Objectives. Aging and Forgetfulness Define Dementia Types of Dementia Treatment

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1 Dementia David Lam, MD, FRCPC, Psychiatry Assistant Clinical Professor Department of Psychiatry and Behavioural Neurosciences McMaster University Hamilton, Ontario

2 Objectives Aging and Forgetfulness Define Dementia Types of Dementia Treatment

3 Aging and Forgetfulness Memory loss is not a normal part of aging Most people remain alert as they age Benign senescent forgetfulness memory loss + other changes in mental powers = dementia Mild cognitive impairment (MCI)

4 Definition of Dementia Latin word Demens Not a disease Umbrella term to describe a group of symptoms Loss of recent memory and other mental abilities which interfere with daily life

5 Definition of Dementia Gradual memory loss Learning problems Problem with daily tasks Confusion Loss of language skills Reasoning and judgement Personality change Behavioural problems

6 Dementia - Epidemiology The 65 and older segment of the Canadian population is quickly growing. The fastest growth is in the 85+ category. By 2021, seniors will constitute about 18% of the Canadian population, projected to be ~ 7 million people. Health Canada. Canada s Aging Population

7 Dementia - Epidemiology Incidence of dementia with age, it doubles every 5 years after age 60. Canadian Study on Health and Aging (CSHA) = Canadians with dementia =

8 Dementia - Epidemiology new cases of AD in 2001, > ½ were women. By 2011, > new cases of AD per year. By 2031, >3/4 million Canadians will be diagnosed with AD or another dementia.

9 Types of Dementia Alzheimer s Disease (AD) Vascular Dementia (VaD) Lewy Body Dementia (LBD) Frontotemporal Dementia (FTD)

10 Alzheimer s Disease Most common form of dementia ~ % First described by Dr. Alois Alzheimer Patient was Auguste D. 51 y.o. woman Decline in mental functions Delusions Hallucinations

11 Alzheimer s Disease Exact cause still unknown Hallmarks of the disease Amyloid plaques Neurofibrillary tangles Brain cells shrink A decrease in brain size A decrease in brain chemicals Inflammation reaction occurs in the brain. To protect the brain - cytokines are released. As brain cells become more impaired, levels of these protective substances increase to toxic levels and damages the brain more than it protects.

12 Alzheimer s Disease Confirmed risk factors: Old age Family history of dementia Risk of developing AD 2-3x if a parent or a sibling has AD. History of vascular disorder ApoE-e4 gene (abnormal genetic variation)

13 Alzheimer s Disease The disease process begins slowly Memory loss Language problems (aphasia) Problems with identifying and recognizing things (agnosia) Problems with activities and coordination (apraxia) Problems with complicated functions (executive functioning)

14 Alzheimer s Disease Mild Problems with: Balancing a cheque book Preparing a complex meal Managing a difficult medication schedule Forgetting appointments Driving

15 Alzheimer s Disease Moderate Problems with: Simple food preparation House hold clean up, yard work (difficulty using common items) Forgetful of personal history (children s names) Personality changes Trouble with directions (can t find their way home) Some aspects of self care

16 Alzheimer s Disease Severe Problems with: Personal care, feeding, grooming, toileting Problems with communicating to others and understanding May have troubles with movement Unable to recognize family Requires regular supervision or care

17 Alzheimer s Disease Profound Largely oblivious to their surroundings Totally dependent on caregivers

18 Alzheimer s Disease Generally bed bound Terminal Require constant care Susceptible to accidents and infectious diseases, such as pneumonia, which often will lead to death

19 Alzheimer s Disease Typical course of Alzheimer's Disease MMSE Score MCI Mild Moderate Severe Alzheimer's Disease The average survival ~ 8 10 years after symptoms start. Years Adapted from Feldman et al., Clinical Diagnosis and Management of Alzheimer s Disease, 1991

20 Lewy Body Dementia May account for 5-10 % and possibly as much as 25 % of dementias Abnormal deposits in the brain, Lewy bodies It shares features of AD and Parkinson s disease Delusions and hallucinations Sensitive to neuroleptic medications

21 Vascular Dementia Third most common form of dementia ~ % Usually affects people between 60 and 75 Occurs in men > women It is caused by a series of strokes in the brain Strokes are due to blocked or burst blood vessels in the brain

22 Vascular Dementia Risk Factors for Stroke High blood pressure Diabetes High cholesterol Heart disease/abnormal heart rhythms

23 Vascular Dementia Symptoms usually occur quickly Symptoms progress in a step-wise pattern Presentation depends on what area of the brain is affected: Confusion/memory loss Abnormal movements/gait/coordination Language problems Inappropriate emotions

24 Vascular Dementia Transient Ischemic Attacks (TIAs) TIAs increase the risk of suffering a stroke VaD is diagnosed through a neurological examination and brain scanning investigations VaD and AD can occur together

25 Frontotemporal Dementia Broad spectrum of disorders, Pick s disease, behavioural variant, Progressive non-fluent aphasia, semantic dementia. Frontal and temporal lobes affected. Symptoms begin gradually and progress slowly. Age of onset between 40 and 60. Usually see behavioural changes first. Disinhibition, impulsivity, impaired social awareness, decline in personal hygiene, and repetitiveness. May also see apathetic type.

26 Treatment Assess for medical and reversible causes Psychosocial and behavioral interventions: Educate patient and family Ensure patient safety, such as driving Address legal issues - POA Regular health monitoring Medications

27 Treatment Medications used to treat mild to moderate cases of AD Acetylcholinesterase inhibitors Prevents breakdown of acetylcholine (Ach) Ach important in mental abilities Medications do not stop AD Medications act to slow the progression Tacrine (Cognex)

28 Donepezil (Aricept) Acetylcholinesterase inhibitor. Once daily dosing. Initiated at 5 mg/day and then increased to 10 mg/day after 4-6 weeks. Clinical trials indicated that the 10 mg/day dose was more effective than the 5 mg/day dose.

29 Rivastigmine (Exelon) Acetylcholinesterase and butyrylcholinesterase inhibitor. Twice daily dosing. Initiate at 1.5 mg bid. It may be increased after 4-6 weeks to 3 mg bid. Subsequently, every 4-6 weeks can be increased to 4.5 mg bid and 6 mg bid. Again, better effects at higher doses but more side effects. Patch 5 and 10. Good kidneys.

30 Galantamine (Reminyl) ER Acetylcholinesterase inhibitor and nicotinic receptor modulator via allosteric potentiation, which enhances cholinergic transmission. Razadyne in the U.S. Starting dose is 8 mg daily. The dosage may be increased to 16 mg daily in 4 weeks, and then 24 mg daily after another 4 weeks.

31 Common Side-effects Nausea, vomiting, diarrhea, anorexia, muscle cramps and fatigue. Caution if there is a history of cardiac conduction defects, history of GI bleeds, asthma.

32 Memantine (Ebixa) FDA approved in October 2003 for the treatment of moderate to advance Alzheimer s disease (Ebixa/Namenda). It works differently than the other medications for Alzheimer s disease (NMDA antagonist). It involves Glutamate, its receptor (NMDA), and calcium in the brain cell. It was approved in Canada at the end of 2004.

33 Memantine (Ebixa) It is for the treatment of moderate to severe Alzheimer s disease. It is not covered by the provincial drug plan. Start at 5 mg daily, and increase by 5 mg every week. The recommended dose is 10 mg twice daily.

34 Memantine (Ebixa) It is well tolerated. Common side-effects may include: dizziness, constipation, headaches, high blood pressure, confusion (rapid ), seizures (rare). Good kidneys.

35 Antipsychotic Medications Non-cognitive symptoms of dementia can include depression, anxiety, hallucinations (hearing voices and seeing things), delusions (believing in something that is untrue), and agitation (verbal aggression, physical aggression). These symptoms can impact care. Behavioural problems are common in people with dementia (about 80%). Difficult behaviours and incontinence are the cause of most admissions to LTC.

36 Antipsychotic Medications Depression can be treated with antidepressants. Anxiety can be treated with antidepressants or benzodiazepines. Delusions and hallucinations are treated with antipsychotic medications. Agitation, particularly physical aggression, has been treated with antipsychotic medications.

37 Antipsychotic Medications All medications have potential for side-effects and adverse effects. Problems with AP medications. They have been associated with an 1.6 x increase risk for death (mainly strokes). Unclear why this may be. More research is needed. These medications are now reserved for patients who s symptoms are very disruptive and debilitating (unsafe to themselves and others). There is often no good alternatives. Keep in mind that these symptoms are also very uncomfortable to patients and can affect their physical health as well. Risk benefit analysis.

38 Take Home Points 1. Dementia is a memory problem plus other cognitive changes that affects a person s functioning that is a decline from their previous level of functioning. 2. Old age is the most consistent risk factor for developing a dementia. 3. Alzheimer s Disease is the most common type of dementia. 4. Medical, psychosocial, safety, and legal issues have to be addressed. 5. Medications available for treatment are not disease modifying.

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