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Normal Aging, Brain Injury and Alzheimer’s Disease. Annual Conference for Professionals in Brain Injury April 11, 2013. Presenters. Jean Wood, Minnesota Board on Aging Mark Kinde, Minnesota Department of Health Michelle Barclay, Alzheimer’s Association. Overview of Session.

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normal aging brain injury and alzheimer s disease

Normal Aging, Brain Injury and Alzheimer’s Disease

Annual Conference for Professionals in Brain Injury

April 11, 2013

  • Jean Wood, Minnesota Board on Aging
  • Mark Kinde, Minnesota Department of Health
  • Michelle Barclay, Alzheimer’s Association
overview of session
Overview of Session
  • Normal brain changes with age
  • Brain injuries in older adults
    • Prevalence, causes and comorbidities
  • Alzheimer’s Disease and other dementias
    • Prevalence, identification and management
  • Falls prevention to reduce risk for brain injury
    • community interventions
demographics of aging
Demographics of Aging
  • The baby boomers started turning 60 in 2006.
  • According to the 2010 Census -

In 2010, there were 683,000 Minnesotans age 65 and older.

in 2030, there will be 1.3 million Minnesotans age 65 and older.

  • The 85+ population is the fastest growing.
normal brain changes with aging
Normal Brain Changes with Aging
  • Brain and spinal cord lose nerve cells and weight.
  • Nerve cells may transmit messages more slowly.
  • Reduced or lost reflexes or sensation may occur in some people.
  • Some slight slowing of thought, memory and thinking is natural.
brain injury epidemiology mn
Brain Injury Epidemiology, MN
  • When & where do brain injuries happen?
  • To whom?
  • What are the leading causes?
  • What other illnesses or injuries occur in conjunction with brain injury?
  • What do we know about outcomes?
  • How much do brain injuries cost?
  • Who pays?
what about drugs alcohol
What about drugs & alcohol?


ED Treated


TBI Mortality by year, Minnesota, 55+

Centers for Disease Control and Prevention , National Center for Health Statistics. Multiple Cause of Death 1999-2010 on CDC WONDER Online Database, released 2012. Data are from the Multiple Cause of Death Files, 1999-2010, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at on Feb 13, 2013 5:58:52 PM


Dementia is a loss of mental function in two or more areas such as language, memory, or judgment severe enough to impact daily life.

Alzheimer’s disease is the most common cause of dementia.




Alzheimer’s Disease

Vascular Dementia

Dementia with Lewy bodies

Parkinson’s Dementia

Frontotemporal dementia

Corticobasal Degeneration

Progressive Supranuclear Palsy

Jakob-Creutzfeldt Disease

alzheimer s prevalence with age
Alzheimer’s Prevalence with Age

65-74 years (1.6%)

75-84 years (19%)



Hebert et al 2000

alzheimer s disease risk factors
Alzheimer’s Disease Risk Factors
  • Age
  • Family history
    • Patients with a 1st degree relative have a 10-30% increased chance of developing AD (van Duijn 1991)
  • Genetic factors
  • Mild Cognitive Impairment (MCI)
  • Vascular risk factors
  • Head injury
  • Amyloid in the brain (PET Scan)








progression of alzheimer s disease
Progression of Alzheimer’s Disease
  • Early Stage:

2 - 4 years in duration

  • Middle Stage:

2 - 10 years in duration

  • Late Stage:

1 - 3 years in duration

early stage ad
Early Stage AD
  • Symptoms Interfere with everyday functioning
    • Forgetfulness
    • Trouble with time/sequence relationships
    • More mental energy needed to process
    • Trouble multi-tasking
    • Writes reminders, but loses them
    • Personality changes
    • Shows up at the wrong time or day
    • Changes in appearance
    • Preference for familiar things
middle stage ad
Middle Stage AD
  • Fluctuating disorientation
  • Diminished insight
  • Learning new things becomes difficult
  • Restricted interest in activities
  • Declining recognition of acquaintances, distant relatives, then more sig. relationships
  • Mood and behavioral changes
  • Functional declines
  • Alterations in sleep and appetite
  • Wandering
late stage ad
Late Stage AD
  • Severe disorientation to time and place
  • No short term memory
  • Long-term memory fragments
  • Loss of speech
  • Difficulty walking
  • Loss of bladder/bowel control
  • No longer recognizes family members
  • Inability to survive without total care
alzheimer s disease course prevention treatment strategies
Alzheimer’s Disease:Course, Prevention, Treatment Strategies


Primary Prevention

Secondary Prevention



Mild Cognitive Impairment


Pre-symptomatic AD



10 to 15 mil

Numbers of people


20 to 60 mil

Mild, moderate or severe impairment

AD brain changes

Mild symptoms


Early AD brain


No symptoms

No disease

No symptoms

Treat cognition

Treat behaviors

Slow progression

Prevent or delay emergence of symptoms

Stimulate memory

Slow progression

Identify at-risk

Prevent AD




Nearly 90,000 Minnesotans

have Alzheimer’s disease.

5.4 million Americans have the disease.

number of people over 65 with ad in mn
Number of people over 65 with AD in MN

Alzheimer’s Association Facts & Figures Report 2012


Alzheimer’s disease is the

sixth leading cause of death

in the United States.

AD is the fifth leading cause of death for those aged 65 and older.

change in leading causes of death 2000 2008
% change in leading causes of death: 2000 - 2008

Alzheimer’s Association Facts & Figures Report 2012


Nearly 240,000 Minnesotans are caregivers for someone with Alzheimer’s disease.

Seventy percent of people with Alzheimer’s disease live at home.

economic value of caregiving in mn
Economic Value of Caregiving in MN

Alzheimer’s Association Facts & Figures Report 2011

age of alzheimer s family caregivers
Age of Alzheimer’s Family Caregivers

*Average age = 52 years

Alzheimer’s Association Facts & Figures Report 2012

impact on the caregiver s health
Impact on the Caregiver’s Health
  • 33% of Alzheimer’s family caregivers have symptoms of depression
  • Alzheimer’s family caregivers are more likely than non-caregivers to:
    • Report that their health is fair to poor.
    • Have high levels of stress hormones, reduced immune function, slow wound healing, new hypertension and new coronary heart disease.

People with Alzheimer’s disease are high users of healthcareand long-term care services.

Total cost was three times higher for Medicare beneficiaries age 65+ with AD in 2004.

Average Medicare payments per person for beneficiaries age 65+ with and without ADRDs in 2008 (2011 dollars)

Alzheimer’s Association Facts & Figures Report 2012


Current data suggests that less than 35% of people with Alzheimer’s and other dementias have a diagnosis of the condition in their medical record.

Boise et al., 2004, Boustani et al., 2005, Ganguli et al., 2004, Valcour et al., 2000

Impact of Co-Existing Medical Conditions:Percentage of Medicare beneficiaries 65+ with ADRD and a co-existing medical condition in 2009

Alzheimer’s Association Facts & Figures Report 2012

benefits of early identification
Benefits of Early Identification
  • Rule out other causes of cognitive impairment
  • Start treatment early
  • Better manage co-existing conditions
  • Understand the symptoms and how to manage them
  • Make decisions and future plans
  • Build a support system
  • Lower anxiety
  • Avoid crisis-driven care
  • Participate in clinical trials or other research
provider practice tools
Provider Practice Tools

Cognitive Impairment ID Flow Chart

Dementia Work-Up / Provider Checklist

Intervention Checklist

early intervention
Early Intervention
  • Goal 1: Educate about medications
  • Goal 2: Reduce excess disability
    • Treat conditions that worsen symptoms or lead to poor outcomes (depression, uncontrolled diabetes or blood pressure, etc.)
    • Make safety part of the plan
  • Goal 3: Educate about the disease, common pitfalls, and actions that lead to success
    • Taking Action Workbook
  • Goal 4: Encourage lifestyle changes that may reduce disease symptoms or slow symptom progression
    • Living Well Workbook
medical interventions cognitive behavioral symptoms
Medical Interventions: Cognitive & Behavioral Symptoms
  • Cholinesterase Inhibitors (early- late) - Cognex®, Aricept®/ Donepezil, Exelon®, Razadyne®
    • Side Effects: nausea, vomiting, increased bowel frequency
  • Glutomate blocker (NMDA receptor antagonist: mid/late) - Namenda®
  • Goal: to maintain function and reduce impact of symptoms
medical treatment co morbid conditions and behavioral symptoms
Medical Treatment – Co-morbid Conditions and Behavioral Symptoms
  • Co-morbid medical conditions
    • Diabetes, cholesterol, blood pressure, sleep dysregulation
  • Psychiatric / Behavioral Symptoms
    • Depression
    • Anxiety
    • Aggression / Agitation
    • Hyper-sexuality
reducing excess disability
Reducing Excess Disability
  • Treat conditions that worsen symptoms or lead to poor outcomes
    • Depression
    • Co-existing medical conditions (diabetes, blood pressure, sleep dysregulation)
    • Stop smoking, limit alcohol
  • Address Safety Issues
    • Medication management
    • Fall risk
    • Home modification / simplification
    • Driving assessment
    • Gun safety
    • Financial safety
    • Medical emergency
    • Employment Issues, when applicable

Current Services in Minnesota

Early Stage

* limited availability


Current Services in Minnesota

Middle Stage

* limited availability


Current Services in Minnesota

Late Stage

* limited availability


Minnesota Resources

Telephone / Internet Resources

falls in older adults
Falls in Older Adults
  • Falls are the leading cause of injury for children and for adults 35-years and older.
  • Falls and fall-related injuries among adults over age 65 are on the rise.
  • MN ranks 5th among states in number of fall-related deaths.
proven steps to reduce fall risk
Proven Steps to Reduce Fall Risk
  • Ask fall risk screening questions of the adults you work with.
  • Refer individuals at risk for falls to their physician for a comprehensive assessment.
  • Know your community resources. Connect individuals to the resources that can help them take steps to reduce their risks.

contact information
Contact Information

Jean Wood, Minnesota Board on Aging


Mark Kinde, Minnesota Department of Health


Michelle Barclay, Alzheimer’s Association