Dementia and Aging

1. Dementia and Aging Steven Huege, M.D Assistant Professor of Clinical Psychiatry Perelman School of Medicine at the University of Pennsylvania

2. 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

3. 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)

4. 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

5. Population with Alzheimer’s in U.SAlzheimer’s Association

6. 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

7. NIA: Updated criteria for Dementia • Interfere with the ability to function at work or at usual activities • Represent a decline from previous levels of functioning and performing • Are not explained by delirium or major psychiatric disorder • Cognitive impairment is detected and diagnosed through a combination of (A) history-taking (B) an objective cognitive assessment • The cognitive or behavioral impairment involves a minimum of two of the following domains: • Impaired ability to acquire and remember new information • Impaired reasoning and handling of complex tasks, poor judgment. • Impaired visuospatial abilities • Impaired language • Changes in personality, behavior, or comportment

8. NIA: Alzheimer’s Criteria Meets criteria for dementia + • Insidious onset. Symptoms have a gradual onset over months to years • Clear-cut history of worsening of cognition by report or observation • 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

9. 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

10. Tangles and Plaquesladulab.anat.uic.edu/images/ADstain.jpg

11. Symptoms of Alzheimer's at various stages of illness • Mild • Moderate • Severe

12. 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

13. 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

14. Severe • MMSE <5 • Minimal verbal ability • Incontinent • Unable to perform even basic ADL’s • Immobile • Completely dependent on others for all aspects of care

15. 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

16. Biomarkers for Alzheimer’s DementiaSperling, et.al. 2011

17. Neuropsychiatric Symptoms of ADBased on Scores on MPI > 4, Lyketsos, C. JAMA 2002

18. Pharmacological Treatments • Cholinesterase inhibitors • Memantine • Antidepressants/Antipsychotics • None are disease modifying, preventative or curative • Symptomatic treatments only

19. Survival by Dementia TypeFitzpatrick, et.al 2005

20. 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.