Is It Normal Aging or Is It Alzheimer Disease

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					    Is It Normal Aging
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


















    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
• 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
• 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
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
              –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
  – 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
       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

                     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

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,
  10 Warning Signs of Dementia
• New problems with words in speaking/writing
• Misplacing things and losing ability to retrace
• Decreased or poor judgment
• Withdrawal from work or social activities
• Changes in mood and personality

Source: The Alzheimer‟s Association,
Mild Cognitive Impairment(MCI)
• A theoretical construct not yet a true diagnosis
• Middle ground between normal aging changes
  and dementia… 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
• 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
• 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
• 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,
• Alzheimer‟s Disease Education and Referral
  Center (ADEAR)
• National Institute on Aging,
• 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
Is It Alzheimer‟s Disease?

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