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

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.

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

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

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”]

Morris Kantor,1934 b. Minsk, Russia

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

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

Alzheimer’s 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 /

Dementia Types – Alzheimer’s

Vascular Dementia

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

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

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

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

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 OK Dementia Types – Lewy Body Dementia with Lewy Bodies (DLB)

Dementia Types – Frontotemporal Lobe Personality change Loss of social inhibition Apathy (not depression ) Memory May be OK

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

3-point stance

Blast injuries

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

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

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

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

Diagnosis History Physical Exam Lab studies Brain imaging Neurobehavioral testing

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

Blue Green Red Violet Yellow Orange Black

BLUE GREEN RED YELLOW

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

MDPatient

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

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

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

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

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

A Person with Alzheimer’s– Early “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

Cognitive Performance Scale A Person with Alzheimer’s– Later

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

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 Feeding tubes Who determines reimbursement for (and controls) medications and long term care?