General Dementia Knowledge: Signs, Symptoms, ProgressionPanelists:Ellen LindseyPhipps Slaughter, PsyD Moderator: E. Ayn Welleford, MSG, PhD May 9, 2011
CHANGES WITH AGING TYPICAL CHANGES A-TYPICAL CHANGES• Making a bad decision once in a • Consistent poor judgment and while decision making• Missing an occasional monthly • Loss of an ability to manage payment money• Forgetting which day it is and • Inability to keep track of the date remembering later or the season• Sometimes forgetting which word • Difficulty having a conversation to use • Misplacing things and loss of the• Losing things from time to time ability to retrace steps to find them • Trouble with visual and spatial relationships • Challenges in planning or solving problems
DEMENTIA Dementia IS NOT a specific disease. Dementia is aMemory loss generally GROUP OF SYMPTOMSoccurs in dementia, but affecting intellectual andmemory loss alone does social abilities severelynot imply you have enough to interfere withdementia. daily functioning. DEMENTIA Alzheimers disease There are many is the most common cause of a progressive causes of dementia dementia. symptoms.
DEMENTIAPer the Diagnostic Statistical Manual IV- Revised (DSM-IV-TR), dementias share a common symptompresentation but are differentiated based on etiology, or cause.The essential feature of any dementia is the development of multiple cognitive deficitsthat include:• memory impairmentand at least one of the following cognitive disturbances:• aphasia (language disturbance),• apraxia (impaired ability to carry out motor activities despite intact motor function),• agnosia (failure to recognize or identify objects despite intact sensory function), and• executive dysfunction (difficulty in planning, organizing, sequencing, abstracting).The deficits must also be sufficiently severe and must represent a decline from a previouslyhigher level of functioning.The diagnosis of dementia may be accompanied by subtypes and specifiers such as• Early (before the age of 65) or Late Onset (after 65)• With Behavioral Disturbance (e.g., wandering, striking out during care);• With Delirium (if delirium is superimposed on dementia);• With Delusions (if delusions are most prominent feature);• With Depressed Mood (if depressed mood is most prominent feature); and• Uncomplicated (if none of the aforementioned predominates the clinical presentation).
DEMENTIA CAUSES CHANGES IN personality memory / mood behavior language navigation thought
TYPES OF DEMENTIA CORTICAL SUBCORTICAL• Result from a disorder affecting the • Result from dysfunction in parts of cerebral cortex (outer layers of the the brain that are below the cortex. brain) playing a critical role in • Examples are dementias of the types cognitive processes such as memory Huntingtons disease, Parkinsons and language. Disease, and AIDS dementia• Alzheimers and Creutzfeldt-Jakob complex disease are two such forms. • Characteristics include changes in• Characteristics include severe personality and attention span, with memory impairment and aphasia a slowing down of thinking. (inability to recall words or • Early symptoms include understand common language). depression, clumsiness, irritability or apathy. But the end stages of subcortical dementia result in the same breakdown of brain function as in the cortical dementias.
ALZHEIMER’S DISEASE brain disorder, most common form of dementia ASSOCIATED RISK FACTORS: • Age • Family history Affects 5% of people at age • Down syndrome 65 • Incidence higher in women • Alcohol use • Atherosclerosis Affects 50% of people age • Blood pressure 85+ • Cholesterol • Depression Late-onset • Diabetes (type 2) (age 65+) is most common, slowest- progressing Average course of DAT: 6-20 years
AD (cont.) – 10 WARNING SIGNS Memory loss that disrupts daily Challenges in Changes in functioning planning or mood and solving personality problems Difficulty Withdrawal completing from work or familiar tasks at social activities home, at work or WARNING at leisure SIGNS Decreased or Confusion with poor judgment time or place Misplacing Trouble things and understanding losing the visual images ability to retrace New problems and spatial steps with words in relationships speaking or writing
AD – STAGESIt is important to keep in mind that stages are general guides, and symptoms vary greatly. Noteveryone will experience the same symptoms or progress at the same rate. This seven-stageframework is based on a system developed by Barry Reisberg, M.D., clinical director of the NewYork University School of Medicines Silberstein Aging and Dementia Research Center.Stage 1: No impairment (normal function)The person does not experience any memory problems. An interview with a medicalprofessional does not show any evidence of symptoms of dementia.Stage 2: Very mild cognitive decline (may be normal age-related changes or earliestsigns of Alzheimers disease)The person may feel as if he or she is having memory lapses — forgetting familiar words or thelocation of everyday objects. But no symptoms of dementia can be detected during a medicalexamination or by friends, family or co-workers.
AD – STAGESStage 3: Mild cognitive decline (early-stage Alzheimers can be diagnosed in some,but not all, individuals with these symptoms)Friends, family or co-workers begin to notice difficulties. During a detailed medical interview,doctors may be able to detect problems in memory or concentration. Common stage 3difficulties include:• Noticeable problems coming up with the right word or name• Trouble remembering names when introduced to new people• Having noticeably greater difficulty performing tasks in social or work settings• Forgetting material that one has just read• Losing or misplacing a valuable object• Increasing trouble with planning or organizing
AD – STAGESStage 4: Moderate cognitive decline (Mild or early-stage Alzheimers disease)A careful medical interview should be able to detect clear-cut problems in several areas:• Forgetfulness of recent events• Impaired ability to perform challenging mental arithmetic• Greater difficulty performing complex tasks, such as planning dinner for guests, paying bills or managing finances• Forgetfulness about ones own personal history• Becoming moody or withdrawn, especially in socially or mentally challenging situationsStage 5: Moderately severe cognitive decline (Moderate or mid-stage AD)Gaps in memory and thinking are noticeable, and individuals begin to need help with day-to-day activities. At this stage, those with Alzheimers may:• Be unable to recall their own address or telephone number or the high school or college from which they graduated• Become confused about where they are or what day it is• Have trouble with less challenging mental arithmetic; such as counting backward from 40 by subtracting 4s or from 20 by 2s• Need help choosing proper clothing for the season or the occasion• Still remember significant details about themselves and their family• Still require no assistance with eating or using the toilet
AD – STAGESStage 6: Severe cognitive decline (Moderately severe or mid-stage AD)Memory continues to worsen, personality changes may take place and individuals needextensive help with daily activities. At this stage, individuals may:• Lose awareness of recent experiences as well as of their surroundings• Remember their own name but have difficulty with their personal historyRemember:It is difficult to place a person with Alzheimers in a specific stage as stages may overlap.• Distinguish familiar and unfamiliar faces but have trouble remembering the name of a spouse or caregiver• Need help dressing properly and may, without supervision, make mistakes such as putting pajamas over daytime clothes or shoes on the wrong feet• Experience major changes in sleep patterns — sleeping during the day and becoming restless at night• Need help handling details of toileting (for example, flushing the toilet, wiping or disposing of tissue properly)• Have increasingly frequent trouble controlling their bladder or bowels• Experience major personality and behavioral changes, including suspiciousness and delusions (such as believing that their caregiver is an impostor)or compulsive, repetitive behavior like hand-wringing or tissue shredding• Tend to wander or become lost
AD – STAGESStage 7: Very severe cognitive decline (Severe or late-stage Alzheimers disease)In the final stage of this disease, individuals lose the ability to respond to their environment, tocarry on a conversation and, eventually, to control movement. They may still say words orphrases.At this stage, individuals need help with much of their daily personal care, includingeating or using the toilet. They may also lose the ability to smile, to sit withoutsupport and to hold their heads up. Reflexes become abnormal. Muscles grow rigid.Swallowing impaired.
AD - TREATMENT• No treatment is available to slow or stop the deterioration of brain cells in Alzheimers disease.• The US Food and Drug Administration has approved five drugs that temporarily slow worsening of symptoms for about 6 - 12 months.• These are effective for only about half of the individuals who take them.• Inconclusive research: o Vitamin E o Anti-inflammatory drugs o Estrogen o Vaccine o Diet www.alz.org/research/overview.asp
VASCULAR DEMENTIA CAUSES: • Untreated high blood pressure The second most • Diabetes common dementia after • High cholesterol Alzheimers disease • Heart disease ASSOCIATED SYMPTOMS: Result of a damage to the • Confusion and agitation; depression brain caused byVaD can be cortical and subcortical problems with • Unsteady gait the arteries serving the brain • Problems with memory or heart. • Urinary frequency, urgency, incontinence • Night wandering Approx. 25-30% of all dementias • Decline in ability to organize are VaD thoughts/actions, difficulty planning • Poor attention/concentration Prevalence of VaD ranges from TREATMENT: 1 to 4 percent in people over the Damage caused by infarcts cannot be age of 65. reversed. Future cerebrovascular incidents can be controlled (control of cardiovascular risk factors)
FRONTOTEMPORAL DEMENTIA CAUSES: (Fronto-temporal areas • Unknown Group of diseases of the brain are generally associated • Possible genetic mutations. characterized by with personality, the degeneration behavior and language). ASSOCIATED SYMPTOMS: of nerve cells in In these dementias, the F-T areas of portions of these lobes atrophy. • socially inappropriate behaviors the brain • loss of mental flexibility • decline in personal hygiene • language problems, and Begins earlier and progresses • movement disorders faster than AD • difficulty with concentration and thinking. TREATMENT: • Irreversible dementing process Occurs at ages younger than • Agitated symptoms respond to AD, i.e., 40-70. antipsychotic meds • Compulsive symptoms respond to SSRIs (antidepressants) • Some patients also benefit from Picks disease affects parts of ADHD meds to stimulate frontal One form of thisthe brain that contain fibrous condition is lobe function • Behavioral interventions may be tangles made up of an Picks disease. abnormal protein called tau protein effective to encourage behavioral control whenever possible
CREUTZFELDT-JAKOB DISEASE CAUSES: abnormal versions of a protein called a CJD is a degenerative brain prion. disorder that leads to dementia and, ultimately, death. TRANSMISSION (rapid progression) Risk of CJD is low. Cannot be transmitted through coughing, sneezing, touching or Variant CJD is linked primarily to The "classic" sexual contact.eating beef infected Creutzfeldt-Jakob with disease has not CJD DEVELOPS:bovine spongiform been linked to encephalopathy contaminated beef. • Spontaneously (majority of cases) (mad cow disease. • Genetic mutation (family history) • Contamination. (very low number of exposures to infected human 1 in 1 million people are tissue during a medical procedure) diagnosed with CJD per year (usually older ASSOCIATED SYMPTOMS: adults). personality changes, anxiety, depression, memory loss, impaired thinking, blurred vision, insomnia difficulty swallowing, motor issues.
MIXED DEMENTIAS• AD and another type of dementia can exist at the same time• This may account for nearly half of the cases where AD is present
SUBCORTICAL DEMENTIAS• Dementia due to Parkinson’s disease• Lewy body dementia• Alcohol-induced persisting dementia• Progressive supranuclear palsy
DEMENTIA DUE TO PARKINSON’S DISEASE GENERAL PD SYMPTOMS: • Movement problems (tremor, stiffness, slowness) PD is a • Walking problems (freezing, shuffling gait) progressive • Speech problems (soft voice, trails off, monotonous) disorder of the CNS • Other oral problems (drooling, difficulty swallowing) • Fatigue • Blank facial expression Results from a DEMENTIA SYMPTOMS IN PD PATIENTS: deficiency in the neurotransmitter • Slowed reaction time DOPAMINE • Impulse control problems • Hallucinations or delusions • Short-term memory problems (but with hints they can recall info) Affects more than • Problems with recognizing emotions in others’ 1.5 million people in the US speech or facial expressions TREATMENT There is no known treatment that stops or reverses dementia due to PD • Medications that increase dopamine production20-40% havemore severe 50%+ of people help control movement aspects of PD (not cognitive) symptoms/ with PD have MCI. • Some surgeries can be helpful (e.g., Deep Brain dementia stimulation), but not for dementia symptoms • Stem cell research is being conducted, results are
DEMENTIA WITH LEWY BODIES CAUSES: - Not known Deposition of Lewy bodies - LB often found in the brains of people w/PD. in both, SYMPTOMS: cortical and subcortical • Core criteria (must have two): o Fluctuating attention and concentration o Recurrent, well-formed visual hallucinations o Newly emerged PD-type motor problems Has features • Suggestive features (these may be present): of both PD and AD o History of REM sleep behavior disorder (violent sleep behavior or sleepwalking) o Sensitivity to neuroleptic (antipsychotic) meds • Supportive clinical features (don’t have to be Affects 1% of present): those age 65, o Repeated falls, Syncope (fainting), Depression 5% over age 85 TREATMENT • Older antipsychotics (e.g., Thorazine, Haldol) are usually avoided because they can cause deadly Usually reactions in LBD patients progresses more rapidly • Anti-dementia medications (e.g., Aricept, Reminyl) than DAT have been found to be somewhat effective in (average = 6 years) slowing cognitive decline and calming behavior • Dopamine-enhancing drugs appear effective in addressing motor symptoms
ALCOHOL-INDUCED PERSISTING DEMENTIA ASSOCIATED SYMPTOMS: Sometimes referred to as Wernicke- o Severe memory impairment Korsakoff’s syndrome o Inventing false memories (confabulation) o Reduction in speech o General apathy o Gait problems (coordination) A dementia syndrome caused o Tremors by many years of heavy drinking o No insight into difficulties o Hallucinations (in some patients) Usually the result of a combination of TREATMENT malnutrition (thiamine deficiency) and • Can be partially reversed if caught early and brain damage directly caused by treated with high doses of thiamine • alcohol Abstinence from alcohol is ESSENTIAL to stop progression of dementia o Support programs can help maintain Accounts for < 5% abstinence of all dementias o Periodic blood tests, breathalyzers can also be useful
ANOTHER WAY OF LOOKING AT DEMENTIAS REVERSIBLE IRREVERSIBLE• Depression, delirium • Dementia of the Alzheimer’s• Emotional disorders type• Metabolic disorders (e.g., • Dementia of the Parkinson’s hypothyroidism type• Eye and ear impairments • etc.• Nutritional (e.g., B12 deficiency)• Tumors• Infections• Alcohol, drugs, medication interactions
REVERSIBLE COGNITIVE IMPAIRMENT COGNITIVE IMPAIRMENT DUE PSEUDODEMENTIA DELIRIUM TO MEDICAL CONDITION• Dementia patients: bad guesses • Acute period of confusion brought • Malnutrition• Pseudodementia patients: “I don’t about by many potential causes • Vitamin deficiency (e.g., B12) know.” • Medical conditions • Electrolyte imbalance • Medications (alone or in • Cardiac and/or pulmonary• Dementia patients: slow onset, combination with one another) conditions• Pseudodementia patients: • Altered sleep schedule (most • Insufficient oxygenation of blood problems appeared rather often in dementia patients) to brain suddenly • Intoxication by legal or illicit • Metabolic conditions substances • Organ failure leading to• Dementia patients: unaware of insufficient metabolization of deficit • Always rule out delirium before nutrients, medications• Pseudodementia patients: keenly diagnosing dementia aware of deficits (and often • The cause of the delirium could complain of distress) be deadly, must discover it early• TREATMENT • TREATMENT • Psychotherapy (if available and • consists of treating the the patient is willing) underlying medical condition • Antidepressant medications (e.g., • Rule of thumb: delirium lasts one Zoloft, Wellbutrin, Celexa) week for each decade of the • Maintaining physically active patient’s life (e.g., 65 y.o. = 7 daily regimen decades = 7 weeks) • Regular sleep habits
PREPARING FOR A DOCTOR’S VISITIf someone is experiencing symptoms, or is concerned about dementia it iscritical to GET EVALUATED. The confusion or memory loss may be treatable. Why? If you have AD, you want to be involved in your own planning for the future while you are still able. Current treatment is most effective when started early.
PREPARING FOR A DOCTOR’S DIAGNOSIS POST DIAGNOSIS VISIT • Write a list of symptoms, be specificKeep a log • Include when, how often and where • Develop list with input from other family members Clinical Examination Develop a List Get legal Educate Develop relationship Grow a current and financial yourself Neuropsychological long-term with your issues in support about the and Testing care plan healthcare order system diseaseprevious team health Blood Testsproblems Brain Imaging Tests • prescription, vitamins Bring allmedication • herbal supplements and • over the counter medication
Alzheimer’s Association Educational programs for families and professionals • 24-hour Helpline • Information and referrals1-800 272-3900 • Care consultationThe Alzheimers Association is the leading voluntary • Support groupshealth organization in Alzheimer’s, care, support and • Online communityresearch. Its mission is to eliminate Alzheimer’s diseasethrough the advancement of research; to provide and • Safety servicesenhance care and support for all affected; and to reducethe risk of dementia through the promotion of brainhealth. www.alz.org
VIRGINIA DEPARTMENT FOR THE AGING www.vda.virginia.gov
VIRGINIA EASY ACCESSVirginia Easy Access is a FREE resource providing a simple method to search forspecific services anywhere in Virginia. Virginia Easy Access is a gateway toVirginiaNavigator (which lists over 21,000 programs and services throughout theCommonwealth) and to the 2-1-1 Virginia Call Center. easyaccess.virginia.gov
VCU – Department of Gerontology www.sahp.vcu.edu/gerontology/
Ellen Phipps Lindsey K. Slaughter, PsyDVP Programs & Services Psychology DirectorAlzheimers Association, Licensed Clinical PsychologistCentral & Western VA Piedmont Geriatric Hospital1160 Pepsi Place, Suite 306 P. O. Box 427Charlottesville, VA 22901 5001 E Patrick Henry Highway434-973-6122 Burkeville, VA 23922-0427 434-767-4424 E. Ayn Welleford, MSG, PhD, AGHEF Gerontologist Chair & Associate Professor Department of Gerontology PO Box 980228 Virginia Commonwealth University Richmond, VA 23298-0228 804 828-1565 http://www.sahp.vcu.edu/gerontology/
UPCOMING EVENTS and SURVEY• WEDNESDAY, MAY 11 – ELDER ABUSE, NEGLECT AND EXPLOITATION – see registration at www.alzpossible.org• TUESDAY, JUNE 21 – LIVEABLE COMMUNITIES & PERSON-CENTERED CARE• FRIDAY, JUNE 24 – PUBLIC POLICY AND DEMENTIA CARE• TUESDAY, JUNE 28 – CULTURAL COMPETENCE AND DEMENTIA CARE• A survey will be issued tomorrow to all attendees. In order to evaluate this project for the General Assembly of Virginia we ask that this short questionnaire be completed by everyone who participates in the GTE initiative. Your answers are extremely valuable. This and any other forms you complete related to this project are strictly confidential. Your responses will not be linked with your name in any data base. The data will be used only for the purposes of evaluation and all results will be grouped, so that no single person or organization may be distinguished. Your participation is voluntary. You have the right to withdraw at any time or refuse to answer any questions. Estimated time to complete this survey is no more than 5 minutes. THANK YOU!
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