Dementia and Aging

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17 Νοε 2013 (πριν από 3 χρόνια και 8 μήνες)

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Dementia and Aging

Steven Huege, M.D

Assistant Professor of Clinical Psychiatry

Perelman School of Medicine at the
University of Pennsylvania

Dementia and Aging


Contrary to popular belief: Dementia and
Memory loss are
not

part of normal aging


Cognitive processing does slow down, but
progressive short term memory loss is not
normal and warrants a thorough work
-
up

Dementia


Syndrome characterized by a deterioration of
cognitive ability from a previous level leading to
impairment in functioning.


Can have many causes


Infectious (HIV, syphilis)


Toxic/Metabolic (Cu, Pb, ETOH, Folate, B12 deficiency)


Neurodegenerative/Vascular (Alzheimer’s,
Parkinson’s, Lewy Body, FTD, Prion)


“Structural” (Normal Pressure Hydrocephalus, Tumor)


Prevalence of Dementia


Major health problem, especially as
population ages


3
-
11% of community
-
dwelling adults age >65
have dementia


20
-
50% age >85 have dementia


In 2000, 4.5 million people had Alzheimer’s


Population with Alzheimer’s in U.S

Alzheimer’s Association

Alzheimer’s Dementia


Major health problem, especially as
population ages


3
-
11% of community
-
dwelling adults age >65
have dementia


20
-
50% age >85 have dementia


In 2000, 4.5 million people had Alzheimer’s

NIA: Updated criteria for Dementia

1.
Interfere with the ability to function at work or at usual activities

2.
Represent a decline from previous levels of functioning and performing

3.
Are not explained by delirium or major psychiatric disorder

4.
Cognitive impairment is detected and diagnosed through a combination of
(A) history
-
taking (B) an objective cognitive assessment

5.
The cognitive or behavioral impairment involves a minimum of two of the
following domains:

I.
Impaired ability to acquire and remember new information

II.
Impaired reasoning and handling of complex tasks, poor judgment.

III.
Impaired visuospatial abilities

IV.
Impaired language

V.
Changes in personality, behavior, or comportment

NIA: Alzheimer’s Criteria

Meets criteria for dementia +

A.
Insidious onset. Symptoms have a gradual onset over months to years

B.
Clear
-
cut history of worsening of cognition by report or observation

C.
The initial and most prominent cognitive deficits are evident on history


and examination in one of the following categories.


a. Amnestic presentation


b. Nonamnestic presentations:



i. Language presentation



ii. Visuospatial presentation: The most prominent deficits



are in spatial cognition, including object agnosia,



impaired face recognition, simultanagnosia, and alexia



iii. Executive dysfunction: The most prominent deficits are



impaired reasoning, judgment, and problem solving


Pathology of Alzheimer’s


Senile (Amyloid) Plaques


Extracellular


Result from accumulation of proteins and an
inflammatory reaction around deposits of
β
-
amyloid


Neurofibrillary Tangles


Intracellular


Aggregates of hyperphosphorylated microtubular
protein tau


Tangles and Plaques

ladulab.anat.uic.edu/images/ADstain.jpg


Symptoms of Alzheimer's at various stages
of illness


Mild


Moderate


Severe

Mild AD


MMSE 20


Memory complaints
-
cardinal symptom!


Decreased knowledge of current events


Difficulty performing complex tasks


Impaired concentration


Less able to manage travel, finances


Disorientation


Word finding difficulty


Pt may not be aware of deficits

Moderate


MMSE 15


Inability to recall address, names of family members


Some disorientation


Still retain major biographical info about self


Initially able to toilet, feed, but may become more
impaired as illness progresses


Worsening language and apraxia


Severe


MMSE <5


Minimal verbal ability


Incontinent


Unable to perform even basic ADL’s


Immobile


Completely dependent on others for all
aspects of care

Mild Cognitive Impairment

(MCI)


Memory Impairment beyond normal limits


Performance < 1.5 SD on memory testing


No major impairment in functioning


Able to carry out all ADL’s


70% of pts with MCI will progress to dementia


Biomarkers for Alzheimer’s Dementia

Sperling, et.al. 2011

Neuropsychiatric Symptoms of AD

Based on Scores on MPI > 4, Lyketsos, C. JAMA 2002

Symptom

MCI

%

AD%

Delusions

2

38

Hallucinations

4

18

Agitation

15

53

Depression

20

58

Anxiety

16

35

Disinhibition

1

25

Irritability

24

45

Sleep

28

72

Eating

20

57

Aberrant Motor Activity

7

43

Apathy

20

97

Pharmacological Treatments


Cholinesterase inhibitors


Memantine


Antidepressants/Antipsychotics


None are disease modifying, preventative or
curative


Symptomatic treatments only

Survival by Dementia Type

Fitzpatrick, et.al 2005

Conclusion


Dementia can be thought of a
“biopsychosocial” illness.


The cognitive impairment from dementia
requires pt, caregivers, and physicians to
address all aspects of pt’s life.