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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