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Alzheimer’s Dementia “A Psychiatrist’s Perspective”

Alzheimer’s Dementia “A Psychiatrist’s Perspective”. Juan R. Jaramillo, M.D. Pathways October 22, 2002. Alzheimer’s Dementia Introduction. Alois Alzheimer 1907 “a peculiar disease of the cerebral cortex” Brain atrophy Characteristic microscopic lesions---plaques and tangles.

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Alzheimer’s Dementia “A Psychiatrist’s Perspective”

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  1. Alzheimer’s Dementia“A Psychiatrist’s Perspective” Juan R. Jaramillo, M.D. Pathways October 22, 2002

  2. Alzheimer’s DementiaIntroduction • Alois Alzheimer 1907 • “a peculiar disease of the cerebral cortex” • Brain atrophy • Characteristic microscopic lesions---plaques and tangles

  3. Alzheimer’s DementiaIntroduction • Best care is offered by multidisciplinary team • Physicians, social workers, lawyers, psychologists, recreational therapists, chaplains and, especially… • Nurses and relatives • Ideally a Board Certified Psychiatrist

  4. Alzheimer’s DiseaseIntroduction • Psychiatric symptoms are common • Their approach is a “juggling act” • Palliative care…still • Evidence-based please ! • “Quality of Life” as a guiding principle

  5. Alzheimer’s DementiaEpidemiology • Responsible for 60-70% of dementia cases • Risk increases with age • 1 % at age 60, risk doubles every 5 years • Other risk factors: low educational level, h/o head trauma, h/o depression, ?? women, genetics

  6. Alzheimer’s DementiaGenetics • Chromosome 21---amyloid precursor protein (APP) gene • Chromosome 14---presenilin 1 gene • Chromosome 1-----presenilin 2 gene • Chromosome 12---late onset dementia

  7. Alzheimer’s DementiaGenetics • Most cases are not familial but “sporadic” • But still with a genetic component • Apolipoprotein E---epsilon 4 allele-----chromosome 19 • Risk increases for those with a first degree relative that has it

  8. Alzheimer’s DementiaPathophysiology • Neuronal loss, amyloid angiopathy • Medial temporal lobe most affected • Temporal parietal areas and frontal lobes • Amyloid beta peptide (a normal protein) overproducedorinefficiently cleared • All these are present in the normal old age brain

  9. Alzheimer’s DementiaClinical Features • Typically after age 50, but most cases in 8th and 9th decades • Insidious and gradually progressive decline in mental abilities • Memory, job performance, poor tolerance to routine disruption • MMSE declines by 3 or points per year

  10. Alzheimer’s DementiaClinical Features • Independent tasks become more difficult • Hygiene may suffer • Delusional beliefs may develop • Same for hallucinations • Behavior problems

  11. Alzheimer’s DementiaClinical Features • Frequency of Behaviors Apathy---------------72 % Agitation-------------60 Anxiety---------------48 Irritability------------42 Depression-----------38 Disinhibition---------36 Nighttime behavior---24 Delusions-------------22 Hallucinations--------10

  12. Alzheimer’s DementiaDiagnosis • Clinical diagnosis can be accurate • Family’s insight is essential • DSM-IV TR Criteria • Memory plus 1 (or more) of *Aphasia *Apraxia *Agnosia *Executive functioning

  13. Alzheimer’s DementiaDiagnosis (DSM-IV TR) • “Significant impairment” • Gradual onset and continuing cognitive decline • “Not due to something else” • Early vs. Late • Brain imaging (CT or MRI) not diagnostic

  14. Alzheimer’s DementiaDiagnosis • Most important “something-elses” *Medications *Medical conditions (NPH, brain tumors) * Other psychiatric conditions *Benign forgetfulness *Mild Cognitive Impairment *Other dementias (Lewy Body, Vascular)

  15. Alzheimer’s DementiaDiagnosis • Diagnostic testing *Mini Mental Status Examination---bedside test. Takes 10 minutes. 24 (or less) out of 30 points=Dementia *Dementia Rating Scale *Alzheimer’s Disease Assessment Scale (ADAS-cog) *Neuropsychiatric Inventory *Apathy Evaluation Scale

  16. Alzheimer’s DementiaPsychiatric Complaints • Cognitive • Behavioral • Psychiatric

  17. Alzheimer’s Dementia1. Cognitive Problems • Cholinesterase Inhibitors Donepezil (5 to 10 mg/day). Then Galantamine. Then Rivastigmine ?. • Promising: Memantine. • Others: Vit E ?, Estrogen (women), Ginkgo Biloba ?,Aspirin ?,Selegiline, Folic Acid ?

  18. Alzheimer’s DementiaOther treatments “likely to be beneficial” • Ginko Biloba ???? Also for patients with mild cognitive impairment. 40 mg three times a day. Careful with interactions • Selegiline 5 mg twice a day • Reality Orientation

  19. Alzheimer’s DementiaOther treatments “unlikely to be beneficial” • Estrogen---”should not be used” (AAN) • Aspirin---”unknown” • Vitamin E---some groups use it--2.000 units per day, in combination with Donepezil

  20. Alzheimer’s Dementia2. Depression • Present in about 20 to 30 % of patients • Difficult to diagnose ! • All antidepressants may work---SSRI’s should be tried first---Citalopram especially, Venlafaxine and others are OK • Start low, but full doses often needed • Treatment can have a big impact on Quality of Life

  21. Alzheimer’s Dementia3. Delusions • False, “unbreakable” ideas • May occur in any stage • Not confabulations • Very amenable to treatment a) Medications-----Risperidone * Olanzapine, Quetiapine b) Reassurance, benign disinterest

  22. Alzheimer’s Dementia4. Hallucinations • Relatively rare • Not illusions • If present and strong, often times unresponsive • Antipsychotics-----Risperidone Olanzapine and Quetiapine • Low doses and short term !

  23. Alzheimer’s Dementia5. Dangerous, careless behaviors • Driving, handling equipment, wandering • Wandering promotes institutionalization • Anxiolytics (Lorazepam) or antipsychotics (Risperidone) • ? Daily vigorous exercise • ? Badges, armbands

  24. Alzheimer’s Dementia6. Restlessness, agitation, hostility • The most frequent behavioral problems that the psychiatrist is consulted for • r/o medical reasons • Reality orientation, creativeness, humanness • Medications---”trial and error”, avoid “prn’s”, start with low doses • Multiple classes of medications (cont.)

  25. Alzheimer’s Dementia6. Restlessness, agitation, hostility • Price is paid in side effects • Consider hospitalization • Geropsych unit • As disease gets more advanced, behavior problems diminish

  26. Alzheimer’s Dementia7. Overelated, intrusive behavior • History of bipolarity is frequent • Neuroleptics (Risperidone) and Benzodiazepines (Lorazepam) • Maybe even mood stabilizers (Lithium, Valproate, Trileptal)

  27. Alzheimer’s Dementia8. Insomnia and daytime somnolence • Usually difficult to treat • ? Medical causes • May use medications * Aspirin, Tylenol, Benadryl *Trazodone *Chloral Hydrate * Temazepam • Chronic severe insomnia is major problem

  28. Alzheimer’s Dementia9. Repetitive screaming and crying out • Difficult to treat • Try non-medical options first----isolation, activity, one to one, soothing music • Medication---trial and error---multiple classes

  29. Alzheimer’s Dementia10. Inappropriate sexual behavior • Most often in men • Behavioral techniques---privacy v.s. limit-setting • Hormonal therapy---medroxyprogesterone injections

  30. Alzheimer’s Dementia11. General regression and refusal to eat • Often times these patients seem to be in no distress • ? Stimulants (Pemoline, MPH) ? Nutritional supplements • Trying too hard may make matters worse • Avoid tube feeding

  31. Alzheimer’s DementiaBehavioral Modification • To reduce urinary incontinence • To increase functional independence • To decrease problem behaviors • For eating and activities of daily living

  32. Alzheimer’s DementiaMedical-Legal Issues • CELA---Certified Elder Law Attorney • The 4 basic documents *Living Will *Durable Power of Attorney for Health Care *Durable Financial Power of Attorney *Last Will

  33. Alzheimer’s DementiaImpact on Caregivers • Women are 81% of caregivers • 20% of caregivers stop working • 69-100 hours/week spent in care giving • Caregivers are more likely to make more physician visits, take more medication, have a higher incidence of depression, more likely to be hospitalized

  34. Alzheimer’s DementiaImpact on Caregivers • Education programs for family caregivers (short term and long term) • Education for staff in long term care facilities • Support groups • Respite

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