Henry Pacheco MD Medicine amp Public Health Director National Hispanic Council on Aging NHCOA Washington DC National Hispanic Council on Aging NHCOA Working to improve the lives of Hispanic older adults their families and caregivers ID: 752754
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Alzheimer's and Other Dementias
Henry Pacheco, M.D.Medicine & Public Health DirectorNational Hispanic Council on Aging (NHCOA)Washington, DC
National Hispanic Council on Aging (NHCOA)
Working to improve the lives of Hispanic older adults, their families, and caregiversSlide2
Learning ObjectivesTo provide an overview of dementias with focus on Alzheimer’s Disease
To describe risk factors, signs and symptoms and progression of Alzheimer's DiseaseTo describe some diagnostic and treatment challenges for primary care providers (PCPs)To understand the importance of focusing on the caregivers of people with Alzheimer’sSlide3
What is Dementia?
“Dementia is a general term for a decline in mental ability severe enough to interfere with daily life.” ( ALZ Assoc, 2012)
Not a specific diseaseDescribes a collection of symptoms Caused by many disorders that affect the brainResults in impaired intellectual functioning
Interferes with normal activities and social relationships.
Loss of cognitive abilities, personality changes, agitation, delusions, loss of emotional control, behavioral problems, inability to solve daily problems.Slide4
Types of DementiaAlzheimer's Disease – 60-80% of all dementias
Vascular Dementia -10%-20%Dementia with Lewy Bodies (DLB) – 5%- 10%Mixed DementiaParkinson's DiseaseFronto-Temporal Lobar Dementia (FTLD) 15%- 25%Creutzfelt-Jacob DiseaseNormal Pressure HydrocephalusSlide5
Alzheimer's Disease
What is Alzheimer’s Disease (AD)?It is an irreversible, progressive and fatal neuro-degenerative brain disease.
Characteristics:1)Loss of memory, (inability to learn new and recall old information), and
2) Decline or loss of one or more of the following
:
Language (aphasia)
Purposeful action (apraxia)
Recognition (agnosia)
Executive function (think abstractly, judgment)
Interference
with social or occupational functions of daily life
DSM-IV Criteria for Diagnosis of Alzheimer'sSlide6
The Impact of Alzheimer's Disease and the Aging of the Population
5.4 million people in the US have AD 11 to 16 million adults 65+ projected to have AD by 2050 in US24 million with AD worldwideAD is the most common form of dementiaMortality secondary to AD is up 20% in the past decadeCost of caring for people with AD ~ $200 billion a year and growing
Source: ALZ Assoc. 2012, NIH, AOASlide7
Normal Age-Related Cognitive DeclineDecrease in the rate of information processing, especially non-verbal informationReduced spontaneous recall
Small decrease in executive skillsStill able to learn new information, but decline in recallSources: AMA Therapeutic Insight Management of Alz Disease, 2010Slide8
Potential Causes of Cognitive Impairment
Chronic alcohol or drug abuse Tumors Subdural hematoma Normal pressure hydrocephalusMetabolic disordersHypothyroidismHypoglycemiaCertain medication side effects
Medicines interactingDepressionPsychotic disordersHIV DementiaLyme’s Disease, SyphilisHepatic & uremic encephalopathyLow literacy or language impairment (may appear as cognitive impairment)Slide9
Alzheimer’s Disease
Older age is primary risk factor: AD incidence doubles every 5 years after age 65Family historyLower educational levelFemaleGenetic Risk factors: mutation in 3 genes associated with ADAmyloid Precursor Protein (APP)Presenillin -1 (PS1)Presenillin-2 (PS2)
Apo lipoprotein E (APOE)Pathophysiology:Disorder in B- amyloid metabolism Extensive B
- Amyloid
plaque deposits
between neurons( possibly no symptoms)
Neurofibrillary
tangles
(protein Tau), loss of synapse, neuronal death from inflammation (cognitive impairment)
Loss of neurons leading to abnormalities in multiple regions of the brain (neuro degeneration) with loss of neurotransmitters (acetyl choline)
Sources: 1)NIH ,2012 , 2) AMA Therapeutic Insight Management of
Alz
Disease, 2010Slide10
Neurons
The brain has billions of neurons, each with an axon and many dendrites.
To stay healthy, neurons must communicate with each other, carry out metabolism, and repair themselves.
AD disrupts all three of these essential jobs.
Inside the Human Brain
Slide 14Slide11
Symptoms of Alzheimer's
Early: forgetfulness (2-4 years)Mild cognitive impairment (MCI) between normal forgetfulness of aging and the development of ADModerate: (2-10 years)Change in sleep patterns, delusions, depression, agitation
Difficulties in simple tasks, dressing driving, reading or writing Forgetting details of current events, losing self-awareness Argumentative, aggressive behavior, poor judgmentUsing the wrong words, mispronouncing, confusing sentencesWithdrawing from social contact
Advanced: (1-4 years)
Fails to understand conversations
Fails to recognize family members
Can’t perform basic activities of daily living
( eating, dressing, and bathing), incapacitated
Incontinence , swallowing problems
Death usually from infections such as pneumoniaSlide12
Diagnosis of Alzheimer’s Disease
Medical History (hx)Deficits, rate of progression, personality, behavior changes, gait movement problems.Family HxAny hx. of dementia or neurologic conditionsPast Med History
Hx. of Hypertension, strokes, diabetes, employment hx (exposure to toxic materials), psychiatric hx., substance abuseLabsMostly to uncover or rule out treatable medical conditions responsible for cognitive deficits: HCT, TSH, Electrolytes , fasting glucose, Vit. B12 level, folate deficiency, RPR, HIV,
ESR.
Future Tests ( research)
May include bio-markers for AD in
cerebro
-spinal fluid (CSF,) blood and urine
Physical
Exam
Thorough neurological.
exam, sensory deficits, peripheral neuropathy, gait ,etc./ mental status assessment. Any co-morbidities?
Neuropsychological
cognition testing
Early
diagnosis of AD is challenging; PCP typically
conduct tests
such as
;
Montreal
Cognitive Assessment (
MoCA
),
Mini-mental
State Exam (MMSE),
clock
drawing
test
Mini Cog.
Other
tests include
CT or MRI
, PET scans (not routine) may be left to the neurologist,
CSF analysis
Referrals/consultations
Neurologist, social and support services
Differential Diagnosis
Treatable causes of cognitive impairment
The differentiation of Mild Cognitive Impairment
(MCI) from normal aging and
early Alzheimer’s – not always clear
Must
distinguish AD from
other dementias such as Lewy
Body
or
FTLD because the
usual AD medications may
have adverse effect
on these dementiasSlide13
Importance of Early Diagnosis
To allow effective preparation for:Family & patient counselingLife style modificationsDiet/aerobic exerciseControl of chronic diseases HTN, diabetes, etc.Start disease treatment earlier Early planning for the
future (not overwhelm the patient or the family)There are often subtle cognitive impairments in early AD that may go underdiagnosed by PCPs this may be specially the case among African American & Hispanic patientsSlide14
Primary Treatment of Alzheimer’sNon pharmacological
Care planning through the stagesCoordinated care options for patientsSupport of careSlide15
Care Planning For Alzheimer's Patients
While patient still able to understand & communicate effectivelyAdvance directives, durable power of attorneyPlanning for quality of life, driving, etc.Mental health evaluation Functional assessments on regular basisCognitive assessment on regular follow -upsBehavioral assessment ( mood, activities, etc.)
Discuss medicationsTerminal careSlide16
Primary Treatment of Alzheimer’sPharmacological
For Mild to Moderate A.D.Cholinesterase Inhibitors (for mild/moderate AD) may for a limited time delay or prevent symptoms. Aricept® (donepezil) (widely used)Exelon® (rivastigmine)Razadyne® (galantamine) Cognex® (tacrine
) (rarely used now)For Moderate to Severe A.D.Namenda® (memantine)Aricept Slide17
The Caregivers
Estimated that 15 million people provide unpaid care for patients with AD Caregivers are generally older (52+) and femaleSpouses (the largest group of caregivers)Daughters (the sandwich generation)Family membersFriends, neighbors, members of non-profit organizations
AD represents a very significant emotional, psychological, financial and physical burden for caregivers and their families.Caregivers are vulnerable to physical, emotional and financial stressEssential AD care involves providing information and support interventions (psycho-educational, supportive, psychotherapy, etc.) to caregivers Sources: ALZ Assoc. 2012Slide18
Care Planning For CaregiversEvaluate understanding of Alzheimer’s Dementia and provide education
Referral to resources: local community and national resources(Alzheimer’s Association, day care, respite programs,)Evaluation of support system (family, friends)Coping, stress, depression and potential abuseCaregiver training (safety precautions at home )Keeping a log for Alzheimer’s patientPlacement of Alzheimer’s patient in nursing h
omeSlide19
Coping with Difficult BehaviorsA presentation by: Thomas Magnuson, M.D. Assistant Professor, Department of Psychiatry, UNMC
www.unmc.edu/media/intmed/.../dealingwithdifficultbehaviorsi_.pptSlide20
Grants and FundingGrants.govProvides current funding information from NIH, CDC, FDA AHQR
Grantswww.grantWatch.comAlzheimer’s FoundationSlide21
BibliographyNational Institute of health/National Institute on AgingNational
Institutes of Health. US DHHS. Alzheimer's Disease Education & Referral (ADEAR) Center. Alzheimer's Disease Fact Sheet. Bethesda, MD: National Institutes of Health; 2011. NIH Publication 11-6423Current Medical Diagnosis & Treatment 20132010 Progress Report, National Institute on Aging, National Institute of Health & Human Services, Dec 2011
Alzheimer's Association Facts and Figures 2012Slide22
Thank You!