Dementia in the 21st Century

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Dementia in the 21st Century

Presenter: Sharon J. Kernen, Ph.D.

Comprehensive Forensic & Clinical Neuropsychology Assessments

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Overview•The cost of increasing dementia•Statistics•Definition of dementia•Cognitive domains: What is lost?•Myths•Epidemiology•Risk factors •Variations

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Cont.•DSM-5 terminology•Diagnostic criteria•Stages of dementia•ADLs vs. IADLs•Behaviors•Cause•Treatment•Future

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Some favorite beings

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Background:What’s her name again?• UNM Grad• Forensic, clinical, and geriatric

neuropsychology• Seven years in Second Judicial District• Past history as certified personal trainer,

program manager, and aerobics director working with “Mature Adults”• Wife, mom and nana, and head dog

wrangler

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THE IMPACT

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Where are we going?•36 million with dementia globally•Triple that number in 2050•Approximately affects one in 20 over age 65 and one-fifth of people over 80

•90% eventually require full-time nursing care

•Average life span: six years post-diagnosis

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Cost:$$$$$$$

In 2010 worldwide cost of dementia care in general population estimated at $604 billion. In the U.S. estimated at $157 billion to $215 billion

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Dementia is………..

Defined broadly: a syndrome of acquired intellectual impairment produced by brain dysfunction. Often called, “a cruel and unusual disease.”• Phillipe Pinel used it to refer to intellectual deterioration and idiocy• Others called it “senility• Dementia praecox: Schizophrenia• Presenile Dementia: Alois Alzheimer

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Dementia Myths A global impairment Must impair memory A behavioral disorder Inevitable with aging Cannot have an acute

onset An untreatable disorder

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• “Dementia” is a loss of mental functions not due to delirium. It comprises of 3 or more deficit areas:▫Memory▫Language▫Perception▫Praxis▫Calculations▫Semantic knowledge▫Executive function▫Personality▫Social behavior▫Emotional awareness or expressionDocumented by mental status assessments

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My memory is bad; will I have dementia?

Context:Subjective memory complaints are very common in the general population• 34% to 56%• It is not clear that this frequent

complaint is associated with future risk of dementia.• Most studies evaluated elicited rather

than spontaneous SMC▫ A Veteran’s Affairs sponsored review of Six Brief Assessments (06/28/2010)

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Brief Cognitive Assessments•Blessed Orientation‐Memory‐

Concentration (BOMC) Test•Mini‐Cog•Montreal Cognitive Assessment (MoCA)•General Practitioner Assessment of

Cognition (GPCOG)•St. Louis University Mental Status

(SLUMS) Exam•Short Test of Mental Status (STMS)

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EPIDEMIOLOGY

•Single greatest predictor: Longer lifespan

•After onset of dementia: 5 to 6 years•World Health Organization: 35.6 million globally will triple by 2050

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Types of Dementia: Variations

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Cortical vs. Subcortical•Cortical

▫Alzheimer’s▫Frontotemporal▫Asymmetric cortical atrophiesFrontal-subcorticalDementia with Lewy BodiesParkinson’s DiseaseHuntington’s DiseaseProgressive Supranuclear PalsyVascular DementiaCreutz-Jacob…….etc.

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Alzheimer’s: Most Prevalent

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Overlapping nature of AD

Possibilities of Mixed Etiologies

From:Mendez, M. & Cummings,J. (2003). Dementia:A Clinical Approach. Third Edition, p. 9

ADFTD

DLBVascular

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DSM-5: Diagnostic TerminologyMild/Major Neurocognitive Disorder due to…..page

602• Alzheimer’s Disease• With Lewy Bodies• Vascular• Traumatic Brain Injury• HIV Infection• Prion Disease• Parkinson’s Disease• Huntington’s Disease• Another medical condition• Multiple etiologies• Unspecified

Note: The word “dementia”

is never used.

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Confused yet?•Beyond renaming it “cognitive decline,” you must specify “possible” or “probable” and include the ICD code for due to…..

•Page 603 and 604 will help with that.

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DSM-5 Definitions – p. 611•Probable Alzheimer’s Disease: diagnosed if there is evidence of a causative Alzheimer’s disease genetic mutation from either genetic testing or family history

•Possible Alzheimer’s Disease: diagnosed if there is no evidence of causative Alzheimer’s disease genetic mutation or family history and all three of the following are present:

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DSM-5 cont.—p. 611 •(1) Clear evidence of decline in memory

and learning•(2) Steadily progressive, gradual decline in

cognition, without extended plateaus•(3) No evidence of mixed etiology (i.e.,

absence of other neurodegenerative cerebrovascular disease or another neurological or systemic disease or condition likely contributing to cognitive decline

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If it were only this simple…..

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What is Executive Function?Executive function has evolved to broadly describe an array of loosely defined control processes responsible for planning, coordinating, sequencing, and monitoring other cognitive skills, enabling goal-directed and future-oriented behavior. Some also place extremely functional activities such as attention, visuospatial function, reasoning, and planning among the tasks to be under the guidance of executive function. In other words, executive function may be described by several related but dissociable processes, including divided attention, updating and monitoring, task shifting, response inhibition, and visuospatial function or the perception of the surrounding world.

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Tracking Progression•Neuropsychological Evaluation, usually on a yearly basis with the first assessment used as a baseline

•An initial baseline MRI and repeated when neuropsychological evaluation shows cognitive decline

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DLB•Also includes Early symptoms ofexecutive dysfunc-tion rather than memory

• Fluctuating cognition

• Visual hallucinations

• ParkinsonismDSM-5—p.618

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RISKY BUSINESS

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Overlooked Early Symptoms•Used to be sociable, now withdrawn•Some memory lapses•Misplacing items•Mood changes•Temperamental•Easily agitated•Confusion

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Warning Signs•Recent memory that affects daily life•Difficulty performing regular tasks•Problems with language•Disorientation of time and space•Decreased or poor judgment•Problems with complex tasks•Misplacing things•Changes in mood and behavior•Relating to others•Loss of initiative

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Apathy: A consistent sign

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Activities of Daily Living (ADLs)Functional Skills

Basic physical needs• Grooming and personal hygiene• Dressing• Toileting/Continence• Transferring• Ambulating• Eating

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Instrumental Activities of Daily Living (IADLS)

•Categorized separately from ADLs•Managing finances•Managing medications•Appointments•DrivingADLs are more preserved and impairment shows up in later stages, dependent on physical functioningIADLs performance is more sensitive to early cognitive decline

Complex Activities Related to Independent Living

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Challenging BehaviorsNegative behavior related to:

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Cont.•Aggression: verbal or physical

▫Important to understand cause▫Focus on feelings and not facts▫Try not to get upset▫Limit distractions▫Try relaxing activity▫Shift focus▫Speak calmly▫Take a break▫Ensure safety

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•Delusions•Hallucinations•Wandering•Physical and verbal aggression•Sexually inappropriate•Paranoia•Sundowning •Depression

What happens between early and late stage dementia? Trouble with a capital T

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Pharmaceutical Intervention for Aggressive Behaviors and/or Psychiatric Disorders

•Antidepressants: citalopram/Celexa, sertraline/Zoloft, venlafaxine/Effexor

•Anxiolytics: most of the benzodiazepines•Antiparkinsonian Agents: dopaminergic

agonists, MAO-B inhibitors, dopamine facilitator •Beta Blockers: prazosin/Minipress•Antiepileptic Drugs: topiramate/Topamax gabapentin/Neurontin, lamotrigine/Lamictal•Neuroleptics: risperidone/Risperdal,

quetiapine/Seroquel, olanzapine/Zyprexa

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Antipsychotics acceptable?•Studies reveal that more than 90% of those

with dementia develop at least one BPSD with serious clinical implications. Often the cause of moving to care in a facility

•Atypical antipsychotics bring risks such as increased mortality and prescribing has significantly declined

•However, there are instances where BPSD pose greater risk to individuals and families than antipsychotic medications

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Decision-making for Antipsychotic Therapy

•First identify and remove triggers•Try non pharmacological alternatives

(Behavioral therapy with a mental health professional)

•Assess severity and consequences of behavior, determining overall risks of behavior, especially harm to caregiver or life-threatening to patient

•Accept it as a short-term intervention

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Psychosocial Interventions• Routine activity• Separate person from whatever is upsetting• Assess for pain or other physical problem• Review medications, especially new ones• Travel with them to where they are in time• Don’t disagree, respect the person’s thoughts even if

incorrect (Never argue against a delusion)• Speak slowly and calmly: Tone more important than

words• Avoid finger-pointing, scolding or threatening• Redirect to an enjoyable activity• If you are the cause, leave the room• Validate and reassure of your love• Avoid triggers in the future

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Undesirable Consequences•Aggression, sexual or physical often concludes with interaction with theLaw

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Rather than jail…Deserving of thesame treatment given to those with a mental disorder:a psychiatric evaluation and pharmaceuticalintervention.

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Why can’t I think?

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Oxidative Stress: is essentially an imbalance between the production of free radicals and the ability of the body to counteract or detoxify their harmful effects through neutralization by antioxidants.•Believed a critical factor in normal aging and in neurodegenerative diseases through multiple mechanisms

•Protein synthesis may be one of the earliest processes disrupted by oxidative damage eventually resulting in cellular death

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Other possible contributors• Inflammatory reactions• Immune mechanisms•Clusterin: associated with atrophy of the

entorhinal cortex•Estrogen loss: postmenopausal women at higher

risk as estrogen has a cytoprotective effect to prevent amyloid toxicity; some say “not true”

•Dyslipidemia, hypertension, downs syndrome, TBI•Gene mutations (APOE4 Allele)• Insulin resistance• Infection•Depression•Epigenetics

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So what is the research trying to say?THE CAUSE OF AD IS

UNKNOWNSeveral investigators believe it is a convergence of environmental and genetic risk factors which trigger a pathophysiologic cascade over the decades.

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Treatment of DementiaAcetylcholinesterase Inhibitors

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Acetylcholine:Functions in the body as aneurotransmitter and neuromodulator… A cell released chemical that sends signals to other cells

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CAREGIVER

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From: Crisis Prevention Intervention

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Respite for YOU

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Hope for the Future:Experts predict that a treatment for AD will be available in the next 10 years. Prediction is driven by success in recent drug trials. Last summer a study found that the drug solanezumab could prevent decline by 33% by attacking the actual disease and clearing out amyloid plaques.

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Chapter Office - Albuquerque9500 Montgomery Blvd. NE, Ste. 121Albuquerque, NM 87111Phone (505) 266-4473Fax (505) 266-0108Mailing Address

Alzheimer's Association, NM ChapterP.O. Box 21400Albuquerque, NM 87154

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Please do not hesitate to contact me if you have any further questions:

505-263-8055kershar@comcast.netdr.s.kernen@gmail.com

505-263-8055

…and as always my best regards