1

AD- the extent of the problem

• AD represents over 50% of all dementia cases

• AD prevalence doubles every 5 years after 60 years of age

• AD affects 15 million people worldwide

2

The diagnosis and assessment of AD

• "Listen to the patient, they are telling you the diagnosis."

• "It is possible to make a diagnosis of Alzheimer's disease, just as we can make a diagnosis of other major illnesses."

• "The challenge today is to obtain an early, accurate and specific diagnosis of dementia using an effective diagnostic process."

3

AD prognosisOptimal case

Min

i Men

tal S

tate

Exa

min

atio

n s

core

1 2 3 4 5 6 7 8 9

25 ---------------------| Symptoms

20 |----------------------| Diagnosis

15 |-----------------------| Loss of functional independence

10 |--------------------------------| Behavioral problems

5 |-------------------------------------------|

0 Death |------------------------------------------

Nursing home placement

Feidman and Gracon, 1996Years

4

Definition of the dementiasyndrome

• Multiple cognitive deficits – memory loss – aphasia – apraxia – agnosia – disturbance in executive function

• These lead to functional decline

DEMENTIA

5

Causes of dementia

• Common causes: – Depression– Delirium– Drug toxicity

• Common causes: – Alzheimer's disease– Vascular dementia

• Other causes– Lewy body disease– Pick's disease (dementia

of the frontal lobe type) – Parkinson's disease with

dementia

Reversible dementias Irreversible dementias

6

Differentiating AD from other dementias

Cognitive impairment

Dementia

Alzheimer's disease

Exclude other causes (e.g. delirium and depression, etc)

Exclude other dementias

Differentiating AD from other dementias

7

Dementia  * Insidious onset with unknown date* Slow, gradual, progressive decline* Generally irreversible* Disorientation late in illness* Slight day-to-day variation* Less prominent physiological changes* Consciousness clouded only in late stage* Normal attention span* Disturbed sleep wake cycle; day night

* Psychomotor changes late in illness

Delirium   * Abrupt, precise onset, known date * Acute illness, lasting days or weeks * Usually reversible * Disorientation early in illness * Variable, hour by hour * Prominent physiological changes * Fluctuating levels of consciousness * Short attention span * Disturbed sleep wake cycle; hour-to-hour variation * Marked early psychomotor changes

OR

Dementia or delirium

Ham, 1997

8

Dementia  * Insidious onset * No psychiatric history * Conceals disability * Near-miss answers * Mood fluctuation day to day * Stable cognitive loss * Tries hard to perform but is unconcerned by losses * Short-term memory loss * Memory loss occurs first * Associated with a decline in social function

Depression  * Abrupt onset * History of depression * Highlights disabilities * ’Don't know' answers * Diurnal variation in mood * Fluctuating cognitive loss * Tries less hard to perform and gets distressed by losses * Short- and long-term memory loss * Depressed mood coincides with memory loss * Associated with anxiety

OR

Dementia or depression

Ham, 1997, modified from Wells CE, 1979

9

Risk factors* Age* Family History of AD (ApoE-4) * Head trauma* Low educational level* Environmental factors* Down’s syndrome

Protective factors * Genetic (ApoE-2)* High educational level* Long-term anti- inflammatory drug use, e.g. NSAIDS* Long-term use of estrogens (in women)

AD risk and protective factors

IPA AD Conference, 1996

10

Need for earlydiagnosis

Consistent onset, clinicalpresentation and disease progression

Practicalassessmentmethods

New symptomatictreatments

Patient and caregiver support

Making a diagnosis of AD

IPA AD Conference, 1996

11

IPA AD Conference, 1996

Functionalimpairment * IADL * ADL

Insidious onset Cognitive decline* Memory loss * Aphasia * Apraxia * Agnosia * Executive function difficultiesBehavioral signs

* Mood swings * Agitation* Wandering

Age over 60 years

No gait difficulties

AD

Clinical features of AD

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Cognition * Recall/learning* Word finding* Problem solving* Judgement* Calculation

Function* Work* Money/shopping* Cooking* Housekeeping* Reading* Writing* Hobbies

Behavior* Apathy* Withdrawal* Depression* Irritability

IMPAIRMENT

Adapted from Galasko, 1997

Clinical features of ADMild stage of AD (MMSE 21 30)

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Cognition * Recent memory (remote memory unaffected) * Language (names, paraphasias)* Insight* Orientation* Visuospatial ability

Function* IADL loss* Misplacing objects* Getting lost* Difficulty dressing (sequence and selection)

Behavior * Delusions* Depression* Wandering* Insomnia* Agitation* Social skills unaffected

IMPAIRMENT

Clinical features of ADModerate stage of AD (MMSE 10 20)

Adapted from Galasko, 1997

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Cognition * Attention* Difficulty performing familiar activities (apraxis)* Language (phrases, mutism)

Function* Basic ADLs Dressing Grooming Bathing Eating Continence Walking Motor slowing

Behavior* Agitation Verbal Physical* Insomnia

Clinical features of ADSevere stage of AD (MMSE <10)

Adapted from Galasko, 1997

IMPAIRMENT

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"How is your memory?"

Case-finding Pattie and Gilleard, 1979

Diagnosing AD in primary carecase-finding

16

Clinical History

* Forgetfulness * Getting lost in familiar settings * Difficulties with finance * Deterioration of work or home performance * Inability to recognize, or a lack of interest in, family members * Difficulties driving or using the telephone

Diagnosing AD in primary careclinical history, common presentations

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Clinical History

Ask the following questions: * How did it start? Was it sudden or gradual? * How long has it been going on? * Is the situation progressing? If so, how rapidly? * Is it step-wise or continuous? * Is it worsening, fluctuating or improving? * What changes have you noticed? * Has there been a change in personality? * Has the patient suffered any delusions or hallucinations? * Does the patient become agitated or wander?

Diagnosing AD in primary careclinical history, questioning

18

Functional Assessment

Functional Activities Questionnaire (FAQ)1. Dealing with financial matters, paying bills, writing checks2. Keeping records of taxes, business affairs3. Shopping for everyday necessities: groceries, clothes, etc4. Hobbies or playing games5. Making tea, turning the kettle on and off6. Cooking a balanced meal7. Perception of current events8. Level of attention and understanding: books, television9. Memory: remembering appointments and medications10. Getting about: driving or taking public transport

Pfeffer et al 1982

ScoreMaximum

3333333333

Total 30

ScoreActual

Diagnosing AD in primary carefunctional assessment

19

Cognitive Assessment

Cognitive areaMini Mental State Examination: test outline and scoring

Orientation *What is the (date, day, month, year, season)? * Where are you (clinic, town, country)?

Memory *Name three objects. Ask the patient to repeat them

Attention*Serial sevens. Alternatively ask the patient to spell world backwards (dlrow)

Folstein et al 1975

ScoreMaximum

55

3

5

ScoreActual

Diagnosing AD in primary carecognitive assessments, MMSE

20

Cognitive Assessment

Cognitive areaMini Mental State Examination: test outline and scoring

Recall *Ask for the three objects mentioned above to be repeated

Language*Name a pencil and watch*Repeat, 'No ifs, ands or buts’*A three stage command*Read and obey CLOSE YOUR EYES*Write a sentence*Copy a double pentagon

ScoreMaximum

3

213111

Total 30

ScoreActual

Folstein et al 1975

Diagnosing AD in primary carecognitive assessments, MMSE (continued)

21

The Clock Draw Test

Cognitive Assessment

Time: 5.00 Score: 7 (normal)

Time: 'no real time' Score: 2 (demented)

Thalmann et al 1996.

Time: .10.30 Score: 3 (demented)

Time: 1/4 past 25 Score: 3 (demented)

Diagnosing AD in primary carecognitive assessment

22

Physical examination

* Life-threatening conditions, e.g. mass lesions, vascular lesions and infections * Blood pressure and pulse * Vision and hearing assessments * Cardiac and respiratory function * Mobility and balance * Sensory and motor system examination (tone, reflexes, gait and coordination) and depressive symptoms (sleep and weight)

Diagnosing AD in primary carephysical examination

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Laboratory tests

All patients* Complete blood count* Thyroid function* Vitamin B12 and folate* Syphilis serology * BUN and creatinine * Calcium * Glucose * Electrolytes * Urinalysis * Liver function tests

Most patients   * ECG* Chest X-ray

Diagnosing AD in primary carelaboratory tests

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Neuroimaging

Various CT scan reports in AD * Normal examination for the patient's age * Generalized cerebral atrophy * Small vessel changes, areas of leucoencephalopathy* No signs of subdural hematoma (if head trauma suspected) * Absence of specific areas of cerebral infarctions or evidence of stroke

Diagnosing AD in primary careneuroimaging, computed (axial)

tomography (CT)

25

* Inconclusive diagnosis * Atypical presentation * Behavioral/psychiatric symptoms * Second opinion * Family dispute * Caregiver support

Primary care management of ADspecialist referral

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* Define all contributory factors and other illnesses * Discuss the diagnosis, and differentiate other types of dementia * Withdraw non-essential drugs that may interfere with cognition * Treat or manage concomitant illness (e.g. depression, hearing loss)

The role of the primary care physician in mild to moderate AD

Gauthier, Burns and Pettit, 1997

27

* Discuss the use of symptomatic therapies * Monitor functional ability e.g. driving, safety * Referral to specialist if appropriate * Advise on will-making and advance directives * Refer to local AD association for support * Managing caregivers

The role of the primary care physician in mild to moderate AD

(continued)

Gauthier, Burns and Pettit, 1997

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The role of the primary care physician in severe AD

* Help caregivers discover and optimize the patient's preserved function * Monitor and treat complications * Facilitate caregiver support (respite and day care programs) * Be aware of caregiver burden and stress * Plan institutionalization, if needed * Assist with end-of-life decisions

The role of the primary care physician in severe AD

Gauthier, Burns and Pettit, 1997

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CASE-FINDINGSymptomssuggestingcognitive

impairment

MANAGEMENT OF AD *Follow-up *Patient and caregiver counseling *Management and symptomatic treatment *Specialist referral if indicated

CLINICAL ASSESSMENT *Clinical history

*Physical examination *Laboratory tests

*Functional assessment *Cognitive assessment

Functional decline and cognitive impairment

DIFFERENTIAL DIAGNOSIS *Exclude delirium depression other causes of dementia *Evaluate evidence for AD (neuroimaging)

YES

AD diagnosis

Diagnosing AD in primary careA systematic approach summary

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* Cognitive ability* Functional ability * Behavior * General health * Routine health checks

Primary care management of ADfollow-up

31

* Caring for patients * Self-help * Support services * Medico-legal help * Caregiver well being

Caregiver support in primary care