The Memory Spectrum: Is it Alzheimer

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The Memory Spectrum Is it Alzheimers Disease?
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• Helle Brand, PA
• Banner Alzheimers Institute

Powerpoint Templates.
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The Memory Spectrum
Memory Function
Time
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Memory Complaints in Normal Adults

• Situation Percentage of elderly
• Names 83
• Where I put things 60
• Knowing I have told someone 49
• something
• Forgetting a task after starting 41
• Losing the thread of conversation 40
• From Boller et al, Arch Neurol 1991

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Aging, memory and intellect
Decrease
Dont change

• Verbal IQ
• Vocabulary
• Store of information
• Comprehension

Speed of memory retrieval Speed of
processing Multi-tasking ability Memory-formation
efficiency
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Types of Memory

• Short term
• Long term
• Motor learning
• These depend on different regions within the
  brain.

Brain memory regions
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Brain changes with aging

• Brain weight
• decreases by about 0.5 per year after age 30
• Neuron loss
• region-specific
• 10-25 loss in cerebellum, cortex,
  hippocampus, substantia nigra
• Loss of synapses (connections between neurons)
• Mild degree of Alzheimer-type pathology

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MRI Brain Normal vs. AD
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Age-Associated Cognitive Impairment

• Loss of memory for words and names
• Slowed processing speed
• Difficulty sustaining attention when faced with
  competing environmental stimuli
• No functional impairment

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Mild Cognitive Impairment (MCI)

• Transitional state /evolving construct
• Cognitive impairment greater than expected for
  age
• Memory complaint corroborated by an informant
• Normal general cognitive function
• Normal activities of daily living
• Memory impairment for age and education
• criteria for dementia not met
• Petersen, 2000

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Outcome of an MCI Diagnosis
Amnestic MCI

• Increased risk for the development of AD within
  the next few years
• Rates of conversion to AD
• MCI 10-15 per year
• Normal elderly 1-2 per year

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Normal Aging
Alzheimers disease
Mild Cognitive Impairment
No change over time
Other dementias
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Dementia

• This term does not define a cause and is not a
  diagnosis!
• Progressive decline in cognitive function
• Decline in functional ability
• Due to damage or disease in the brain
• Many different causes
• AD most common dementia in the elderly

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Clinical Presentation of Dementia
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Progression of Dementia

• Typically progresses over 7 10 years
• Often described using stages
• Mild, Moderate, Advanced (Severe)
• Early , Middle, Late Stage
• Has become the 6th leading cause of death among
  older people
• Requires different strategies and services along
  the way

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Top 10 warning signs

• 1. Changes in memory disrupting daily life
  forgetting recently learned information
  repetitive questioning forgetting dates or
  events relying on notes or others to remember
  things formerly handled on their own
• 2. Challenges in planning or in solving
  problems, difficulty concentrating and taking
  longer to do things they did before cant
  remember or follow a recipe, cant track or pay
  bills
• 3. Difficulty completing familiar tasks at home,
  work, or leisure trouble driving to familiar
  location, playing a game, keeping up with
  hobbies

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The warning signs, continued

• Confusion with time or place losing track of
  dates, seasons, passage of time, forget where are
  or how they got there. Trouble understanding if
  something is not happening immediately
• Trouble understanding visual images and spatial
  relationships trouble judging distances,
  reading, driving, judging color or contrast. May
  see a mirror or window and think someone else is
  in room
• Problems with words when speaking or writing
  Have trouble following or joining in on a
  conversation, forget train of thoughts. May call
  things by wrong name, struggle to find or
  substitute a word.

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The warning signs, continuing

• Misplacing things, having difficulty retracing
  steps May put things in unusual places, may
  accuse others of taking things.
• Diminished or poor judgment trouble with
  decision making, such as when dealing with money
  may pay less to personal appearance, safety, or
  social appropriateness. Impulsive.
• Withdrawal from work or social activities,
  hobbies, work projects or sports

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The warning signs, completed

• 10. Changes in mood and personality can be
  confused, suspicious or paranoid, depressed, more
  fearful or anxious, more easily upset, irritable.
  Less apt to get out of home/comfort zone
• Sound familiar?

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Early (MILD) Stage Dementia

• Features
• Recent memory loss that affects job skills
• Difficulty performing tasks Problems with
  language Misplacing things Problems with
  abstract thinking
• Disorientation of time
• Poor/ decreased judgment
• Changes in mood /behavior Loss of initiative
  Changes in personality
• May have difficulty in a crowd

• Treatment
• Cholinesterase Inhibitor
• Manage depression and other co-existing health
  problems

Maintaining Independence
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Early changes in AD, continued

• may get lost driving or be unsure of self in new
  surroundings
• Forget appointments, family events
• Lists may not make sense

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Special concerns early on

• Medication management
• Driving
• Weight loss
• Mood, especially depression
• Changing awareness and concern for safety
• Need for life planning financial, legal

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Middle (MODERATE) Stage

• Features
• More dependent in daily living tasks
• Severe memory loss
• Fluent aphasia
• Disorientation to time and place
• Impaired judgment and problem solving
• Personality and behavioral changes

Treatment Cholinesterase inhibitor
and/or Namenda Manage mood, behavior and
co-existing illness
Living with help
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Moderate Stage Alzheimers

• Memory loss, confusion and attention worsen over
  a 2-10 year span
• Judgment and problem solving a problem
• Loss of ability to handle complex tasks, gradual
  problems with taking care of self
• Personality and behavior changes
• Increasing dependence
• Cant think logically, organize thoughts

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The concerns with mid stage AD

• Behaviors suspiciousness, irritability,
  restless, loss of impulse control, seeing or
  hearing things not present, agitation, wandering,
  sleep disturbance
• Changing communication/expectations
• Increasing dependence, behaviors cause increasing
  caregiver burden/stress
• Safety/Vulnerability need 24 hour supervision

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Late (SEVERE) Stage Dementia

• Features
• Severe memory loss
• Limited verbal ability
• Orientation only to self
• No independent self-care function
• No judgment/problem solving skills
• Incontinence (bladder/bowel)

Treatment Cholinesterase inhibitor
and/or Namenda Comfort strategies including mood
and pain
Anticipatory comfort care
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Late to End Stage Alzheimers

• Memory loss is severe, including long term
• Loss of recognition of others beyond self
• Problems controlling bowel/bladder
• Fully dependent for care needs
• Minimal to no speech
• Changes in posture/walking, may not walk
• and/or become bed bound

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Issues in advanced Alzheimers

• Risk for falls
• May be prone to infection or skin breakdown
• Weight loss
• Potential for seizures
• Increasing sleep
• Planning for death and dying medical decision
  making, timely hospice referrals

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Alzheimers disease diagnosis

• Diagnosis of exclusion
• History the changes over time
• Physical and Neurologic exams
• Cognitive Testing
• Labs and Imaging Studies
• By definition insidious onset, gradual changes
  in multiple domains affecting function

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The treatment of Alzheimers

• Cholinesterase inhibitors indicated for
  early/mild dementia, typical side effects are
  nausea, vomiting, anorexia ,frequent loose stool,
  vivid dreams, leg cramps. Start slow, assess
  tolerance, maintain at best tolerated level for
  continued cognitive benefit.
• Aricept (donepezil) 10 mg, 23 mg
• Razadyne (galantamine) 8 mg bid or 16,
  24, 32 mg daily in extended release form
• Exelon, oral or patch (Rivastigmine)
  6-12 mg oral, 9.5 or 13.3mg/24 hours in patch
  form
• Namenda (memantine) (NMDA receptor
  antagonist) indicated for moderate stages. 10
  mg bid. NEW 24 mg daily
• Typical side effects include headache,
  constipation, paradoxical confusion

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Cholinesterase Inhibitor Therapy in AD
Disease Severity
Early-Stage Dementia
MCI

• Benefits cognition

• Benefits cognition?

Moderate Dementia

• Benefits cognition
• Preserves global status
• Preserves ADLs
• Benefits behavior?

Severe Dementia

• Benefits cognition
• Preserves global status
• Preserves ADLs
• Benefits behavior?

Class approved for mild-moderate AD Donepezil
also approved for severe AD
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1-Year, Placebo- Controlled Trial of Donepezil
Slowing of Cognitive Decline
Winblad et al. 2001
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Memantine Therapy for AD
Disease Severity
Mild-Moderate Dementia
MCI

• Inconsistent effects

• Role unknown

Moderate-Severe Dementia

• Benefits cognition
• Preserves global function
• Preserves ADLs
• Benefits behavior

Approved for moderate-severe AD in the U.S.,
alone or in combination with cholinesterase
inhibitors
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Cholinesterase Inhibitor Therapy in AD
Disease Severity
Early-Stage Dementia
MCI

• Benefits cognition

• Benefits cognition?

Moderate Dementia

• Benefits cognition
• Preserves global status
• Preserves ADLs
• Benefits behavior?

Severe Dementia

• Benefits cognition
• Preserves global status
• Preserves ADLs
• Benefits behavior?

Class approved for mild-moderate AD Donepezil
also approved for severe AD
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Other treatments Its not just memory

• Mood/ behavioral symptoms address environmental
  factors, then medication (
  antidepressants, antipsychotics)
• Sleep disturbance non PM formulary, no benzos.
  (Trazodone, Mirtazapine, Melatonin)
• Pain Routine Acetaminophen

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Caregiver stress

• Care becomes 24/7 job
• Caregivers become socially isolated
• Family dynamics a consideration
• At risk for deterioration of their own health,
  physical and emotional status
• Caregivers more often die first

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Sharing the care helps

• Barriers include caregiver reluctance from
  stoicism, guilt, promises made, perfectionism,
  isolation
• Myths persist re financial concerns
• The system makes it hard!
• Family dynamics are definitely part of the
  equation, possibly the solution!

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Options to extend care

• Consider a volunteer network
• Senior centers
• Day Care programs
• Home care agencies
• Alternative residences
• Hospice care

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Hope for the futureThe Alzheimers Prevention
Initiative

• 1st approved study to provide prevention
  therapies to people at greatest genetic risk of
  developing AD
• Building a registry of volunteers who may be
  interested in participating in future prevention
  research in the U.S.
• We need YOU!
• www.endalznow.org or call 602-839-6900

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In closing.

• Remember
• The mind forgets, but the heart remembers!
• Questions?