1. The Memory Spectrum: Is it Alzheimer’s Disease?.
The Memory Spectrum: Is it Alzheimer’s Disease?
Helle Brand, PA
Banner Alzheimer’s Institute
Powerpoint Templates.

3. The Memory Spectrum Memory Function Aging Time Normal Mild Cognitive
DEMENTIA
Mild
Cognitive
Impairment (MCI)
Memory Function
Time

4. Memory Complaints in Normal Adults
Situation Percentage of elderly Names 83 % Where I put things 60 % Knowing I have told someone 49 % something Forgetting a task after starting 41 % Losing the thread of conversation 40 % From: Boller et al, Arch Neurol 1991

5. Aging, memory and intellect
Don’t change
Decrease
Verbal IQ Vocabulary Store of information Comprehension
Speed of memory retrieval
Speed of processing
Multi-tasking ability
Memory-formation efficiency

6. Types of Memory Brain memory regions Short term Long term
Motor learning
These depend on different regions within the brain.
Brain memory regions

7. Brain changes with aging
Brain weight:
decreases by about 0.5% per year after age 30
Neuron loss:
region-specific
10-25% loss in cerebellum, cortex, hippocampus, substantia nigra
Loss of synapses (connections between neurons)
Mild degree of Alzheimer-type pathology

8. MRI Brain: Normal vs. AD

9. Age-Associated Cognitive Impairment
Loss of memory for words and names Slowed processing speed Difficulty sustaining attention when faced with competing environmental stimuli No functional impairment

10. Mild Cognitive Impairment (MCI)
Transitional state /evolving construct
Cognitive impairment greater than expected for age:
Memory complaint corroborated by an informant
Normal general cognitive function
Normal activities of daily living
Memory impairment for age and education
criteria for dementia not met
Petersen, 2000

11. Outcome of an ‘MCI Diagnosis’
Amnestic MCI
Increased risk for the development of AD within the next few years Rates of conversion to AD: MCI: 10-15% per year Normal elderly – 1-2% per year

12. Normal Aging Mild Cognitive Impairment No change over time
Alzheimer’s disease
No change over time
Other dementias

13. Dementia
This term does not define a cause and is not a diagnosis! Progressive decline in cognitive function Decline in functional ability Due to damage or disease in the brain Many different causes AD: most common dementia in the elderly

14. Clinical Presentation of Dementia
A6-133 Tariot Toolkit Track II_Arial 4/20/2017 2:44 PM
Clinical Presentation of Dementia
Cognition
Function
Behavior
Clinical Presentation of AD
Symptoms of Alzheimer’s are often characterized as those of cognition, function, and behavior.
Cognition is the ability to perceive, think, remember, and reason. It includes memory, language skills, and the ability to process information. It also includes executive functioning, i.e., planning ability and performing tasks with multiple elements or steps. Loss of memory and impaired judgment are often the first signs noticed by the patient or family members.
Function, for present purposes, is the ability to perform daily tasks such as shopping, managing finances, preparing meals, making social contacts, caring for oneself (personal hygiene, feeding oneself, dressing appropriately), and using basic utensils and appliances.
Behavior encompasses noncognitive features such as agitation, aggression, delusions, withdrawal and apathy. Specific behaviors in people with AD include wandering, shadowing, repetition, disinhibition, paranoia, and hallucinations.
It is helpful for clinicians to think about managing the disease according to these three primary categories, and to remember that specific symptoms in each category and their appearance and decline over time are different in each patient.

15. Progression of Dementia
Typically progresses over 7 – 10 years Often described using “stages” Mild, Moderate, Advanced (Severe) Early , Middle, Late Stage Has become the 6th leading cause of death among older people Requires different strategies and services along the way

17. Top 10 warning signs:
1. Changes in memory disrupting daily life: forgetting recently learned information; repetitive questioning; forgetting dates or events; relying on notes or others to remember things formerly handled on their own
2. Challenges in planning or in solving problems, difficulty concentrating and taking longer to do things they did before : can’t remember or follow a recipe, can’t track or pay bills
3. Difficulty completing familiar tasks at home, work, or leisure: trouble driving to familiar location, playing a game, keeping up with hobbies

18. The warning signs, continued
Confusion with time or place: losing track of dates, seasons, passage of time, forget where are or how they got there. Trouble understanding if something is not happening immediately
Trouble understanding visual images and spatial relationships: trouble judging distances, reading, driving, judging color or contrast. May see a mirror or window and think someone else is in room
Problems with words when speaking or writing: Have trouble following or joining in on a conversation, forget train of thoughts. May call things by wrong name, struggle to find or substitute a word.

19. The warning signs, continuing
Misplacing things, having difficulty retracing steps: May put things in unusual places, may accuse others of taking things.
Diminished or poor judgment: trouble with decision making, such as when dealing with money; may pay less to personal appearance, safety, or social appropriateness. Impulsive.
Withdrawal from work or social activities, hobbies, work projects or sports

20. The warning signs, completed
10. Changes in mood and personality: can be confused, suspicious or paranoid, depressed, more fearful or anxious, more easily upset, irritable. Less apt to get out of home/comfort zone
Sound familiar?

21. Early (MILD) Stage Dementia
Features
Recent memory loss that affects job skills
Difficulty performing tasks; Problems with language; Misplacing things; Problems with abstract thinking
Disorientation of time
Poor/ decreased judgment
Changes in mood /behavior; Loss of initiative; Changes in personality
May have difficulty in a crowd
Repetitiveness, forgetfulness, difficulty with IADLs
Treatment Cholinesterase Inhibitor Manage depression and other co-existing health problems
Maintaining Independence

22. Early changes in AD, continued
may get lost driving or be unsure of self in new surroundings Forget appointments, family events Lists may not make sense

23. Special concerns early on
Medication management Driving Weight loss Mood, especially depression Changing awareness and concern for safety Need for life planning: financial, legal

24. Middle (MODERATE) Stage
Features
More dependent in daily living tasks
Severe memory loss
Fluent aphasia
Disorientation to time and place
Impaired judgment and problem solving
Personality and behavioral changes
Treatment
Cholinesterase inhibitor and/or
Namenda
Manage mood, behavior and co-existing illness
Living with help

25. Moderate Stage Alzheimer’s
Memory loss, confusion and attention worsen over a 2-10 year span
Judgment and problem solving a problem
Loss of ability to handle complex tasks, gradual problems with taking care of self
Personality and behavior changes
Increasing dependence
Can’t think logically, organize thoughts

26. The concerns with mid stage AD
Behaviors: suspiciousness, irritability, restless, loss of impulse control, seeing or hearing things not present, agitation, wandering, sleep disturbance Changing communication/expectations Increasing dependence, behaviors cause increasing caregiver burden/stress Safety/Vulnerability: need 24 hour supervision
At least 75% experience some behavioral disturbance

27. Late (SEVERE) Stage Dementia
Features
Severe memory loss
Limited verbal ability
Orientation only to self
No independent self-care function
No judgment/problem solving skills
Incontinence (bladder/bowel)
Treatment
Cholinesterase inhibitor and/or
Namenda
Comfort strategies including mood and pain
Anticipatory comfort care

28. Late to End Stage Alzheimer’s
Memory loss is severe, including long term
Loss of recognition of others beyond self
Problems controlling bowel/bladder
Fully dependent for care needs
Minimal to no speech
Changes in posture/walking, may not walk
and/or become bed bound

29. Issues in advanced Alzheimer’s
Risk for falls
May be prone to infection or skin breakdown
Weight loss
Potential for seizures
Increasing sleep
Planning for death and dying: medical decision making, timely hospice referrals

30. Alzheimer’s disease: diagnosis
Diagnosis of exclusion History: the changes over time Physical and Neurologic exams Cognitive Testing Labs and Imaging Studies By definition: insidious onset, gradual changes in multiple domains affecting function

36. The treatment of Alzheimer’s
Cholinesterase inhibitors: indicated for early/mild dementia, typical side effects are nausea, vomiting, anorexia ,frequent loose stool, vivid dreams, leg cramps. Start slow, assess tolerance, maintain at best tolerated level for continued cognitive benefit.
Aricept (donepezil) 10 mg, 23 mg
Razadyne (galantamine) 8 mg bid or 16, 24, 32 mg daily in extended release form
Exelon, oral or patch (Rivastigmine) mg oral, 9.5 or 13.3mg/24 hours in patch form
Namenda (memantine) (NMDA receptor antagonist); indicated for moderate stages. 10 mg bid. NEW: 24 mg daily
Typical side effects include headache, constipation, paradoxical confusion

37. Cholinesterase Inhibitor Therapy in AD
Disease Severity
Early-Stage Dementia
MCI
Benefits cognition?
Benefits cognition
Moderate Dementia
Benefits cognition
Preserves global status
Preserves ADLs
Benefits behavior?
Severe Dementia
Benefits cognition
Preserves global status
Preserves ADLs
Benefits behavior?
Class approved for mild-moderate AD Donepezil also approved for severe AD 37

38. MMSE LS Mean Change from Baseline (±SE)
1-Year, Placebo- Controlled Trial of Donepezil: Slowing of Cognitive Decline
MMSE LS Mean Change from Baseline (±SE)
–2.5
–2.0
–1.5
–1.0
–0.5
0.5
1.0
Donepezil HCI
Placebo
Weeks 52 36 24 12
*P = †P < .05
‡P = .001 * † ‡
Clinical Improvement
Clinical Decline
Winblad et al. 2001

39. Memantine Therapy for AD*
Disease Severity
Mild-Moderate Dementia
MCI
Role unknown
Inconsistent effects
Moderate-Severe Dementia
Benefits cognition
Preserves global function
Preserves ADLs
Benefits behavior
*Approved for moderate-severe AD in the U.S., alone or in combination with
cholinesterase inhibitors 39

40. Cholinesterase Inhibitor Therapy in AD
Disease Severity
Early-Stage Dementia
MCI
Benefits cognition?
Benefits cognition
Moderate Dementia
Benefits cognition
Preserves global status
Preserves ADLs
Benefits behavior?
Severe Dementia
Benefits cognition
Preserves global status
Preserves ADLs
Benefits behavior?
Class approved for mild-moderate AD Donepezil also approved for severe AD 40

41. Other treatments: It’s not just memory
Mood/ behavioral symptoms: address environmental factors, then medication ( antidepressants, antipsychotics)
Sleep disturbance: non PM formulary, no benzos. (Trazodone, Mirtazapine, Melatonin)
Pain: Routine Acetaminophen

42. Caregiver stress
Care becomes 24/7 job Caregivers become socially isolated Family dynamics a consideration At risk for deterioration of their own health, physical and emotional status Caregivers more often die first

43. Sharing the care helps
Barriers include caregiver reluctance from stoicism, guilt, promises made, perfectionism, isolation Myths persist re: financial concerns The system makes it hard! Family dynamics are definitely part of the equation, possibly the solution!

44. Options to extend care
Consider a volunteer network Senior centers Day Care programs Home care agencies Alternative residences Hospice care

45. Hope for the future: The Alzheimer’s Prevention Initiative
1st approved study to provide prevention therapies to people at greatest genetic risk of developing AD Building a registry of volunteers who may be interested in participating in future prevention research in the U.S. We need YOU! or call

47. In closing…. The mind forgets, but the heart remembers! Remember:
Questions?