Martha Stearn, MD

Institute for Cognitive Health

St John’s Medical Center

Jackson, Wyoming

An Overview of the Dementias

Regions of the Human Brain

2% of the total body weight

Uses 20% of the body’s blood supply

Achieves it’s maximum weight at age 20

Most of brain’s oxygen use goes to grey matter

Interesting Facts

Infancy communicationChildhood language and spatial

Young Adult brain growth peaks

Middle Age memory, learning, more difficult

Old Age continued slowing, more memories and wisdom

The Life Cycle of the Brain

The CerebrumThe Cortex

The frontal lobe – executive function, socialization, language

The parietal lobe – memory, visuospatial

The temporal lobe – short-term memory

The occipital lobe - vision

Parts of the Brain and their Function

The Limbic System

The Hippocampus

The Basal Ganglia

The Amygdala

Brain StemCerebellum

The Old Brain

100 billion cellsOne trillion

connections

The Cortical Neuron

SEROTONIN low levels in depression

DOPAMINE low levels in DLB

ACETYLCHOLINE low levels in AD, TBI, DLB, Vascular dementia

NOREPINEPHRINE

GLUTAMATE high levels in AD

Neurotransmitters

What happens to those short term memories?

Loss of intellectual abilities of sufficient severity to interfere with occupational or social functioning

to the point that one cannot function independently successfully

The Memory ContinuumPRECLINICAL the stage is being setCLINICAL Mild Cognitive ImpairmentDEMENTIA Conversion to dementia

Definition of Dementia

All involve abnormal deposition of specific proteins in the brain (amyloid and tau) that is a progressive process gradually damaging more neurons over timeClinical significance

These proteins can be biomarkers for identifying those at riskCertain lifestyle changes have been shown to

reduce that rate of protein depositionResearch geared toward drugs that will eliminate,

prevent or dissolve these proteins

Neuropathology of the dementias

Alzheimer’s Disease

Vascular Dementia

Dementia with Lewy Bodies

FrontoTemporal Dementia

Dementia of Parkinson’s DiseaseNPH

The Dementias

Most common cause of dementia

Characterized by short term memory loss and, usually later, visuospatial deficits

6th leading cause of death in the United States

Risk increases starting at age 65; nearly 50% chance of having the disease by age 85

Alzheimer’s Disease

Short term memory loss

(AMNESIA) and at least one of the following domain dysfunctions:

APHASIAAGNOSIAABSTRACTIONAPRAXIA

Definition of Probable Alzheimer’s

Also known as multi-infarct dementiaOften presents as a mix with ADRisk factors similar to those for heart disease:

HyperlipidemiaHTNSmokingDiabetesFamily history for vascular disease

Onset may appear more rapidly than ADMay not be progressive if risk factors controlled

VASCULAR DEMENTIA

VISUAL-SPATIAL PROBLEMS OFTEN MORE PROMINENT FROM THE START

HALLUCINATIONS COMMON

MENTAL STATUS TENDS TO FLUCTUATE UNPREDICTABLY

DIFFICULTY WITH CIRCADIAN RHYTHM

PARKINSONISM ON PHYSICAL EXAM

DEMENTIA WITH LEWY BODIES

More common than AD in the 50-65 age group

Memory loss less likely to be presenting symptom

Behavioral issues, change in personality, disinhibition are presenting hallmarks

Language difficulties

FRONTOTEMPORAL DEMENTIA

Cholinesterase inhibitorsDonepezil Rivastigmine GalantamineGlutamate inhibitor Memantine Atypical antipsychotics

QuetiapineMirtazapineRisperidoneHaloperidol—can be deadly for pts with dlb

Important Dementia Drugs

• Bad drugs: • antihistamines, haloperidol, hypnotics,

benzodiazepines; narcotics

• Anticholinergics: • bladder control meds; diarrhea control meds;

some asthma drugs, eg tiotropium, ipratropium

Dangers Of Polypharmacy

Behavioral issuesInsomniaDepressionNot eatingAnxietyHallucinationsParanoia

Common Symptoms

Falling

Driving

Wandering

Malnutrition

Aspiration

Why People Die From AD

Making a diagnosisMedications

Lifestyle Team approach

Dealing with caregiver burden

How we can make a difference

Neuropsychological testingPhysical therapy for balance and fall

preventionSpeech therapyOccupational therapy for home safety

evaluation and driving evaluationSupport groupsExercise classesBrain ImagingBlood work: TSH, B12, Lipids, complete

metabolic profile, CBC

Treatment and Diagnostic Modalities