  that off the control group
• Perimenopausal symptoms occur at a younger age in
  women with developmental disabilities and they
  are most often misdiagnosedthe psychological
  masquerade
• once again

31
Down syndrome my potentiate male urogenital
symptomatology

• Compulsive behaviors, such as increased
  masturbatory vigor, may lead to a greater
  incidence of incontinence
• Testosterone levels diminish at a faster rate in
  males with Down syndrome than in controls
• Combined with hypothyroidism, found in 50 of
  Down syndrome adults over the age of 30,
  hypo-endocrine function can look like agitated
  depression? a psychological masquerade

32
Support Strategies

• Observe for voiding patterns, either an increased
  or decreased frequency, or changes in continence
• Observe for signs of infection frequency,
  urgency, accidents, discomfort, unusual odor,
  color or bleeding, without fever or obvious
  symptoms (hypotension? sepsis)
• Regular screening tests and examinations if
  clinically indicated, replenish those hormones
• Good hygiene practices

33
Heart and Blood Vessels

• Decreased responsiveness to stress, leading to
  difficult breathing and fatigue
• Heart rate decreases due to slower contraction of
  muscle fibers atrial fibrillation is common
• Slow return to normal HR after exercise
• Build up of calcifications and fat in arteries
• Decreased elasticity of arteries leads to heart
  needing to pump faster
• Angina? non-compliance? psychological
  masquerade

34
Protecting the Heart

• Encourage regular,
• moderate exercise
• Slow the pace of activities
• Watch for signs of decreased endurance distress,
  dizziness, confusion or non-compliance
• Change position slowly to prevent dizziness
• Reduce or stop cigarette smoking
• Healthy low sodium diet, and the blood pressure
  monitored and treated if needed

35
Pulmonary System

• Lungs become less elastic vital capacity and
  tidal volume decrease (very accelerated in CP)
• As breathing becomes less efficient, tolerance
  for exercise decreases
• Decreased cough reflex
• Decreased cilia that lines the respiratory tract
• This combined with decreased gag reflex leads to
  high incidence of aspiration pneumonia

36
Protecting the Lungs

• Avoid smoking and second-hand smoke
• Encourage deep breathing, physical activity
• Allow for a slow pace of activity schedule
  frequent rest periods
• Avoid subclinical dehydration
• Immunizations for lung diseases (yearly flu
  vaccines and a periodic one for pneumonia)
• Watch for signs of infection (increased coughing,
  shortness of breath, thick or colored sputum,
  increased confusion)

37
Musculoskeletal Changes

• Decrease in muscle mass, strength and tone the
  incredible shrinking process
• Decrease in joint mobility
• Increased porosity and fragility of bones due to
  global decrease in calcium mass (??? in CP)
• Shortening of the spinal cord
• Increased likelihood of developing symptomatic
  and painful arthritis (? in Down syndrome)

38
Protecting theMusculoskeletal System

• Encourage independent movement,
• activities, exercise and maximal self-care
• Implement safeguards to prevent falls
• Promote safe use of mobility aids
• Provide seating that is comfortable, firm, and
  not too deeply cushioned to cause spinal strain
• Consider calcium and vitamin D supplements,
  weight-bearing exercise programs, and above all,
  the administration of bisphosphonates

39
Movement and Activity Changes May Indicate
Systemic Disease

• Amyotrophic lateral sclerosis
• Addisons disease
• Hypothyroidism
• Myasthenia gravis
• B12 and thiamine deficiency
• Brain tumors

• Strokes
• Unrecognized traumas (epi and sub)
• Infections
• Occult leg, arm or hip fractures
• Medication reactions and toxicities

40
A Word on Brain Attacks

• 750,000 strokes/year 158,000 deaths
• 350,000 survivors have irreversible loss
• 86 due to occlusion, 14 to hemorrhage
• Developmentally disabled at higher risk
• Risk increased by hypertension, ASCAD, CHF,
  arrhythmia, diabetes, obesity, hyperlipidemia
  (and metabolic syndrome), hypothyroidism,
  hyperuricemia, tobacco use, etc.
• Those teeny weeny baby aspirins work!

41
Stroke Treatment is Inadequate

• Studies show that the elderly with a
  developmental disability, when brought to the ER
  for stroke and myocardial infarction, are less
  likely to receive rapid and definitive diagnostic
  studies or prompt administration of thrombolytic
  agents

42
Nervous System Changes with Aging

• Loss of nerve cells and fibers with decreased
  conduction
• Decreased blood flow and oxygen to brain
• Less REM stage of sleep decreased sleep
  efficiency and poor sleep hygiene
• The spectrum of sleep apnea Down syndrome has
  more apnea (small airways, increased size of
  adenoids, heavier body)
• Altered (decreased) pain response

43
Balance and Protective Responses

• Sense of balance decreases due to loss of hair
  cells in middle ear
• Slow movement and less sensation lead to slower
  reaction time and decreased protective responses
• A dangerous duo more likely to fall and less
  likely to catch oneself

44
Developmental Disabilities and Parkinsons Disease

• Often misdiagnosed as depression, and sometimes
  as psychosis (those masks!)
• ?Dopamine? tremor, inability to rapidly initiate
  movement and appearance of cogwheel rigidity
• A bed or chair-bound individual with CP may be
  hard to evaluate for evolving motion disorders
• Keep accurate notes that describe all abilities,
  for example, wrist range of (passive) movement
• Correct diagnosis is often impossible in elders
  when the diagnostician/caregiver doesn't know the
  person

45
Neurochemistry of Aging

• In Parkinsons its the atrophy and
  decay of D2 receptors and the CNS production of
  dopamine this exacerbates a diminishing desire
  for activity
• A decline in serotonin and serotonin receptors
  may also occur this potentiates depression and
  isolation from others

46
Behavior and Cognition

• Intelligence and ability to learn dont
  necessarily change aging oftentimes slows
  activity in prefrontal cortex? a retrieval
  problem
• DD and aging ?difficulty processing, organizing
  new information, and recalling old information
• Mental illness (especially depression) is more
  prevalent in elders with a developmental
  disability than in the general population

47
Mental Illness and Aging with a Developmental
Disability

• Compared to an age-matched cohort, adults with
  mental retardation have five times the incidence
  of many psychiatric disorders
• The majority of individuals over the age of 50
  who have a diagnosis of mental retardation, also
  have a serious mental illness
• Mental illness in itself creates a barrier
  towards achieving a healthy lifestyle and
  adequate medical care, including mental health
  services ?Severity ?likelihood of
  treatment

48

• But the biggest mental health concern, for all
  of us, is dementia
• Normal Blood Flow Early
  Stages
• SPECT SCANS
• Advanced End
  Stage

49
Dementia

• Dementia is the loss of cognitive and
  intellectual ability without a major impairment
  in perception or consciousness
• It is characterized by disorientation, decreased
  memory, reasoning and judgment, and by the
  anxiety, mood lability and impulsiveness that
  these losses produce

50
Is It Dementia?

• Two Types of Organic Problems
• Reversible (organic brain syndrome)
• Irreversible (true, progressive dementia)
• Individuals must have an intensive medical
  evaluation to determine if declining brain
  function is indeed a form of an irreversible
  dementia, i.e., a progressive decline that might
  be slowed but not stopped

51
Dementia

• Reversible
• D Drugs, Delirium (alcohol, etc.)
• E Emotions (such as depression),
  Psychoses, and Endocrine Disorders
• M Metabolic Disturbances
• E Eye and Ear Impairments
• N Nutritional Disorders
• T Tumors, Toxicity, Trauma to Head
• I Infectious Disorders
• A Arteriosclerosis and Stroke

52
Dementia

• Irreversible
• Alzheimers
• Multiple infarctions (vascular and embolic)
• Lewy Body Dementia
• Picks Disease (Frontotemperal Dementia)
• Parkinsons
• Heady Injury
• Huntingtons Disease
• Jacob-Cruzefeldt Disease

53
Dementia

• Facts about the Irreversible
• Alzheimer's disease, the most common type of
  irreversible dementia (80-85)
• Multi-Infarct dementia second most common type of
  irreversible dementia (10-12)
• Death of cerebral cells
• Blockages of larger cerebral vessels or emboli in
  the arterial tree going to the outer cortex
• More abrupt in onset but may be gradual
• Associated with previous strokes, hypertension
• Can be traced through diagnostic procedures

54
The Most Common Dementia is Underdiagnosed and
Undertreated

• Five million people in the United States have the
  diseaseAlzheimersand only half are diagnosed.
  
• DSM-IV Diagnosis Progressive impairments in
  memory, activities of daily living (ADLs),
  behavior, and cognition.
• Why not diagnosed half of the time?
  Insidious and slow progression

55
Alzheimers Disease

• 1906, first described by the German physician,
  Alois Alzheimer now, 10 of those 65, and 50
  of those over 85
• Symptoms progress slowly, from inability to
  recall words to absent minded forgetfulness, to
  forgetting where or why one is going somewhere,
  forgetting the time or place one is at, and
  eventually to forgetting the faces of long-term
  and significant others, and eventually the
  ability to communicate
• Final stages include the loss of basic skills,
  like eating, dressing and toileting

56
Brain Changes in Alzheimers

• Normal Brain
  Early Alzheimer
  Changes

57
Down Syndrome and Alzheimers

• General population has first surge of AD
  diagnosis in the 7th decade (the 60s) Down
  syndrome experiences this in the 5th decade.
• 20-40 of those with Down Syndrome will develop a
  clinical dementia almost all Down Syndrome
  adults (by age 45 or 50) develop the AD brain
  changes (plaques and tangles).
• In both populations there is a rare but very
  serious form of Alzheimers that progresses
  rapidly over a two-three year time span.

58
Worries About Alzheimers Concerns All of Us

• In California, by 2030, 580,000 will have
  Alzheimer's
• currently the number is about 320,000.

59
Alzheimer Neurochemistry

• An enzyme important in the division of other cell
  types has been shown to play a role in
  Alzheimer's disease.
• This enzyme, Pin1, can restore the function of
  tau molecules misshapen by phosphates.
• Pin1 is found bound in the tau tangles in brain
  biopsy samples adjacent cells are found to be
  depleted of this enzyme.
• The Big Question Does excessive Pin1, or does
  an intracellular lack of Pin1, lead to tangle
  formation?

60

61
Behavioral Changes in Persons with Alzheimers
Disease

• Nearly all persons with AD exhibit behavioral
  changes
• Diverse behavioral symptoms occur
• Multiple symptoms occur simultaneously
• Behavioral changes become more frequent with
  disease progression
• Behaviors are recurrent after onset

62
Behavioral Changes in Persons with Alzheimers
Disease

• Behavioral changes have a neurobiological basis
  that can be studied by
• Neuroimaging
• Neuropathology
• Neurochemistry
• Behavioral changes respond to treatment
• Psychotropic agents (main line agents)
• Cholinesterase inhibitors (some help)

63
Multiple Behavioral Changes Occur Simultaneously
with 0,1,2,3 Symptoms (Psychosis, Agitation,
and/or Depression)
64
Once Present, Behavioral Symptoms Commonly Recur
of Patients
Patients re-examined five times in one year.
Next means at the following visit. Always
Present means at all five visits
65
Non-Pharmacologic Behavioral Interventions

• 3 Rs Repeat, Reassurance, Redirection
• ABCs Antecedents, Behavior, Consequences
• Support caregiver
• Alzheimers Disease International / Alzheimers
  Association

66
Nonpharmacological Strategies

• Also Remember the four Ss
• Maximize Safety and Limit the Risks
• Promote Structure and Consistency
• Enhance Serenity and Limit Confusing Stimuli
• Nuture Sanity and Supports for All Caregivers

67
Medicating Alzheimers

• Mood lability and agitation medications
• Mood stabilizers (anticonvulsants like Depakote
  Lamictal and Trileptal)
• Anxiolytics like the SSRIs (Zoloft, Lexapro,
  Paxil, Prozac, etc.), and the atypical
  antipsychotics (like Risperdal and Geodon)
• Medications for the decline in ADLs
• Acetyl-(and butyryl)cholinesterase inhibitors
  (like Aricept, Namenda, Cognex and Reminyl)
• ?slows the progression of disease?

68
Psychosis and Its Treatment in Alzheimers

• Prevalence of Psychosis
• 25 cross-sectional
• 50-70 longitudinal
• Features
• Theft, disinhibition, misidentification, lying
• Pathophysiology
• Decreased frontal/temporal lobe metabolism and
  vascular perfusion
• Increased neocortical neurofibrillary tangles

69
Persons with AD and Psychosis Have Significantly
More NFT in Their Neocortex
NFT counts per 1 mm in the frontal, temporal,
parietal, hippocampal and allocortical entorhinal
regions of the brain
2



(Farber et al, Archives of General Psychiatry,
2000 57 1165-1173)
70
Medications for Psychosis in AD

• Atypical antipsychotics
• Risperidone
• Olanzapine
• Quetiapine
• Ziprasidone
• Conventional neuroleptics
• Haloperidol

71
Reduction of Psychosis in Persons with AD by
Olanzapine
Placebo
5 mg
10 mg
15 mg
Changes in the Neuropsychiatric Inventory (NPI)
Psychosis Score ?delusions and
hallucinations (too much of a good thing, is
bad)
(Street et al, Arch General Psychiatry 2000 57
968)
72
Reduction of Psychosis in Persons with AD by
Risperidone
Percent of Patients Whose Delusions Resolved With
Treatment
(Katz et al, J Clinical Psychiatry 1999 60 107)
73
Agitation in Persons with AD

• Prevalence
• 40 cross-sectional
• 60-80 longitudinal
• Features
• Aggression, vocalization, resistance to care
• Pathophysiology
• Decreased frontal/temporal metabolism/perfusion
• Increased frontal neurofibrillary tangles

74
Medications for Treating Agitation

• Atypical antipsychotics
• Conventional neuroleptics
• Anticonvulsants/mood stabilizers
• Selective serotonin reuptake inhibitors
• Trazodone
• Buspirone
• Beta-blockers

75
Reduction of Agitation in Persons with AD by
Risperidone
(p0.02)
(p0.06)
Percent of symptomatic patients with anxiety
level scores of 0 or 1 at the end of the study
(Katz et al, J Clinical Psychiatry 1999 60 107)
76
Reduction of Agitation in Persons with AD by
Olanzapine
Placebo
5 mg
10 mg
Reductions in the agitation Score (again, avoid
too much of a good thing)
(Street et al, Archives of General Psychiatry,
2000)
77
Comparative Effects of Risperidone and
Haloperidol on the Mini Mental State Exam (MMSE)
Score
Change in the MMSE Score ( new does not equal
better)

Placebo
Risperidone
Haloperidol
(DeDeyn et al, Neurology 1999 53 946)
78
Carbamazepine Treatment of Agitation in Persons
with AD
of Patients
(Tariot et al, Am J Psychiatry 1998 155 54-61)
79
Depression in Persons with AD

• Prevalence
• 25 cross-sectional
• 50 longitudinal
• Information source influences frequency estimates
• Features
• Major depression rare
• Depressive symptoms common
• Exacerbates cognitive and functional disability

80
Treating Depression in Persons with Alzheimers
Disease

• Selective serotonin reuptake inhibitors
• Citalopram, sertraline, fluoxetine, paroxetine,
  etc.
• Tricyclic agents
• Nortriptyline
• Combined serotonin and noradrenergic reuptake
  inhibitors
• Venlafaxine

81
Reduced Depression and Irritability in Persons
with AD Treated with Citalopram
Irritability
Depression
Changes in the score on the GBS Scale
The Gottfries-Bråne-Steen Scale used to measure
mental health symptoms and function in
dementia (Nyth and Gottfries, British Journal of
Psychiatry 1990 157 894)
82
Cholinergic Deficit in AD

• Atrophy of nucleus basalis at the base of the
  brain
• Loss of the enzyme choline acetyltransferase
• Reduced synthesis of the transmitter
  acetylcholine
• Limbic and neocortical cholinergic deficits
• Acetylcholine receptors largely intact

83
Cholinesterase Inhibitors

• Tacrine (Cognex)
• Aricept (Donepezil)
• Rivastigmine (Exelon)
• Galantamine (Reminyl)

84
Reduced Psychotropic Use in Persons on Donepezil

(Small et al, Clinical Therapeutics 1998 20 838)
85
Cholinesterase Inhibitors and Behaviors

• 1. Evidence that they reduce apathy, visual
  hallucinations, anxiety, depression, and some
  aberrant motor behavior
• 2. Much less consistent effects on agitation
  or delusions (i.e., delusional thinking)
• 3. Effects less than 30 over placebo
• 4. Independent of effect on cognition
  variable and short-lived
• 5. Increased frontal and temporal perfusion

86
Amyloid Production and Accumulation
A Review The Mechanism Of Alzheimers Disease
Nerve Cell Death
Neurochemical Deficiency
Cognitive and Behavioral Changes
87
Amyloid Production and Accumulation
Anti-Amyloid Agents
Nerve Cell Death
Anti-Oxidants
Neurochemical Deficiency
Cholinesterase Inhibitors
Cognitive and Behavioral Changes
Psychotropic Agents
88
What Can Lower the Risk of AD?

• Eat a healthy balanced diet with fish as a
  frequent source of meat protein fruit and
  vegetable juices are important
• Exercise the mind and the body they are one
  strong body? healthy mind
• Diagnose and treat depression
• Diagnose and treat the highs high blood
  sugar, high blood pressure and high cholesterol
  levels

89
Exercise and Activities as Brain Food

• Alzheimers Association has an
  ongoing Maintain your Brain campaign

90
Depression and AD

• People who had untreated depression, even two
  decades before their diagnosis of AD, may be
  more likely to develop AD than those who have
  never shown signs of depression
• A study of people over age 65 suggested that the
  severity of the depression was related to risk of
  developing AD

91
Incidence of AD in Down syndrome by Depression
History
p 92
Cumulative Incidence of Dementia by Premorbid
Depression
Cumuative Incidence
93
Cholesterol History and Alzheimers Disease

• AD is caused, at least in part, by an abnormal
  accumulation of the beta-amyloid protein in
  specific brain regions
• Both the generation and clearance of
  beta-amyloid are regulated by cholesterol
• Elevated cholesterol levels increase
  beta-amyloid in cellular and most animals models
  of AD
• Drugs that inhibit cholesterol synthesis may
  decrease risk for AD in select populations

94
Incidence of AD in Downs syndrome by
Hypercholesterolemia History
p 95
Hypercholesteremia and Alzheimers
DementiaAnother Down Syndrome Study
Cumuative Incidence
96
Hypertension

• Untreated high blood pressure or diabetes, along
  with smoking in middle age, increases the risk of
  dementia (by 20-40)
• Untreated hypertension is correlated with
  hippocampal atrophy, a structure markedly
  affected by Alzheimers disease (those NFTs)
• Some drugs used to treat high blood pressure
  (like ACE inhibitors) may exert an independent
  lowering of risk for developing dementia in
  select genetic populations

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In Summary So What Can Lower the Risk of
Alzheimers in All of Us?

• Eat a healthy balanced diet with fish as a
  frequent source of meat protein
• Exercise the mind and the body they are one and
  the workouts are synergistic
• Identify and have depression treated
• Medicate high cholesterol levels and high blood
  pressure maintain good control of diabetes and
  other systemic diseases
• THATS A LOT TO DO!!!

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Do It All! Swim Against the Tide!