This presentation was delivered to students at UC San Diego on May 2, 2012 by Dawn DeStefani, BSW, who is the director of programs and services for The Glenner Memory Care Centers in San Diego. Learn more at www.glenner.org.

1. Issues in Aging:
Alzheimer’s Disease
Presenter
Dawn DeStefani, BSW
Director Of Programs & Services
May 3, 2012

2. What is Normal Aging?
 Although we do experience minor changes in our memory and thinking as we age,
these changes do not affect daily functioning or the ability to live independently.
 Memory changes are a normal part of the aging process—it's common to have less
recall of recent memories and to be slower remembering names and details.
 Alzheimer’s disease is not a normal part of aging or “just what happens when we get
old.”
 If Alzheimer’s was part of the natural aging process, then every person over 65 years
of age would have Alzheimer’s disease.
Source: About.com Health's Disease and Condition, Carrie Hill, PhD
Source: MSN Health, Healthwise, http://health.msn.com/health-
topics/aging/articlepage.aspx?cp-documentid=100097440

3. Examples
Normal Aging Not Normal Aging
 A person might forget part of an  A person with Alzheimer’s disease will
experience. forget the whole experience.
 A person who forgets something will  A person with Alzheimer’s won't recall
eventually remember the the information at a later time.
information.
 A person with Alzheimer’s disease is less
 A person can follow instructions and less able to follow instructions over
without difficulty. time.
 A person is able to use notes or  A person with Alzheimer’s gradually
reminders. become less able to benefit from memory
aids or forgets to use them.
 A person can still manage their own
personal care (bathing, dressing,  A person with Alzheimer’s loses the
grooming, etc.). ability to engage in these kinds of tasks.
 A person is able to manage their  A person is unable to track spending, pay
finances. bills, manage savings/checking accounts.
Source: About.com Health's Disease and Condition, Carrie Hill, PhD

4. Brief History
 Alois Alzheimer, a German physician, is
credited with being the first to describe
AD.
 In 1906, Dr. Alzheimer observed a
patient, Auguste Deter, in a local
asylum who exhibited strange
behaviors. He followed her care and
noted her memory loss, language
difficulty and confusion.
 After her death at the age of 51 he
examined her brain tissue. The slides
showed what are now known as
plaques and tangles that are
Alois Alzheimer recognized as Alzheimer’s disease.
 In 1911, Doctors were using Dr.
Alzheimer’s research to base diagnosis.
 In the 1960’s British pathologists
determined that AD was not a rare
disease of the young but rather what
had been termed “senility.”
Auguste Deter  In the 1990’s researchers identified
that the beta amyloid protein was a
factor in AD.

5. What is Alzheimer’s disease?
 Alzheimer’s is a progressive,
degenerative and incurable neurological
brain disease that causes deterioration
of brain nerve cells and ultimately death.
 The deterioration is caused by:
 a build up of abnormal substances called
amyloid plaques (an insoluble protein
deposit);
 And neurofibrillary tangles.

6. Plaques and Tangles
Neuron-
 Healthy neurons help guide nutrients
transmits and molecules from the cell body to
to brain the ends of the axon and back.
Axon –
 Plaques form when protein pieces
conducts called beta-amyloid clump together.
nerve Beta-amyloid comes from a larger
signal protein found in the fatty membrane
Communication
surrounding nerve cells.
Dendrites  Beta-amyloid is chemically "sticky"
– signal
receiver
and gradually builds up into plaques.
 Neurofibrillary tangles (NFTs) which
are found inside neurons, are
abnormal collections of a protein
called tau.
 In AD, when NFT’s build up nutrients
and other essential supplies can no
longer move through the cells, which
eventually die.
Source: Alzheimer’s Association: http://alz.org/alzheimers_disease_4719.asp Brain Tour

7. Inside the Brain
Cortex
In the Alzheimer brain:
 The cortex shrivels up,
damaging areas involved in
thinking, planning and
remembering.
Ventricles  Shrinkage is especially severe
in the hippocampus, an area
of the cortex that plays a key
role in formation of new
memories.
 Ventricles (cerebrospinal
fluid-filled spaces within the
Hippocampus brain) grow large
Source: Alzheimer’s Association: http://alz.org/alzheimers_disease_4719.asp Brain Tour

8. Alzheimer’s Brain Normal Brain
Source: Image from the Alzheimer’s Society of Saskatchewan with permission from Alzheimer’s Broken Brain.

9. So what is Dementia?
 Dementia is a set of signs and symptoms, not a disease.
 Dementia is characterized by memory loss, changes in mood and
communication difficulties.
 Types of diseases with the symptom of dementia are:
 Alzheimer’s disease
 Most common.
 Vascular dementia
 stroke related, 2nd most common type of dementia
 Dementia with Lewy Body
 Lewy bodies are deposits of a protein called alpha-synuclein
that form inside the brain’s nerve cells. Affects memory,
concentration, speech.
 Frontotemporal dementia
 a rare disorder that affects the frontal lobes and the temporal
lobes (sides) of the brain. Affects behavior, personality and
memory later.
 Wernicke-Korsakoff syndrome
 most common cause is alcoholism, but the syndrome can also
be associated with AIDS, cancers.

10. Dementia…not
 In a few cases, dementia is caused by a problem that can be treated. Once
treated, the symptom of dementia often disappears. Examples include:
 Having an underactive thyroid gland (hypothyroidism) can cause
difficulty with concentration and forgetfulness.
 Vitamin B12 deficiency. B12 supports the function and development of
the brain, nerves, blood cells, and many other parts of the body.
 Dehydration – severe dehydration causes confusion.
 Malnutrition – prevents the brain from functioning properly.
 Urinary Tract Infections – a type of infection that affects brain function.
 In some, depression can cause memory loss; often referred to as
Pseudodementia.
 Medications - Taking some medicines together may cause symptoms
that look like dementia. This includes prescribed, over the counter,
herbals, vitamins and supplements.
Source: WebMD http://www.webmd.com/alzheimers/tc/dementia-topic-overview
Source: About.com http://alzheimers.about.com/od/diagnosisofalzheimers/a/reversible.htm

11. What is Mild Cognitive
Impairment?
 Mild cognitive impairment (MCI) is a condition in which a person
has problems with memory, language, or another mental
function severe enough to be noticeable to other people and to
show up on tests, but not serious enough to interfere with daily
life.
 Individuals with MCI have an increased risk of developing
Alzheimer’s disease over the next few years, especially when
their main problem is memory.
 Not everyone diagnosed with MCI goes on to develop
Alzheimer’s.
 There is currently no treatment for MCI approved by the FDA.
Source: Alzheimer’s Association: www.sanalz.org

12. Risk Factors
 Age – Biggest risk factor
 10% of individuals over the age 65 will have AD.
 After age 85, the risk reaches nearly 50 percent.
 Family History
 Research has shown that those who have a parent, brother
or sister with Alzheimer’s are more likely to develop
Alzheimer’s. The risk increases if more than one family
member has the illness.
 Genetics –
 Risk Genes
 Deterministic Genes
Source: Alzheimer’s Association San Diego Chapter – www.sanalz.org

13. Risk Factors
 Risk Genes
 Risk genes increase the likelihood of developing a disease
but do not guarantee it will happen.
 APOE-e4 is one of three common forms of the APOE
(apolipoprotein) gene.
 Everyone inherits a copy of some form of APOE from
each parent.
 Those who inherit one copy of APOE-e4 have an
increased risk of developing Alzheimer’s.
 Those who inherit two copies have an even higher risk,
but not a certainty.
 In addition to raising risk, APOE-e4 may tend to make
symptoms appear at a younger age than usual.
Source: Alzheimer’s Association San Diego Chapter

14. Risk Factors
 Deterministic Genes/Early Onset :
 directly cause a disease, guaranteeing that anyone
who inherits them will develop the disorder.
 Scientists have found rare genes that directly cause
Alzheimer’s in only a few hundred extended families
worldwide.
 This type is known as “familial Alzheimer’s disease”,
and many family members in multiple generations
are affected. True familial AD accounts for less than
5% of the cases.

15. Stages of AD
 Mild or Early Stage
 Friends, family or co-workers begin to notice
deficiencies. Some common difficulties
include:
 Word finding problems
 Decreased ability to remember names
 Performance issues in social or work settings
 Reading a passage and retaining little material
 Losing or misplacing a valuable object
 Decline in ability to plan or organize
Source: National Alzheimer’s Association

16. Stages of AD
 Moderate or Middle Stage
 Major gaps in memory and deficits in cognitive function emerge. Some
assistance with day-to-day activities becomes essential. Some common
difficulties include:
 Inability to recall important details such as their current address, their
telephone number.
 Confused about where they are or about the date, day of the week or
season.
 Need help choosing proper clothing for the season or the occasion.
 May have increasing episodes of urinary or fecal incontinence and need
assistance with toileting and personal care.
 Lose most awareness of recent experiences and events as well as of their
surroundings.
 Tend to wander and become lost.
 Experience significant personality changes and behavioral symptoms.
 including suspiciousness and delusions (for example, believing that their
caregiver is an impostor)
 hallucinations (seeing or hearing things that are not really there)
 compulsive, repetitive behaviors such as hand-wringing or tissue shredding
Source: National Alzheimer’s Association

17. Stages of AD
 Severe or Late Stage
 This is the final stage of the disease when individuals lose the
ability to respond to their environment, the ability to speak and,
ultimately, the ability to control movement.
 Frequently individuals lose their capacity for recognizable speech,
although words or phrases may occasionally be uttered.
 Need full assistance with eating and toileting and there is general
incontinence.
 Individuals lose the ability to:
 walk without assistance
 sit without support
 ability to hold their head up
 Reflexes become abnormal and muscles grow rigid
 Swallowing is impaired
Source: National Alzheimer’s Association

18. What is it like with AD?
 Who was the story
about?
 Who were the characters
in the story?
 What is the story about?
 Where did the story take
place?
 When did the story take
place?

19. When was the last time you
needed help with…?
 Bathing
 Personal care (toileting
and all that goes with it)
 Getting dressed
 Brushing your teeth
 Combing your hair

20. Common Behaviors
 Anxiety  Refusal to eat
 Paranoia, suspicion  Eating non food items
 Depression  Wandering, pacing
 Outbursts – emotional,  Hoarding
verbal, physical  Repetitive behaviors such
aggression. as actions, word
 Rummaging  Inappropriate social
 Poor grooming, dressing, behaviors such as
hygiene undressing in public,
 Sexually inappropriate inappropriate
behaviors conversation with others.

21. How Do We Know it is AD?
 A process of elimination through testing.
 100% diagnosis for AD comes at autopsy when the brain can be examined.
 Diagnosing AD
 Physician will review your medical history
 Mini Mental Status Exam administered (assesses mental function through a series
of questions)
 A physical exam will be completed
 Diagnostic tests will be ordered to rule out other illnesses or deficiencies that
mimic memory loss. Such as: Anemia, malnutrition or certain vitamin
deficiencies, excessive use of alcohol, medication side effects, infections,
diabetes, kidney or liver disease, thyroid abnormalities, problems with the heart,
lung or blood vessels.
 Neurological Exam which includes: Reflexes, coordination and balance, muscle
tone and strength, eye movement, speech and sensation.
 Brain Imaging through:
 Structural imaging provides information about the shape, position or
volume of brain tissue. Structural techniques include magnetic resonance
imaging (MRI) and computed tomography (CT).
 Functional imaging reveals how well cells in various brain regions are
working by showing how actively the cells use sugar or oxygen. Functional
techniques include positron emission tomography (PET) and functional MRI
(fMRI).

22. Treatments
 There are 2 types of FDA approved drugs to treat the cognitive symptoms of
AD. These drugs affect the activity of two different chemicals involved in
carrying messages between the brain’s nerve cells.
 The first type are called Cholinesterase (KOH-luh-NES-ter-ays)
inhibitors and they prevent the breakdown of acetylcholine (a-SEA-til-
KOH-lean), a chemical messenger important for learning and memory.
 Cholinesterase inhibitors commonly prescribed:
 Donepezil (Aricept)
 Rivastigmine (Exelon)
 Galantamine (Razadyne)
 Tacrine (Cognex)
 The second type is Memantine (Namenda) and this works by regulating
the activity of glutamate, a different messenger chemical involved in
learning and memory.
 Memantine:
 Approved in 2003 for treatment of moderate to severe Alzheimer's
disease.
Source: National Alzheimer’s Association www.alz.org

23. Preserving Cognitive Function
 Bad News: You cannot prevent Alzheimer’s disease
 Good News: You can help keep your brain sharp with regular social
activity; "mental exercise," such as doing crossword puzzles and
reading; and physical activity, which increases blood and oxygen
flow to the brain and a healthy diet.

24. Impact
 AD is the 7th leading cause of death in the U.S. (Heart Disease is #1)
 Length of the disease is 3 – 20 years
 Currently, there are 5.4 million with AD; SD/Imp Cty=90,000
 By 2029 all Baby Boomers (1946-1964) will be at least 65 – 10 million
of the 78 million are predicted to develop AD.
 More women than men will develop AD
 Avg life expectancy in 2010 – Women 80.8; Men 75.7 (US Census projection)
 2010 Cost of Care is estimated at $172 billion (Healthcare and Long
Term Care)
 Skilled Care:$6K/mo; In Home Care: $3,800/mo; Daycare:$1,500/mo
 Cost to businesses – lost work time, absenteeism, leaves of absence,
quitting work.
 In 2009 there were an estimated 10.9 million unpaid caregivers (family,
friends
 Several studies show hours of caregiving range from 21-40; higher number of
hours as the disease progresses.
 Average age of the caregiver is 51.
 60% of the caregivers are female.
Source: National Alzheimer’s Association
http://www.alz.org/documents_custom/report_alzfactsfigures2010.pdf

25. For More Information on Research/
Clinical Trials
 What is a clinical trial?
 According to clinical trials.gov, clinical trials are biomedical or health-
related research studies in human beings that follow a pre-defined protocol.
Clinical trials can include both interventional and observational types of
studies.
 Interventional studies are those in which the research subjects are assigned by
the investigator to a treatment or other intervention, and their outcomes are
measured.
 Observational studies are those in which individuals are observed and their
outcomes are measured by the investigators.
 http://adrc.ucsd.edu/trials.html
 What Research is going on?
 Studies investigate treatments designed to improve thinking and daily
functioning as well as studying ways to slow decline or delay the onset of
Alzheimer’s’ disease.
 http://adrc.ucsd.edu/research.html
Source: UCSD Shiley Marcos Alzheimer’s Disease Research Center http://adrc.ucsd.edu

26. Additional Resources
 Alzheimer’s Disease Education and Referral Center
(ADEAR) – www.nia.nih.gov/Alzheimers
 Alzheimer’s Association- San Diego Chapter –
www.sanalz.org
 Family Caregiver Alliance – www.caregiver.org
 Southern Caregiver Resource Center –
www.caregivercenter.org
 UCSD Shiley Marcos Alzheimer’s Disease Research
Center – www.adrc.ucsd.edu