Different Types of Dementia
Not Everyone has Alzheimer’s
Haleh Nekoorad-Long, M.D.
Geriatric Psychiatrist
AltaVita Memory Care Centre
www.AltaVitaLiving.com
303-300-3700
MILD COGNITIVE
IMPAIRMENT
• Impaired memory, but otherwise functioning well and
do not meet clinical criteria for dementia
• May be the earliest sign of evolving AD
• Neuropsychological testing helpful
• Rule out any organic (Medical) causes
• The sooner diagnosis, the better outcome with
treatment
Meaning of Dementia
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Impairment in short-term and long-term memory
Impairment in abstract thinking or reasoning
Impairment in Judgment
Personality changes
Apraxia (forgetting how to do things)
Aphasia (difficulty with speech)
Types of Dementia
• Alzheimer’s Disease(55-65%)
• Vascular Dementia(10-15%)
• Dementia with Lewy Bodies(15-20%): parkinsonian,
visual hallucination, fluctuating level of confusion
• Parkinson’s Disease with Dementia: about 40% risk
after 8-10 years of living with Parkinson’s disease.
• Frontotemporal Lobe Dementias(5-8%) : Personality
changes, hypersexuality, aphasia (speech)
ALL OTHER CAUSES OF DEMENTIA(19%)
• Frontal-Temporal Dementia (10%)
• Chronic Alcohol Use
• B12 Vitamin Deficiency
• Infectious Disease (Neurosyphilis, HIV)
• Neoplastic (Meningiomas, Brain tumors)
• Other Degenerative Diseases (Huntington’s, Parkinson’s,
CJD or mad cow disease, Progressive Supranuclear Palsy,
etc.)
Alzheimer's Disease
• Alzheimer disease was first described in 1907 by
Dr. Alois Alzheimer.
• From its original status as a rare disease,
Alzheimer disease has become one of the most
common diseases in the aging population, ranking as
the sixth most common cause of death.
• The incidence of Alzheimer disease is strongly
related to age
ALZHEIMER’S TYPE
• Age is number one risk factor
• Family History (increases risk by 3-4 times)
• Head Trauma
• Female sex
• Gradual presentation (10 years on average)
• Memory impaired early in the course
• Psychiatric symptoms is common (50%): Depression,
Apathy, Agitation, Aggression, Psychosis, Delusions,
Pacing, Wandering, Hoarding, Sleep problems
Prevalence of Alzheimer Disease
(AD) in the US
Prevalence (%)
50
40
30
16%
20
10
0
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32%
8%
1%
2%
4%
60-65
65-70
70-75
>65 years: 10%
>85 years: 32%-47%
68% are women
Today: ~4 million have AD
2050: >14 million will have AD
75-80
80-85
>85
Age (Year)
(Clinical Neuroscience Research Associates (©CNRA,
2000). Available at: www.therubins.com.)
Amyloid Plaques and Neurofibrillary Tangles in Alzheimer’s
Disease and Normal Aging
Plaques
Alzheimer’
s
Tangles
Courtesy of Harry Vinters, MD.
Normal
Positron Emission Tomography (PET)
Studies of Glucose Metabolism (FDG)
Normal
Early Alzheimer's Late Alzheimer's
Child
VASCULAR DEMENTIA
• Cerebrovascular disease (CVD)/ Strokes/Mini-strokes
• Focal signs (weakness on one side, facial droop)
• Abnormal brain imaging
• Relationship between dementia and CVD
• Onset within 3 months of stroke
• Abrupt onset, stepwise decline
• Mixed Alzheimer’s disease and CVD common
VASCULAR DEMENTIA RISK FACTORS
• Age
• History of Vascular Disease: Strokes, Heart Attacks
• Smoking
• Hypertension
• Diabetes
• High Cholesterol
• Atrial Fibrillation
LEWY BODY DEMENTIA
Dementia (more severe executive dysfunction and
visuospatial disturbances than AD)
•Two of three of the following:
•Parkinsonism (motor symptoms)
•Visual hallucinations
•Sleep disorders (Acting out dreams)
•Fluctuating cognition
•Lewy bodies in brain (limbic and neocortex)
•Cholinergic deficit
•Dopaminergic deficit
PARKINSON'S DISEASE WITH DEMENTIA
• Parkinson’s Disease Diagnosis before Dementia
• Bradykinesia (slow movements)
• Rigidity
• Tremors
• Response to dopaminergic treatment
(Levodopa/Carbidopa)
• 40% develop dementia after 8-10 years
• Cortical Lewy bodies and cholinergic deficit
FRONTOTEMPORAL LOBE DEMENTIA (56%)
• Frontal lobe dysfunctions: Personality change, labile
mood, agitation, hypersexuality
• Speech difficulties: Apraxia, naming, fluency, expressive
aphasia, echolalia (repeating your words)
• Usually memory is effected at later stages in the disease
• Abnormal brain imaging
• No great studies about treatment options, but symptom
control with psychotropic medications
Dementia Work Up
• Physical and Neurological Exam
• Labs including: B12, Folate, TSH, UA, CBC, CMP,
syphilis& HIV (if indicated)
• Brain Imaging: PET, MRI, CT
• Neuropsychiatric Testing if not sure of diagnosis
• Question Alcohol or Pain Medication Use
• Depression and Anxiety Screen
• Insomnia/Apnea work up (if indicated)
• Rule Out Delirium
Definition of Delirium
• 30-50% of Ill Geriatric patients become delirious at
some point during their hospital stay
• Rapid Onset (hours to days)
• Brief Duration (days to weeks), Transient
• Alternating level of consciousness, altered attention
(sundowning)
• Disorientation, Disorganization, Memory Impairment
• Psychosis, Irritability
• Disruption of the sleep-wake cycle
Delirium Suspects
• In Demented Patients #1 cause is UTI
• Many other medical problems can cause it
• Dehydration, Pneumonia, Flu, Constipation, CNS
infections, Post-Stroke, Hypoxemia, Hypo-or
Hyperglycemia, Thyroid disease
• Drugs: Benadryl, Pain Meds, Lithium, Sinemet,
Anesthesia (Post-Surgery), Alcohol, Benzos
• Drug withdrawal: Alcohol, Benzos, Opioids
GENETIC FACTORS
• New Studies show 22 gene variants has been linked to
late-onset Alzheimer's disease, including one called
Apolipoprotein E-e4 (APOE-e4) which appeared to have
the strongest impact on risk.
• Recent studies have also associated poor sleep habits to
buildups of brain plaques and people who eat foods high
in copper content appear to have higher incidences of
Alzheimer's disease.
Genetic Testing Not
Recommended, YET!
• For sporadic or familial late-onset Alzheimer disease,
the ApoE 4 gene has been associated with a high risk
of the disease; however, it does not provide sufficient
sensitivity or specificity for diagnosis, and its use as a
diagnostic marker is not recommended.
• If positive, it indicates you are at higher risk, but not
guarantee that you will develop the disease.
Reasons for Delayed
Diagnosis
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Normal aging
Insidious onset/course
Other medical illness/depression
Lack of routine screening
Denial
Memory Meds
• Do not prolong life
• Improve quality of life, prolong self-sufficiency
• Improved cognition and functioning after one year
compared to patients who were never on ACHEIs
• Slowing in deterioration
• Benefit declines as more cholinergic neurons are lost
– Start treatment early
• Decreased risk of Nursing Home Placement
MEMORY ENHANCING MEDS
• ACHEI’s ( Acetyl Cholinesterase Inhibitors)
Aricept(Donepazil): Tablets Disintegrating tablets for patients that
can’t swallow
Razadyne(Galantamine): Capsules
Exelon(Rivastagmine): Capsules and Patches for people that can’t
tolerate capsules secondary to G.I. side effects.
• NMDA: Namenda(Memantine)
TREATMENT EXPECTATIONS
• With memory meds, clinical success is measured by:
Improvement
No Change
Less than expected decline
Behavioral Problems
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Depression / Tearfulness
Anxiety
Isolation
Agitation / Irritability
Psychosis, Visual or Auditory Hallucination
Disturbed Sleep Pattern
Poor Appetite
Inappropriate sexual comments or behavior
DEPRESSION AND ANXIETY TREATMENT
• Antidpressants:
• SSRI’s: Zoloft, Prozac, Paxil, Celexa, Lexapro, Luvox,
Vybriid, Brintallix
• SNRI: Effexor, Cymbalta, Pristiq, Fetzima
• Remeron: Used often because it increases appetite
and improves sleep patterns.
• Wellbutrin: can cause anxiety since it is an stimulating
antidepressant
DEPRESSION VS. APATHY
• Apathy is lack of feeling, emotion, interest, or concern.
Not sad…
• Patient with apathy is not concerned, but family and staff
notice isolation.
• Antidepressants not very effective, at times Ritalin more
effective.
INSOMNIA
• Treatment is effective and needed since the insomnia will
effect the caregiver
• Melatonin can be effective
• Trazadone can be effective
• Be careful with medications such as Ambien, Lunesta
• Stay away from OTC sleeping aids such as Tylenol P.M. and
Advil P.M. since they have Benadryl which can cause
increased confusion the next day!
PARANOIA AND PSYCHOSIS
• Can be difficult to treat
• No FDA approved treatments, and antipsychotics have
black box warning for elder with dementia
• Antipsychotics can be effective to decrease agitation,
psychosis, and help insomnia
• Not comfortable for the patient to feel fear and agitation
POSSIBLE ANTIPSYCHOTICS
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ALL antipsychotics have “black box warning” for use in elderly with dementia
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Seroquel(Quetipine)
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Zyprexa(olanzapine)
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Abilify(no generic)
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Risperdal(risperidone)
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Latuda
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Stay away from Haldol if possible given side effects of unstable gait, tremors,
swallowing difficulties)
Nonpharmacological
Management
• Safety:
– “Child Proofing” the home (OT Eval)
– Driving (Driving Test)
– Limit financial responsibilities
• Serenity:
– Maintain a calm and peaceful atmosphere
• Dimmed lighting
• Peaceful music
Nonpharmacological
Management (cont.)
• Structure:
– Regular Routines
– Keeping things familiar
– Memory Book (OT Eval)
• Sanity of Caregivers
– Day care center (Homestead)
– Respite Care
Caregiver Burden
• Financial costs to caregivers
– Direct costs (eg, medical care): $12,000 per year
– Indirect costs (eg, unpaid, informal care): $35,000 per year
• Psychological costs to caregivers
– >80% report high levels of stress
– ~50% report depression
Sources: www.alzheimers.org/unravel.txt
www.alz.org/caregiver/guide/coping/stress.htm
Signs of Stress in Caregivers
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Anger
Anxiety
Denial
Depression
Exhaustion
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Health problems
Irritability
Lack of concentration
Sleeplessness
Social withdrawal
Alzheimer’s Association. Caregiver stress. Available at: http://www.alz.org/hc/counseling/stress.htm.
REASONS FOR PLACEMENT
• Disease Severity
• Loss of Functional abilities(urine or bowel incontinence)
• Behavior problems( paranoia, agitation, wandering)
Alzheimer’s Association
Resources
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Contact center
Safe Return
Clearinghouse
Multicultural outreach
1-800-272-3900
www.alz.org
Wandering Behavior
• 4%-26% of SNF patients wander
• Up to 59% of patients who reside in a
community wander
• If not located within 24 hours, 46% will die
of hypothermia or dehydration
• No one can predict when wandering will
occur
Safe Return Bracelet
• Registrant and caregiver
ID products
• National information and
photo database
• 24-hour, toll-free crisis line
• Fax alert notification system
• Local chapter support
• Wandering behavior
information and training
AltaVita Memory Care Centre
• Assisted Living Community for the
memory impaired
• Respite Care and Day Care programs
to help stimulate cognition and
decrease isolation
• Licensed facility to use LTC insurance if
available
HOME LIKE ENVIRONMENT
HALEH NEKOORAD-LONG, M.D., ALTAVITA MEMORY CARE CENTRE
NEIGHBORHOOD CONCEPT
HALEH NEKOORAD-LONG, M.D., ALTAVITA MEMORY CARE CENTRE
AltaVita Memory Care Centre
Call for information 303-300-3700
Come by for a tour
Check us online
WWW.AltaVitaLiving.com