Definition of Dementia

1
Definition of Dementia

• An acquired complex of intellectual
  deterioration which affects at least two areas
  of cognitive function.
• A syndrome, not a diagnosis.
• In the past, commonly referred to as senility
  or hardening of the arteries

2
Cognitive Functions

• Memory
• Orientation
• Language
• Judgement

• Perception
• Attention
• Ability to perform tasks in sequence

3
Dementia Brain failure

• Two basic types
  
  1) Reversible dementias
  
  
  
  
  2) Irreversible
  dementias
• All dementias are treatable to a degree

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Reversible Dementias

• Intoxications
• Infections
• Metabolic disorders
• Major depression

• Brain tumors
• Head injuries
• Normal pressure hydrocephalus

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Irreversible Dementias

• Alzheimers disease
• Multi-infarct or vascular dementia
• Parkinsons disease
• Lewy Body disease

• Creutzfeldt-Jakob disease
• Picks disease
• Huntingtons disease
• AIDS dementia complex
• Progressive aphasia

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Diagnostic Evaluation of Dementia

• History from patient and relative or friend
• Clinical exam
• Blood work CBC, Chem profile, Thyroid function
  tests, Syphilis serology, Vit B12, Folate
• Brain scan, CT or MRI

• If indicated -
  Psychological testing - HIV
  - Brain biopsy -
  SPECT or PET scan - Lumbar
  puncture - EEG

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Criteria for Probable Alzheimers Disease

• Dementia established by clinical and
  neuropsychological examination
• Deficits in at least two areas of cognition
• Progressive worsening of memory and other
  cognitive functions

• No disturbances of consciousness
• Onset between ages 40 and 90
• Absence of other disorders to account for dementia

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Prevalence of Alzheimers Disease

• More than 4 million Americans plus their families
• Number doubles every 5 years after age 65
• Estimated cost of 100 billion annually
• Numbers may triple by 2050

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Prevalence of Alzheimers Disease by Age
SOURCE Evans, D.A. et al. (1989). Journal of
the American Medical Association. Vol. 262
2251-2256.
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Stages of Alzheimers disease

• Function Early Stage
• Memory Routine loss of recent memory
• Language Mild aphasia (word finding
  difficulty)
• Orientation Seeks familiar and avoids unfamiliar
• Motor Some difficulty writing and using
  objects
• Mood and behavior Apathy depression
• Activities of Needs reminders with some ADLs
• daily living (ADL)

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Stages of Alzheimers disease
Function Middle Stage Memory Chronic, recent
memory loss Language Moderate aphasia Orientation
May get lost at times, even inside the
home Motor Repetitive actions, apraxia Mood
and behavior Possible mood and behavioral
disturbances Activities of Needs reminders
and help with daily living (ADL) most ADLs
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Stages of Alzheimers disease
Function Late Stage Memory Mixes up past and
present Language Expressive and receptive
aphasia Orientation Misidentifies familiar
persons and places Motor Bradykinesia, at
risk for falls Mood and behavior Greater
incidence of mood and behavioral
disturbances Activities of Needs reminders with
all ADLs daily living (ADL)
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Stages of Alzheimers disease
Function Terminal Stage Memory No apparent link
to past or present Language Mute or few
incoherent words Orientation Oblivious to
surroundings Motor Little spontaneous movement,
dysphagia, myoclonus, seizures Mood and
behavior Completely passive Activities of
Requires total care daily living (ADL)
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Alzheimers Disease Brain Changes

• Loss of brain cells and mass
• Neurofibrillary tangles
• Neuritic plaques
• Change in blood flow glucose utilization

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Neurotransmitters

• Facilitate communication among nerve cells
• Acetylcholine production other
  neurotransmitters reduced in Alzheimers disease
• Communication between nerve cells disrupted
• Nerve cells die

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Definite Risk Factors for Alzheimers Disease

• Increasing age
• Family history genetics
• Female gender
• Down Syndrome

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Genes Linked to Alzheimers Disease
Chromosome Type Age of Onset of Cases
Gene 21
Autosomal 45-65 lt 1
APP (Amyloid
Dominant precursor protein) 14
Autosomal 28-62
lt 1 Presenilin 1
Dominant 1 Autosomal
45-65 lt 1
Presenilin 2
Dominant 19 Risk Factor
gt 60 gt 50
ApoE 4 12 Risk factor
gt 70 ? A2M Source Marx, J.,
(1998, July 24) Science, Vol. 281, 509.
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Possible Risk Factors for AD

• Environmental toxins
• Low formal education occupational attainment
• Previous head trauma
• Cerebrovascular disease

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Strategies for Medical Treatment ofAlzheimers
Disease

• Prevention of disease
• Delay onset
• Slow rate of progression
• Treat primary symptoms (cognitive)
• Treat secondary symptoms (behavioral)

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Tacrine (COGNEXTM)

• Approved for treatment of AD in 1993
• Intended for use with mildly moderately
  impaired patients
• Limited benefit for a limited duration in a
  minority of patients
• High risk of adverse effects
• Rarely prescribed today

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Donepezil (ARICEPTTM)

• Approved for treatment of AD in 1996
• Intended for use with mildly moderately
  impaired patients
• Improvement or stability in almost half of
  patients during clinical trials long-term
  effects unknown
• Minimal adverse effects, usually at higher dose
• Dosage 5 mg or 10 mg tablet once at night

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Rivastigmine (EXELONTM)

• Approved in 2000 for treatment of mild to
  moderate AD
• Improvement or stability in a majority of
  patients during clinical trials who had highest
  dose
• Benefits and minimal adverse effects tied to
  increasing dosage

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Galantamine (REMINYLTM)

• Approved in 2001 for treatment of mild to
  moderate AD
• Twice daily dosage starting at 4 mg tablets each,
  increasing to 8 mg at 4 weeks, then to a maximum
  of 12 mg after 4 more weeks
• Increasing dosage tied to greater benefit and
  more side effects

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Potential Treatments/ Prevention

• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Antioxident agents
• Estrogen
• Alternative medicine
• Others???

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Directions for Research

• Further identify risk factors underlying
  biological causes
  
• Improve diagnostic tools
• Develop better drugs
• Improve approaches to care
• Reduce caregiver distress

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Care of Persons with Alzheimers disease

• Create a supportive atmosphere
• Structure appropriate activities routine
• Design dementia friendly environments
• Facilitate peer groups (for emotional support
  shared activities)

27
Help for Family Caregivers

• Offer education, training and consultation
• Promote respite services, e.g., adult day care,
  companion
• Offer individual and family counseling
• Encourage participation in support groups