Mind Cancer:Alzheimer’s Disease and Related Dementias.

William D. Rhoades, DO FACP

Chair, Department of Medicine Advocate Lutheran General and Chicago Medical School

Missoula Medical Conference

October 24, 2014

Recognition of stages of dementia, diagnosis and treatment

Objectives

Recognize the diagnosis of Alzheimer's disease and related dementias

Discuss the three aspects of dementing illnesses: cognitive losses, functional decline, and behavioral issues

Evaluate treatment modalities for Alzheimer's disease

Stages of Cancer

Stage O: Cancer in situ Stage I: Small cancer not invading deeper

tissues or spread to lymph nodes Stages II and III: Cancers that are larger in

size, have grown more deeply into nearby tissues, and have spread to lymph nodes

Stage IV: Advanced or Metastatic cancer spread to other organs or body parts

Stage 0:Mild Cognitive Impairment;Dementia in situ

Stage O: Mild Cognitive Impairment DIAGNOSTIC CRITERIA

– Isolated memory complaint– Objective memory impairment– Normal general cognitive function– Intact activities of daily living– Not demented

MCI: Diverse Clinical Presentations Amnestic leads to Alzheimer’s Disease Multiple domains, slightly impaired leads to

Vascular Dementia, Alzheimer’s Disease, or questionably due to normal aging

Single non-memory domain leads to Alzheimer’s Disease, Fronto-temporal Dementia, Lewy-Body Disease, Primary Progressive Aphasia, or Parkinson’s Disease

MCI: Progression To Alzheimer’s Disease Annual percentage based on 6 studies

reviewed: 6 to 25% 1 study showed 6% annual conversion to AD 1 study showed 25% annual conversion to

AD 4 studies showed 12-15% annual conversion

to AD Mayo Clinic study extended to 6 years found

80% of patients converted to AD over 6 years

Types of Dementiaand Work-up

Differential Diagnosis of Dementia

5% 10% 65% 5% 7% 8%

Dementia with Lewy bodies

Parkinson’s disease

Diffuse Lewy body disease

Lewy body variant of AD

Vascular dementias and AD

Other dementias

Frontal lobe dementia

Creutzfeldt-Jakob disease

Corticobasal degeneration

Progressive supranuclear palsy

Many others

AD and dementia with

Lewy bodies

Vascular dementias

Multi-infarct dementia

Binswanger’s disease

AD

Small GW, et al. JAMA. 1997;278:1363-1371; American Psychiatric Association. Am J Psychiatry. 1997;154(suppl):1-39; Morris JC. Clin Geriatr Med. 1994;10:257-276.

3

Dementia workup

Laboratory: CBC, CMP, Vitamin B12 level, and TSH +/- RPR, ESR

Imaging: Some brain imaging is recommended CT without contrast if normal is sufficient, if no imaging done MRI of brain without contrast.

Diagnosis: Transient Alteration of Awareness

Mind Cancer: Alzheimer’s Disease

BARRIERS TO DIAGNOSIS AND TREATMENT OF AD By Patients and Families

– Patient lacks insight– Fear of diagnosis– Denial of diagnosis– Fear of loss of function– Belief that there is nothing to

do– Fear of societal implications

i.e. financial, insurance, and embarrassment of a mental illness

By Physicians– Drugs don’t work– Want to be sure of

diagnosis before making it because of implications

– Early diagnosis difficult without family help

– Diagnosis and explanation take time

– Suspect diagnosis but no need to make it

Stage I: Early Stage Dementia

Stage I: Red Flags

Weight loss Vague complaints Poor prescription management Changes in grooming and hygiene Missed or wrong day appointments Apathy and/or depression

Stage I: Alzheimer’s Disease Screening

Recent events Orientation to time Clock drawing test Three item recall Animal naming (>12-15 in 1 minute) Mini-Mental Status Test Neuropsychological testing

Stage I: Early Alzheimer’s disease

Memory impairment Word finding difficulty Difficulty with executive function and complex

tasks Geographic disorientation Reasoning and judgment abilities Usually remain independent

Stage I: Functional losses (independence maintained) Driving?? Unfamiliar locations may present problems Maintaining medications, especially if

complicated and/or potentially dangerous Managing higher finances i.e. taxes, large

purchases, and financial vulnerability

Stage II: Local Spread of Dementia

Stage II: Cognition and Cognitive Losses Memory Orientation Executive Function Language Visual Spatial Skills

Stage II: Functional Losses (living alone) Instrumental Activities of Daily Living

– Shop for yourself– Prepare your own food– Maintain housekeeping– Do laundry– Manage medications– Make telephone calls– Handle finances– Travel on your own

Stage III: Spread of Dementia to family members

Stage III: Advanced Middle-stage Alzheimer’s disease Day-night disorientation Language deterioration Difficulty with simple chores Troublesome behavior:

– wandering– irritability– paranoia

Depression

Stage III: Functional Decline

Inability to maintain Instrumental Activities of Daily Living

Lack of capacity to live safely on your own Begin to see some erosion of Basic Activities

of Daily Living– Assistance with: toileting, eating, dressing,

grooming, getting out of bed or chairs, and walking

Stage III: Behavioral Issues

Day-night disorientation Depression Wandering Irritability Paranoia Hallucinations Delusions Agitation

Stage IV: Widely Metastatic and End-Stage Dementia

Stage IV: Advanced Alzheimer’s disease Hallucinations Delusions Agitation Erosion of all basic activities of daily living Total dependence on caregivers Lack the capacity for basic physical

independence

Treatment Options for Alzheimer’s Disease

Treatment of Stage 0, Stage I, and Stage II disease Reasonable Expectations of Successful

Cholinesterase Inhibitor Therapy– Improve, maintain, or slow decline in ADL and

cognitive function– Control troublesome behaviors– Ease loss of independence– Ease caregiver burden– Delay placement in long-term care facility

FOUR CHOLINESTERASE INHIBITORS

Cognex (tacrine)

Aricept (donepezil)

Exelon (rivastigmine)

Reminyl (galantamine)

Treatment of Stage II and III disease

Memantine (Namenda)– Combination therapy– When to add?– Monotherapy

Behavioral Treatments

Stages I,II, III: Nonpharmacologic TherapyEarly Alzheimer’sUse it or lose itSafety and structureMemory aidsAlleviating depression

Middle-stage ADAdult day careSimplify the environmentRedirect behaviorDo not argue

Treatment of Stage IV disease

Advanced Alzheimer’s diseaseSpecial care unitsStructure and activities based on cognitionAdditional in-home care assistanceManagement of incontinence

Stage IV: End-Stage Alzheimer’s Disease Palliative care Hospice care Hospitalizations Feeding issues including tube feeding Resuscitation decisions

Stage IV: Clinical Management

Goals and end-points of therapy: Social and behavioral therapy Medications to improve or maintain function

and cognition Medications for certain behaviors Recognition of delirium and depression Care of caregivers

Who Are the Caregivers?

The overwhelming majority of patients live at home and are cared for by family and friends– 77% are women– 73% are over 50 years of age– 33% are the sole providers– 45% are children of the patient– 49% are spouses– Remainder are close family members or

friends

Caregiver Burden

Caregivers spend from 40–100 hours per week with the patient

90% are affected emotionally (frustrated, drained)

75% report feeling depressed; 66% have significant depression

Half say they do not have time for themselves and that the stress affects family relations

Many experience a significant loss of income

Factors That Create “Breaking Point” for Caregiver Amount of time spent caring for the patient Loss of identity Patient misidentifications and clinical

fluctuations Nocturnal deterioration of patient

Conclusions Dementia and Alzheimer’s disease represent

Mind Cancer Alzheimer’s disease progresses and the

stages have different symptoms and treatments

Alzheimer’s disease treatments are beneficial in all three domains: cognition, behavior, and function

Attention to caregiver needs are very important in Alzheimer’s disease