Is It Normal Aging or Is It Alzheimer‟s Disease? “Man fools himself. He prays for a long life, yet he fears an old age.” Chinese Proverb Human Life Expectancy At Birth Adapted from: Hayflick L. How and Why We Age. 1994 Life Expectancy Through the Ages 90 80 70 60 50 40 30 20 10 0 0 0 0 0 D 00 00 00 00 00 00 20 40 60 80 A 10 12 14 16 18 20 Life Expectancy at Age 65 • 1965…….5 years • <10 million Medicare beneficiaries • 2005…….20 years • 40 million Medicare beneficiaries • Worldwide over 1/2 of all humans who have ever lived to age 65 are alive today! The Near Future • January 1 2011: first “Boomers” turn 65 • First “Boomers” hit age 85 beginning in 2031 • By 2030 1 in 5 Americans will be >65 • By 2030 those >85 will be nearly 9 million • By 2050 estimated to be nearly 1 million >100 • Today 96,500 persons are >100 years Senile • The USA is rapidly becoming “geriatric” • Latin root, “sen” in “senile” means “pertaining to old age,” not demented! • Gerontology is the study of aging • Geriatrics is the medical care of the aged The New “Age Wave” • 5.3 million persons today have dementia and this number could triple by 2050 • Death rates for heart disease, stroke and cancer are declining…….death rates for dementia are rising! • Dementia is currently the 5-6th leading cause of death and rising quickly Dementia • 60-80% of long stay nursing home residents • Nearly 2/3 of Assisted Living residents • Estimated ½ million Americans have early onset Alzheimer‟s Disease….defined as <65 • Only half of all dementia has been diagnosed and only half of those receive any current treatment Normal Aging or Age Associated Disease? • Osteoarthritis • Osteoporosis • Diabetes mellitus • Atherosclerosis • Hypertension • Alzheimer‟s Commonly Asked Questions • Is memory loss a natural part of ageing? • Why can‟t I remember as well as my wife? • Is it normal to write notes to myself? • Why can‟t I remember names? • Is it normal to forget why I went into the kitchen? • Sometimes my mind just goes blank, normal? • Can I slow age related memory changes? Brain Changes with Aging • Brain weight declines by 10% by age 80 – Normal brain weighs 3lbs at age 20 • Blood flow to the brain declines • Declines in speed of nerve conduction • Loss of neurons occurs throughout life • Brain has huge reserve capacity Brain changes with Aging • Brain weight declines by 10% by age 80 – Normal brain weighs 3lbs at age 20 • Blood flow to the brain declines • Declines in speed of nerve conduction • Loss of neurons occurs throughout life – New networks of nerves created even in late life • Brain has huge reserve capacity Memory Changes with Age • Information processing: – Encoding new information • Reduced efficiency and speed with aging • Short term memory declines – Storage and retrieval • Recall slows with age • Recognition changes little Memory Changes with Age • Consistent theme: – Speed of performance slows with aging – “Less bandwidth” • Fear of memory loss increases – Complaints of nonspecific memory losses – Depression , alcohol and illness can adversely affect memory Memory Changes with Age • Long term memory should not decline – Crystallized memory does not change – Any declines likely represents difficulty in processing new information Memory Changes with Age • Intelligence should not decline with age – Speed of processing information declines – Complex ideas are more affected than simple ones – Ability to perform under stress declines – Prior experiences may aid considerably Aging Changes in Cognition Reading Least change Vocabulary Long term factual memory Immediate memory span Sustained attention Serial(practice-related) learning Delayed recall Motor speed Visuo-spatial skills Most change What Can Worsen Memory? • Any drug that affects the brain: – Sleeping pills, pain pills, antihistamines, incontinence meds, tranquilizers, alcohol, etc • Undiagnosed depression • Fatigue, stress, anxiety • Acute illness with Delirium(Acute confusion) • Stroke…most “TIAs” are really small strokes What Can Worsen Memory? • Extensive white matter changes on Head CT scan….likely quite significant and probably not normal aging – Still somewhat controversial Commonly Asked Questions • What„s the difference between Alzheimer‟s and dementia? – Is it normal and expected with age? • What causes Alzheimer‟s? • Why do we hear so much about it now? • Can we postpone or avoid Alzheimer‟s? Dementia Facts • A very common problem in US: – 1 in 10 persons have a relative in the family – 1 in 4 knows someone who has the disease – Diagnosed every 70 sec in the US Source: Alzheimer‟s Association Alzheimer‟s and Dementia • 60% of all dementias in US are probably related to Alzheimer‟s Disease • One can have Alzheimer‟s Disease and not be demented….yet • Dementia is a diagnosis not a disease The Diagnosis of Dementia – Memory impairment: • Inability to learn new information • Memory abilities that decline from a prior baseline –Education, high intelligence, cultural factors, Source: Diagnostic and Statistical Manual of Mental Disorders. DSM-IV The Diagnosis of Dementia – At least one of the following deficits • Language difficulties (aphasia) • Difficulty with common tasks (apraxia) • Unable to identify common objects (agnosia) • Disturbance in executive functioning –Planning, judgment, decision making Source: Diagnostic and Statistical Manual of Mental Disorders. DSM-IV The Diagnosis of Dementia • A disease course that is progressive • Cognitive problems sufficient to impair a person‟s ability to keep a job, live independently or represents a significant decline from previous level of functioning • No other illness or systemic condition is responsible for cognitive decline Source: Diagnostic and Statistical Manual of Mental Disorders. DSM-IV Diagnosis of Dementia: Testing • History that is consistent • Physical exam that rules out significant neurologic or other disease • Evaluation of mental status – Mini-mental status exam(30 pt screening test) – Clock drawing test, current events, serial 7‟s – Formal neuropsychologic testing Diagnosis of Dementia: Testing • Laboratory testing – Excludes other possible causes of memory loss • Radiology is optional – Head CT or MRI, & rarely PET scanning • The diagnosis is correctly made 85-90% of the time: – Sometimes serial testing is required When is it Alzheimer‟s? HDefinite: typical clinical history and tissue confirmation(biopsy or autopsy) HProbable: typical clinical history, insidious onset, progressive course,and no other obvious cause of dementia HPossible: patients with a second systemic or brain disorder sufficient to cause dementia but not thought to be the primary cause You Know it‟s Alzheimer‟s When... • Insidious onset • Loss of memory is a prominent feature • No disturbance of consciousness • No other disease or manifestation exists that could explain cognitive and functional decline First Symptom Noticed • Trouble remembering 46% new information • Difficulty with 27% complicated tasks • Trouble responding 14% to problems • Frequently getting lost 18% or trouble staying oriented First Symptom Noticed • Trouble expressing 21% thoughts ideas, or following conversations • Change in personality 25% or behavior CHS Alzheimer‟s Disease Caregiver Project: Wave 6, 2000 Alzheimer‟s Disease • First described by Alois Alzheimer in 1906 • Initially termed pre-senile dementia • A.D. is not “hardening of the arteries” • Awareness is greatly increased due to the greater numbers of persons allowed to age Alzheimer‟s Dementia Facts • Life expectancy: 3 to 20 years after diagnosis • Average is about 8 years • Dementia affects 6-8% of all those over 65 – Incidence doubles every 5 years >60 – Estimated 1/3 of those 85 years or over – 47% of >85yo have Alzheimer‟s pathology in their brains at autopsy Alzheimer‟s Facts • No single test exists to make the diagnosis • Plaques and tangles are the lesions seen in the brain at autopsy • Certain areas of the brain are more affected than others (hippocampus for example) • Marked decline in acetylcholine in the brain (neurotransmitter), high levels of amyloid Progression of Alzheimer‟s Disease 30 25 Symptoms 20 Diagnosis MMSE Scores 15 Loss of independence 10 Behavioral problems 5 Nursing home placement 0 Death 0 1 2 3 4 5 6 7 8 9 10 Time(years) Feldman H and Gracon S in Clinical Diagnosis and Management of Alzheimer‟s Disease 1996 Stages of Alzheimer‟s Dementia • Early (2-4years) – Often not recognized by friends and family – Repeat themselves – Frequently misplace items – Gets lost easily – Personality changes; passivity and withdrawal – Word finding problems begin – Lose interest in previously enjoyable activities Stages of Alzheimer‟s Dementia • Middle or moderate stage(2-10 years) – Usually obvious to family and others – Wandering, pacing, disruptive behaviors – Delusions(often paranoid) and hallucinations – Require constant supervision – Sleep cycles disturbed – Sun downing and radical mood swings common – Require help with basic care activities Stages of Alzheimer‟s Dementia • Late stage(1-3years) – Little or no self care abilities – Cannot speak or understand language – Bedbound, chair bound, unable to walk – Cannot recognize even closest relatives – Difficulty swallowing, pneumonia is common – Brain loses the ability to control the body FDA Approved Treatments • Acetyl cholinesterase inhibitors – Aricept, Exelon, Exelon Patch, Razadyne • NMDA receptor inhibitor – Namenda Other Causes of Dementia • Mixed Alzheimer‟s and vascular disease • Lewy body disease • Fronto-temporal dementia(Pick‟s Disease) • Parkinson‟s disease • Pure multi-infarct disease • HIV disease • Many, many more! 10 Warning Signs of Dementia • Memory changes that disrupt daily life • Challenges in planning or solving problems • Difficulty completing familiar tasks • Confusion with time or place • Trouble understanding visual images and spatial relationships Source: The Alzheimer‟s Association, www.alz.org 10 Warning Signs of Dementia • New problems with words in speaking/writing • Misplacing things and losing ability to retrace steps • Decreased or poor judgment • Withdrawal from work or social activities • Changes in mood and personality Source: The Alzheimer‟s Association, www.alz.org Mild Cognitive Impairment(MCI) • A theoretical construct not yet a true diagnosis • Middle ground between normal aging changes and dementia…..is it a forerunner to A.D.? • Memory loss without deficits in other domains and no overt functional impairment – Approximately 12% of MCI patients convert to dementia per year Depression and Memory Losses • Depressive symptoms can mimic symptoms of dementia • Depression can worsen symptoms of normal aging • Depression is more common with older age – Quite common at the time of diagnosis of dementia Memory Changes with Age • Mental function decline is the most feared aspect of aging – Threatens independence, loss of self • Fear of inevitable incompetence is groundless – All functions do not decline with age – Ability to learn new information continues – The majority of older persons do not become demented Dementia • Common diagnosis • Wide variability in how dementia looks • A general lack of public understanding on what is and isn‟t dementia • Denial is common in families Dementia • Can present <65 but far more common with advanced age • Neuropsychologic testing and a good history are often necessary, especially in guardianship cases Selected Resources • Alzheimer‟s Association, www.alz.org • Alzheimer‟s Disease Education and Referral Center (ADEAR) www.alzheimers.org • National Institute on Aging, www.nia.nih.gov • Keeping Your Brain Young, McKhann and Albert. 2002 • The 36 Hour Day, Mace and Rabins (behaviors) • Aging with Grace, Snowden, D. 2001 Is It Normal Aging or Is It Alzheimer‟s Disease?
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