Dementia and Aging
Steven Huege, M.D
Assistant Professor of Clinical Psychiatry
Perelman School of Medicine at the
University of Pennsylvania
Dementia and Aging
• Contrary to popular belief: Dementia and
Memory loss are not part of normal aging
• Cognitive processing does slow down, but
progressive short term memory loss is not
normal and warrants a thorough work-up
Dementia
• Syndrome characterized by a deterioration of
cognitive ability from a previous level leading to
impairment in functioning.
• Can have many causes
– Infectious (HIV, syphilis)
– Toxic/Metabolic (Cu, Pb, ETOH, Folate, B12 deficiency)
– Neurodegenerative/Vascular (Alzheimer’s,
Parkinson’s, Lewy Body, FTD, Prion)
– “Structural” (Normal Pressure Hydrocephalus, Tumor)
Prevalence of Dementia
• Major health problem, especially as
population ages
• 3-11% of community-dwelling adults age >65
have dementia
• 20-50% age >85 have dementia
• In 2000, 4.5 million people had Alzheimer’s
Population with Alzheimer’s in U.S
Alzheimer’s Association
Alzheimer’s Dementia
• Major health problem, especially as
population ages
• 3-11% of community-dwelling adults age >65
have dementia
• 20-50% age >85 have dementia
• In 2000, 4.5 million people had Alzheimer’s
NIA: Updated criteria for Dementia
1.
2.
3.
4.
Interfere with the ability to function at work or at usual activities
Represent a decline from previous levels of functioning and performing
Are not explained by delirium or major psychiatric disorder
Cognitive impairment is detected and diagnosed through a combination of
(A) history-taking (B) an objective cognitive assessment
5. The cognitive or behavioral impairment involves a minimum of two of the
following domains:
I. Impaired ability to acquire and remember new information
II. Impaired reasoning and handling of complex tasks, poor judgment.
III. Impaired visuospatial abilities
IV. Impaired language
V. Changes in personality, behavior, or comportment
NIA: Alzheimer’s Criteria
Meets criteria for dementia +
A. Insidious onset. Symptoms have a gradual onset over months to years
B. Clear-cut history of worsening of cognition by report or observation
C. The initial and most prominent cognitive deficits are evident on history
and examination in one of the following categories.
a. Amnestic presentation
b. Nonamnestic presentations:
i. Language presentation
ii. Visuospatial presentation: The most prominent deficits
are in spatial cognition, including object agnosia,
impaired face recognition, simultanagnosia, and alexia
iii. Executive dysfunction: The most prominent deficits are
impaired reasoning, judgment, and problem solving
Pathology of Alzheimer’s
• Senile (Amyloid) Plaques
– Extracellular
– Result from accumulation of proteins and an
inflammatory reaction around deposits of βamyloid
• Neurofibrillary Tangles
– Intracellular
– Aggregates of hyperphosphorylated microtubular
protein tau
Tangles and Plaques
ladulab.anat.uic.edu/images/ADstain.jpg
Symptoms of Alzheimer's at various stages
of illness
• Mild
• Moderate
• Severe
Mild AD
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•
•
•
•
•
•
•
•
MMSE 20
Memory complaints-cardinal symptom!
Decreased knowledge of current events
Difficulty performing complex tasks
Impaired concentration
Less able to manage travel, finances
Disorientation
Word finding difficulty
Pt may not be aware of deficits
Moderate
•
•
•
•
•
MMSE 15
Inability to recall address, names of family members
Some disorientation
Still retain major biographical info about self
Initially able to toilet, feed, but may become more
impaired as illness progresses
• Worsening language and apraxia
Severe
•
•
•
•
•
•
MMSE <5
Minimal verbal ability
Incontinent
Unable to perform even basic ADL’s
Immobile
Completely dependent on others for all
aspects of care
Mild Cognitive Impairment
(MCI)
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•
•
•
•
Memory Impairment beyond normal limits
Performance < 1.5 SD on memory testing
No major impairment in functioning
Able to carry out all ADL’s
70% of pts with MCI will progress to dementia
Biomarkers for Alzheimer’s Dementia
Sperling, et.al. 2011
Neuropsychiatric Symptoms of AD
Based on Scores on MPI > 4, Lyketsos, C. JAMA 2002
Symptom
MCI %
AD%
Delusions
2
38
Hallucinations
4
18
Agitation
15
53
Depression
20
58
Anxiety
16
35
Disinhibition
1
25
Irritability
24
45
Sleep
28
72
Eating
20
57
Aberrant Motor Activity
7
43
Apathy
20
97
Pharmacological Treatments
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•
•
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Cholinesterase inhibitors
Memantine
Antidepressants/Antipsychotics
None are disease modifying, preventative or
curative
• Symptomatic treatments only
Survival by Dementia Type
Fitzpatrick, et.al 2005
Conclusion
• Dementia can be thought of a
“biopsychosocial” illness.
• The cognitive impairment from dementia
requires pt, caregivers, and physicians to
address all aspects of pt’s life.