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“Doctor, Is My Memory Normal?” Full Service Alzheimer’s Disease Diagnosis and Management Dr Emer MacSweeney , CEO and Neuroradiologist Re:Cognition Health, LONDON, UK What is Cognitive Impairment? Problems with any aspect of thinking ability, including: The various types of memory impairment, executive function, problem solving, visuospatial skills, speech and language, decision making, calculation ability, dyslexia, dyspraxia, and many other processes that normally happen subconsciously Who is affected? All ages, multiple causes Dementias > 65yrs: Alzheimer’s disease 60% Vascular dementia 15–20% Dementia with Lewy bodies 15–20% The First Challenge – Accurate Diagnosis Acquired brain injury (ABI) Stroke/TIA PTSD Stress/ anxiety Encephalitis Radiotherapy Chemotherapy Normal pressure hydrocephalus Traumatic brain injury Vascular disease Brain tumours Frontotemporal Cognitive Impairment Drugs/ Alcohol Parkinson Depression CAA Subdural haematoma Epilepsy HIV MS MCI Alzheimer’s disease Lewy body Mild and progressive neurodegenerative disease Service integration is key for all types of cognitive impairment Neurodegenerative disease Integrated multi-disciplinary clinical team, full range of diagnostics and therapies Acquired Brain Injury Assessment and diagnosis Stress, anxiety, depression, PTSD Capacity Assessment Treatment, therapy and monitoring Children and adolescents Clinical trials Ongoing care support and rehabilitation Education The Second Challenge: coordinating patient-centered specialist services GPs Psychiatrists Neurologists Specialist nurses Neuropsychologists Neuroradiologists Clinical Psychologists Neuropsychiatrist SaLTs OTs Memory Clinics The Patient and Carer Neuro Physios Social and Healthcare Coordination Cognitive Stimulation Home care providers Residential Care Family Intermediate Care Carer Training General Public Education Why is this so important in respect to Alzheimer’s Disease? Alzheimer’s is the only leading cause of death that is still on the rise Based on USA data, a treatment breakthrough by 2015 that delays age of onset of AD by 5 years would result in: Reduction in total number of age 65+ expected to have AD in USA of 29% by 2020 from 5.6 M to 4M 43% by 2050 from 13.5 M to 7.7M Reduction in the number of age 65+ with SEVERE AD in USA of 54% by 2020 from 2.4M to 1.1M 82% by 2050 from 6.5M to 1.2M Alzheimer’s Association, 2011 Alzheimer’s Disease Facts and Figures, Alzheimer’s & Dementia, Volume 7, Issue 2 March 2011 A Treatment Breakthrough Will Change Millions of Lives……. Alzheimer’s Association, 2011 Alzheimer’s Disease Facts and Figures, Alzheimer’s & Dementia, Volume 7, Issue 2 (issued March, 2011) …..And Significantly Extend Quality of Life Case Study: early, accurate diagnosis, latest treatment and ongoing support • 53 year old finance professional: anxiety/depression for 5 years • Gradual and progressive memory problems • Stress/psychological difficulties • Brain MRI reported normal in 2006 and 2011 • NO DIAGNOSIS Referred Re:Cognition Health September 2012 • Clinical Assessment: not able to recall symptom history and declining ADLs but still able to organise family life • Exam room memory testing: MMSE 22 out of 30 • 3T MRI with volumetric analysis • CSF abeta/tau protein ratio • PET FDG (alternative) Latest imaging: PET amyloid Disease process starts years before first symptoms. Amyloid probably present for 10-15 years before symptoms, which equates to 20-30% of healthy 75-80 year olds Increased risk of conversion from normal to MCI in amyloid positive healthy older controls: 8% per year 86% of MCI patients with amyloid present on PET develop clinical AD over 3 years Clinical MCI: 60% convert to AD over 3yrs Treatment and Management • Medication: started on symptomatic drug • Specialist nurse, counsellor, GP and neurologist monitoring Home visits Family dynamics Process for understanding diagnosis • 6 months later: eligible for disease modifying drug trial Perceptions • Dementia and persistent memory loss are symptoms which need attention • Most often, cognitive function decline is caused by actual neurological damage: Alzheimer’s, Parkinson’s, stroke, traumatic brain injury • Accurate diagnosis, treatment and management provides significant longterm quality of life benefits • People with these problems deserve to be treated equally to people with diabetes, heart disease or cancer McKhann et al: Alzheimers Dement . 2011 May ; 7(3): 263–269 Alzheimer’s without dementia Mild Cognitive Impairment (MCI) AD – P = the pathological process of Alzheimer’s Disease is present AD – C = the clinical process of Alzheimer’s Disease with cognitive impairment. New disease modifying treatments are designed to be most effective during the MCI phase to significantly slow further decline. The goal is to achieve Alzheimer’s without dementia Nestor PJ et al Nat Neuroscience 2004 Advances in diagnostics allow earlier diagnosis and earlier intervention R.A. Sperling et al. / Alzheimer’s & Dementia 7 (2011) 280–292 To succeed • Education and changing perceptions - early referral. • Training and expertise - Clinically and financially efficient pathway to diagnosis. • Rapid assessment service for new clinical trials for disease modifying drugs Conclusions In the past…….diagnosis relied heavily on the presence of significant clinical symptoms and treatments were symptomatic only In the future……..accurate diagnosis can now be made early allowing intervention with disease modifying drugs and active therapy to compensate and maintain ADLs, adding life to years not years to life Healthcare resources to address this are a rate-limiting factor: new models of hub and spoke collaboration are needed to enable large numbers of patients to be diagnosed without having to visit specialist centres. We need to break down stigma and support whole families, not just the patient Thank you Dr. Emer MacSweeney – CEO & Consultant Neuroradiologist [email protected] +44 (0)20 33 55 35 36 @ReCogHealth