Alzheimer Dementia: The Threshold Between Normal Aging and Disease

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Explains how physicians differentiate between normal forgetfulness and diseases that affect cognition such as Alzheimer dementia.

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Alzheimer Dementia: The Threshold Between Normal Aging and Disease

  1. 1. 1 Alzheimer’s Dementia The Threshold Between Normal Aging and Disease Garth Turner, MD June 20, 2013
  2. 2. 2 Outline i. “What do you expect, I’m 82 years-old?” ii. A clinician’s approach to cognitive complaints iii. A quick review of Alzheimer’s dementia
  3. 3. 3 Normal aging • Many, but not all cognitive functions naturally decline with age 3
  4. 4. 4 • Our cognitive abilities appear to peak in our 20s and thereafter, there is slow and subtle decline • Perhaps the earliest cognitive ability to decline is processing speed • People are not inclined to notice or be concerned about changes to their cognition before their 40s. 4 Normal aging
  5. 5. 5 • Memory  The most common cognitive complaint as we age  Disproportionate decline in short-term memory (the ability to recall new information shortly after it is presented)  Whereas younger people tend to remember recent events more easily than remote events, older people tend to remember remote events more readily than recent events 5 Normal aging
  6. 6. 6 • Memory  Do not tend to lose autobiographical information  Memory of factual information and general word knowledge is relatively resistant to aging  Do not tend to lose learned skills, but rate of new skill learning in older adults is slower 6 Normal aging
  7. 7. 7 • Attention  Decline in the ability to filter nonessential or irrelevant information when selective attention is required  Performance decline for tasks requiring divided attention  Sustained attention is relatively unaffected 7 Normal aging
  8. 8. 8 • Language  Increased difficulty retrieving names of people, places, and objects (“tip of the tongue” phemonenon)  Rate of verbal output (fluency) declines with age 8 Normal aging
  9. 9. 9 • Executive function  Effectively allows us to plan and organize our way through the day  Requires intact attention, mental manipulation of learned material, abstraction, and adaptation  As we age, there is a relative decline in mental flexibility and tendency towards perseveration  We develop an increasingly rigid or concrete approach to reasoning 9 Normal aging
  10. 10. 10 Outline iii. A quick review of Alzheimer’s disease i. What do you expect, I’m 82 years-old? ii. A clinician’s approach to cognitive complaints
  11. 11. 11 Clinical assessment • History is paramount • Always helpful to obtain information from an independent observer who knows the patient well as persons with dementia are often unaware of their impairments • Important to understand the rapidity of onset and decline. An insidiously developing process is more often typical of dementia. 11
  12. 12. 12 • Cognitive complaints (e.g. memory, language, visuospatial function) • Psychiatric symptoms (apathy, depression, anxiety, insomnia, fearfulness, paranoia, hallucinations) • Personality changes (changes to temper, impulsiveness, disinterest) • Problem behaviors (wandering, agitation, out of bed at night) 12 Clinical assessment
  13. 13. 13 • In addition to cognitive complaints, your clinician wants to know if there has been a functional impairment • Instrumental activities of daily living (IADLs)  Housework (e.g. housekeeping, cooking)  Adherence to medications  Managing money, paying bills  Shopping  Telephone / communication  Transportation 13 Clinical assessment
  14. 14. 14 • After acquiring the history (subjective), your clinician will make both a neuropsychological and a physical assessment (objective) 14 Clinical assessment
  15. 15. 15 • Neuropsychological assessment  Attention  Memory  Executive function  Language  Visuospatial function 15 Clinical assessment
  16. 16. 16 • Determinations  Are the cognitive complaints disproportionate to age?  Could the cognitive complaints be a consequence of a non-neurologic condition (e.g. medical illness, medication effect)?  Are the history, neuropsychological examination, and physical examination concordant and consistent with a syndromic dementia (e.g. Alzheimer’s disease)? 16 Clinical assessment
  17. 17. 17 • As a matter of standard practice, we routinely look for relatively common causes of “reversible dementia”  B12 deficiency  Thyroid dysfunction  Anatomical changes (MRI or CT brain) • Additional tests may be included as clinically indicated 17 Clinical assessment
  18. 18. 18 • Adjunct testing (not standard)  Referral for neuropsychological testing  Lumbar puncture (biomarkers)  Positron emission tomography (PET) 18 Clinical assessment
  19. 19. 19 Outline iii. A quick review of Alzheimer’s disease i. What do you expect, I’m 82 years-old? ii. A clinician’s approach to cognitive complaints
  20. 20. 20 • 1 in 8 people age 65 and older has AD • 45% of persons over age 85 have AD 20 Alzheimer’s disease
  21. 21. 2121 Alzheimer’s disease
  22. 22. 22 • Hallmark and early feature of typical Alzheimer’s disease is a decline in verbal and visual “episodic memory” (memories tied to experiences, e.g. what you ate for dinner) • Progressive decline in other neuropsychological domains (e.g. executive function, language, visuospatial) and ability to carry out IADLs 22 Alzheimer’s disease
  23. 23. 23 • Accumulation of extraneuronal amyloid plaques (amyloid beta) and intraneuronal neurofibrillary tangles (tau) • Neuronal death 23 Alzheimer’s disease
  24. 24. 2424 Alzheimer’s disease
  25. 25. 25 • Mild cognitive impairment (MCI)  Subjective decline in memory or other cognitive dysfunction  Greater than expected for age  No functional impairment (IADLs) • Approx 80% of individuals with amnestic MCI will convert to Alzheimer’s disease within 6 years (a “preclinical” state) 25 The “gray zone” “g
  26. 26. 26 • Alzheimer’s disease (AD) • Frontal temporal lobar dementia (FTLD) • Vascular dementia (VaD) • Dementia with Lewy Bodies (DLB) • Parkinson’s disease with dementia (PDD) 26 Major syndromic dementias
  27. 27. 27 Thank you 27
  28. 28. 28 • Sirven, IJ and Malamut, BL. (2008). Clinical Neurology of the Older Adult. Philadelphia: Lippincott Williams & Wilkins. • 2012 Alzheimer’s Disease Facts and Figures. Alzheimer’s Association ( http://www.alz.org/downloads/facts_figures_2012. pdf ) • Video: Inside the brain: unraveling the mystery of Alzheimer’s disease. National Institute on Aging 28 References

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