2. What Does Alzheimer’s Look Like? James K. Cooper, MD Clinical Professor of Medicine Division of Geriatrics and Palliative Care George Washington University Medical Center Washington, DC

3. This talk is not sponsored by any pharmaceutical or other corporation. The speaker is on the staff of the George Washington University Medical Center. He has no financial interests in any product or other facility that may be mentioned.

4. Images here are presented for single, non-commercial, private, educational purposes. Further reproduction is prohibited.

7. Outline I. Ballpark (Orientation) The game The clubs Our Players II. A Person with Alzheimer’s III. Issues

8. Outline I. Ballpark (Orientation) The game The clubs Our Players II. A Person with Alzheimer’s III. Issues

9. Dementia is Condition of decreased cognitive (brain) function Progressive New Will cause memory loss Not caused by other conditions Depression Metabolic/nutritional abnormalities ‘Medical’ conditions (heart failure, lung disease) [“secondary dementias”]

10. Outline I Ballpark The game The clubs Our Players II A Person with Alzheimer’s III Issues

11. Different Dementias Alzheimer’s Vascular Lewy body Frontotemporal lobe Traumatic Brain Injury Parkinson’s Disease Alcohol CADASIL HIV

12. Recent (Short Term) Memory Age 65+ Other Symptoms Late Characteristic brain changes Amyloid plaques; tangles; in the hippocampus Rita Hayworth/ Scottie/ Floyd Patterson/ Ronald Reagan/ Dr. G Jones [IVF]/ Charlton Heston/ ADM Stockdale/ Charles Bronson / Sargeant Shriver Alzheimer’s

13. Dementia Types – Alzheimer’s

16. Vascular Dementia

17. Winston Churchill Age 65: Lord of Admiralty; Prime Minister Age 79: Nobel Prize, Literature Age 84: finishes History of English Speaking People

18. Vascular Dementia Loss of brain functions due to the accumulation of small strokes or other cell loss due to inadequate blood flow Dementia types - Vascular Difficulty with decisions first Then ↓ short term memory

19. The presence of brain amyloid may not be enough to cause Alzheimer Disease. (JAMA 1997; 277: 813) None 57% Large infarcts 75% Lacunar infarcts93% The Nun Study. Brain Pathology: 61 had amyloid plaques and tangles (signs of Alzheimer’s) Some also had additional vascular disease How many of the 61 Nuns had Alzheimer’s dementia? Vascular lesions % Dementia

20. “Mixed Dementia” May be the most common form of dementia in the USA

21. Brief periods of confusion Visuospatial dysfunction Incoordination or abnormal muscle control: Falls Sleep disorder: central regulation of consciousness Hallucinations …a tau protein abnormality Guy M. Arch Neurology 58:1803 Memory may be unimpaired Dementia Types – Lewy Body Dementia with Lewy Bodies (DLB)

24. Dementia Types – Frontotemporal Lobe Personality change Loss of social inhibition Apathy (not depression ) Memory may be unimpaired

26. Alcohol Related Dementia Normal thiamine, no vitamin deficiencies May be noticed years after drinking stopped Characterized by pre-frontal, frontal lobe signs: poor decision making; retained semantic and ST memory; loss of personal geographic place skills Variable course, often very slow loss

27. 3-point stance

28. Blast injuries

30. Traumatic Brain Injury— predicted to lead to a surge of new dementia cases

31. Mild Cognitive Impairment –Not Dementia.. – May Improve... – No medication is useful.. Schőlzel-Dorenbos: JAGS 2006;54:180 a.k.a. Cognitive Impairment, No Dementia (CIND) Photo: Crestis Panagiotou, ANA via Euro Pressphoto Agency

32. Different Dementias Alzheimer’s Vascular Lewy body Frontotemporal lobe Traumatic Brain Injury Parkinson’s Disease Alcohol CADASIL HIV (Mild Cognitive Impairment) [not dementia]_

33. Does Mr. Pickles need to be tested?? Would Mr. Pickles benefit from treatment??

35. Outline I Ballpark The game The clubs Our Players II A Person with Alzheimer’s III Issues

36. Diagnosis  History  Physical & Neurobehavioral Exam  Lab studies  Brain imaging

37. A Person with Alzheimer’s– Early AD-8 (a screening test) 1.Judgment, e.g., finances 2.Less interest in hobbies 3.Repeats questions, statements, stories 4.Trouble learning to use gadgets, computer, DVD 5.Forgets month or year 6.Trouble handling complex financial affairs, e.g., taxes, investments 7.Trouble remembering appointments 8.Daily problems with thinking or memory Galvin JE et al, The AD8, a brief Informant interview to detect dementia, Neurology 2005:65:559-564

38. Diagnosis  History  Physical & Neurobehavioral Exam  Lab studies  Brain imaging

39. As quickly as you can, please tell me the color of the ink for each word on the next slide. Diagnosis –Neurobehavioral Testing

40. Blue Green Red Violet Yellow Orange Black

41. BLUE GREEN RED YELLOW

42. Diagnosis  History  Physical & Neurobehavioral Exam  Lab studies  Rule out ‘medical’ causes: B12, thyroid, electrolytes...  Brain imaging  MRI or CT

43. MDPatient

44. MDPerson Family/Caregiver Pharmaceutical Industry Medications FDA Social Support Services Residential facilities Medicare, other Insurers Research Community Behavioral Treatment Entrepreneurs Advocacy Groups

47. A Person with Alzheimer’s– Early Feelings Depressed Angry “Dizzy” Disoriented Shrinking personal world

48. A Person with Alzheimer’s– Early Misperceptions Misidentifications Delusions Hallucinations Other Signs

51. OUR RESPONSE to a Person with Alzheimer’s “Of course it upsets me. I was a reporter. I deal with facts. She says things that aren’t true.” --Retired reporter whose wife has Alzheimer’s dementia

54. Cognitive Performance Scale A Person with Alzheimer’s– Later

55. Outline I Ballpark The game The clubs Our Players II A Person with Alzheimer’s III Issues

56. Issues When to Start/Stop Medications How to Protect Financial Resources How to Diagnose Alzheimer’s (and biomarkers) What to do with Mild Cognitive Impairment Is the coalition of NIH, Big Pharma, & Academic Researchers In the public’s best interest? How should we prepare for the expected increase in dementia from traumatic brain injuries? Terminal Care Pacemakers/ICDs Feeding tubes Who determines reimbursement for (and controls) medications and long term care?

57. jcooper@mfa.gwu.edu