100 years of Alzheimers Disease

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100 years of Alzheimers Disease
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As a courtesy .. .. ..
Would all Old Age Psychiatrists Psychogeriatri
cians Geriatric Psychiatrists Older Adults
Psychiatrists Eldercare Mental Health
Facilitators Please leave the room !!
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Why Me ?

• Dr Alan M. Hughes
• Consultant Psychiatrist Senior Citizens
• Inverclyde Royal Hospital, Greenock
• alan.hughes_at_doctors.org.uk

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100 years what's changed ?
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Life Expectancy
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• Q. What is dementia ?

Dementia is an acquired and global impairment of
intellectual functioning. It involves memory,
language, thinking, and perception and is
associated with disability and usually is
progressive and irreversible
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• Q. What is dementia ?

Dementia is an acquired and global impairment of
intellectual functioning. It involves memory,
language, thinking, and perception and is
associated with disability and usually is
progressive and irreversible
A Dementia is too late!
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The Dementias
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SIGN Guideline No 86
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SIGN 86 2 Diagnosis

• DSM-IV / NINCDS-ADRDA Criteria for Alzheimer's
  Disease
• Hachinski or NINDS-AIRENS for vascular Dementia
• Specific criteria for FTD and DLB

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Diagnosis why bother
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Diagnosis Why bother ?
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Diagnosis why bother

• Lechner et al., 1990
• 7 improved
• 43 died
• 41 still independent (5 year study period)
• Tatemichi et al 1993
• Mortality rate following stroke increased
  threefold by presence of dementia
• Hier et al., 1989
• No difference in survival rates VD / AD
• VD diagnosed earlier in life
• More even spread of mortality

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Diagnosis Tests Screens

• The MMSE is proposed as standard
• Addenbrooke's Cognitive Exam
• IQCODE by relatives
• Screen for depression
• Neuropsychology in dificult cases

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• Diagnosis - Remember Me ?

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Diagnosis - Hachinski Scale

• Maximum 18
• 7 Vascular
• 5- 6 Mixed
• lt 4 Alzheimers

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• Diagnosis - Scanning

• CT
• MRI
• SPECT PET
• EEG
• ERP

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The brain in Alzheimers
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How it appears on a scan
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• Diagnosis Biological Markers

• Pupils
• Nasal Biopsies
• Apo E
• P97 protein
• Urine N.T.P.
• Homocysteine

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SIGN 86 Non-drug therapy

• Caregiver Intervention Programmes
• Cognitive Stimulation Programmes
• Behaviour Management
• Individual Reality Orientation Therapy
• Recreational Activities
• Physical Activities

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SIGN 86 Non-drug therapy

• Aromatherapy
• ? melissa officinalis
• Light Therapy
• Music Therapy
• Multisensory Stimulation
• ? moderate dementia

3166.62
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SIGN 86 Drug Therapy
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Cognitive Function ADAS-Cog
-4
0
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N62
MMSE 12
Also Feldman et al, Neurology. 200157(4) pp
613-621
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Cognitive Function MMSE
Winblad et al, Neurology. 200157 pp 489-495
N286
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Cognitive Function ADAS-Cog
-4
0
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N365 N240
Doody et al, Arch. Neurol. 200158 pp 427-433
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Activities of Daily Living
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Functional Decline
357 days on Donepezil
208 days on Placebo
Loss gt1 bADL or Loss 20 iADL or Increase of
1 on CDR
N431
Mohs et al, Neurology. 200157 pp481-488
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Behavioural Disturbances

• Tacrine
• CIBI
• Donepezil
• CIBIC
• Rivastigmine
• NPI-NH
• LBD
• Galantamine
• CIBIC / NPI

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Memantine

• Moderate affinity uncompetitive NMDA-receptor
  antagonist
• Evidence shown for more severe forms (MMSE lt15)
• Good functional behavioural measures
• Poor clinical effect not advised by SMAC and
  SIGN 86

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Gingko Biloba Salvia

• Extract gingko biloba Egb 761
• Modest initial changes
• Significant difference from placebo at 1 year
• Le Bars et al, 1997
• No improvement in function
• Shadlen Larsen 1999
• Poor study on salvia officinalis
• Akhondzadeh et al, 2003

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HRT Oestrogens

• Reduced risk of AD if taking ERT
• Tang et al 1996
• Lerner et al 1996
• Reduced risk may be proportionate with duration
  of ERT
• Double blind PCT shows no benefit for HRT on
  dementia
• Wang et al 2000

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Anti-inflammatory Agents

• Epidemiological studies
• Chickens Eggs
• Indomethacin improves cognition
• (Rogers et al 1993)
• COX-2 is the one of the inflammatory markers
  upregulated in AD
• Lucca, U. 1999

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Antioxidants

• Vitamin E
• Selegeline
• 2 year study of rate to death, institutionalizatio
  n and loss of dependency
• Sano et al, 1997

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Alzheimers Vaccination

• Mice immunized at a young age were protected
  from Alzheimer's in animals that already had the
  disease, the disease was halted and in some cases
  reversed
• AN-1792
• Sore arms and increased antibodies in 100 AD
  patients

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Alzheimers Vaccination

• Transgenic mice did improve on memory testing
• Morgan et al 2000
• Aseptic meningo-encephalitis
• Specific antibodies to plaque
• Hock et al 2002

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NGF Plastic Pellets

• Tiny polymer pellets, some microscopic in size,
  containing a natural protein hold the promise of
  one day being able to treat such
  neurodegenerative diseases as Alzheimer's.
• The system is startlingly effective because it
  targets, within a fraction of an inch, the area
  of the brain where cell death is causing the
  devastating illness.

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Drink yourself to health

• Controls 198.7mg /day (n54)
• AD 73.9 mg /day (n54)
• Maia De Medonca 2002

• Red rather than white or Rosé

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Drink yourself to health

• Caffeine Reduces Risk of Alzheimers Disease
• 5 cups of coffee a day (for mice)
• Juices 'may cut Alzheimer's risk'
• Fruit juice 3 times a week (People)

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Drink yourself to health

• Caffeine Reduces Risk of Alzheimers Disease
• 5 cups of coffee a day (for mice)
• Juices 'may cut Alzheimer's risk'
• Fruit juice 3 times a week (People)