Transcript Orange Shades - University of Alaska Fairbanks

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The Memory Spectrum: Is it
Alzheimer’s Disease?
Helle Brand, PA
Banner Alzheimer’s Institute
Memory Function
The Memory Spectrum
Normal
Aging
Mild
Cognitive
Impairment
(MCI)
DEMENTIA
Time
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
Aging, memory and intellect
Don’t change
Decrease
Verbal IQ
Speed of memory retrieval
Vocabulary
Speed of processing
Store of information
Multi-tasking ability
Comprehension
Memory-formation
efficiency
Types of Memory
Short term
Long term
Motor learning
These depend on
different regions
within the brain.
Brain memory regions
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
MRI Brain: Normal vs. AD
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
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
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
Normal Aging
Alzheimer’s disease
Mild Cognitive
Impairment
No change over time
Other dementias
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
Clinical Presentation of Dementia
Function
Cognition
Behavior
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
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 : can’t remember or follow a recipe,
can’t track or pay bills
Difficulty completing familiar tasks at home,
work, or leisure: trouble driving to familiar location, playing a
3.
game, keeping up with hobbies
The warning signs, continued
4. 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
5. 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
6. 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.
The warning signs, continuing
7. Misplacing things, having difficulty retracing
steps: May put things in unusual places, may accuse
others of taking things.
8. 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.
9. Withdrawal from work or social activities,
hobbies, work projects or sports
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?
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
Maintaining Independence
Treatment
Cholinesterase Inhibitor
Manage depression and other coexisting health problems
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
Special concerns early on
Medication management
Driving
Weight loss
Mood, especially depression
Changing awareness and concern for safety
Need for life planning: financial, legal
Middle (MODERATE) Stage
Features
More dependent in daily
living tasks
Severe memory loss
Fluent aphasia
Disorientation to time and
place
Impaired judgment and
Treatment
problem solving
Personality and
behavioral changes
Living with help
Cholinesterase inhibitor and/or
Namenda
Manage mood, behavior and co-existing illness
Moderate Stage Alzheimer’s
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
Can’t think logically, organize thoughts
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
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)
Anticipatory comfort care
Treatment
Cholinesterase inhibitor and/or
Namenda
Comfort strategies including mood and pain
Late to End Stage Alzheimer’s
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
Issues in advanced Alzheimer’s
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
Alzheimer’s 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
The treatment of Alzheimer’s
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
Other treatments: It’s 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
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
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!
Options to extend care
Consider a volunteer network
Senior centers
Day Care programs
Home care agencies
Alternative residences
Hospice care
Hope for the future:
The Alzheimer’s 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
In closing….
Remember:
The mind forgets, but the heart
remembers!
Questions?