Alzheimer
Alzheimer’s Disease
HEAL 3600:003
Prevention and Control of Disease
Fall, 2017
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# 7 World # 6 U.S.
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Alzheimer’s Disease Defined
Characterized by beta-amyloid deposits and neurofibrillary tangles in the cerebral cortex and subcortical gray matter.
Progressive form of pre-senile dementia
Except it usually starts in the 40s or 50s
Accounts for 60 - 80% dementias in the elderly.
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Alzheimer’s Disease
Neurocognitive disorder
Causes progressive cognitive deterioration
Most common cause of dementia
Dementia is the loss of cognitive functioning
Thinking, remembering, reasoning, and behavioral abilities to such an extent that it interferes with a person’s daily life and activities.
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Dementia is chronic, global, usually irreversible deterioration of cognition
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Etiology of Alzheimer’s
Cause, Causation
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Alzheimer’s Cause
Most cases are sporadic with late onset (≥ 65 yr) and unclear etiology
Risk of developing the disease is best predicted by age.
5 to 15% of cases are familial
half of these cases have an early (presenile) onset (< 65 yr) and are typically related to specific genetic mutations.
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Alzheimer’s Cause
Early-onset Alzheimer’s disease
Has a genetic component
Late-onset Alzheimer's
Arises from complex series of brain changes occurring over decades
The causes probably include a combination of genetic, environmental, and lifestyle factors.
The importance of these factors in increasing or decreasing the risk of developing Alzheimer’s differ from person to person.
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Genetics
At least 5 distinct genetic loci, located on chromosomes 1, 12, 14, 19, and 21, influence initiation and progression of Alzheimer disease.
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Alzheimer’s Cause
Early Onset
Mid 30s to mid 60s
10% of all people with Alzheimer’s
Some inherited changes in 1 of 3 genes
Early-Onset familial Alzheimer’s disease (FAD)
Most people with Down Syndrome develop Alzheimer’s
Chromosome 21,- contains gene that generates harmful amyloid.
Late Onset
Mid 60s – symptoms apparent
90 – 95 % of all people with Alzheimer’s
Complex series of brain changes that occur over decades
Apolipoprotein E (APOE) gene is involved
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Alzheimer’s Ongoing Research
Relationship between cognitive decline and
Vascular conditions
Heart disease, Stroke, and High blood pressure
Metabolic conditions
Diabetes and obesity
Ongoing research will help us understand whether and how reducing risk factors for these conditions may also reduce the risk of Alzheimer’s.
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Pathogenesis Of Alzheimer’s
Development of Alzheimer’. . .
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Development of Alzheimer’s
One great mystery of Alzheimer’s is why it largely strikes older adults
Normal brain aging research is shedding light
Scientists are learning how age-related changes in the brain may harm neurons and contribute to Alzheimer’s damage.
Age-related changes
Atrophy (shrinking) of certain parts of the brain
Inflammation, production of unstable molecules called free radicals,
Mitochondrial dysfunction (a breakdown of energy production within a cell)
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Signs of Dementia
Early Dementia
Recent memory is impaired; learning and retaining new information become difficult.
Language problems (especially with word finding)
Progressive difficulty with independent daily activities (eg, balancing checkbook, finding way around, remembering where they put things).
Development of Alzheimer’s. . .
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Development of Alzheimer’s. . .
Loss of short-term memory (eg, asking repetitive questions, frequently misplacing objects or forgetting appointments)
Other cognitive deficits involving multiple functions-
Impaired reasoning, difficulty handling complex tasks, and poor judgment (eg, being unable to manage bank account, making poor financial decisions)
Language dysfunction (eg, difficulty thinking of common words, errors speaking and/or writing)
Visuospatial dysfunction (eg, inability to recognize faces or common objects)
Behavior disorders (eg, wandering, agitation, yelling, persecutory ideation) are common.
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The disease progresses gradually but may plateau for periods of time.
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Development of Alzheimer’s. . .
Signs of Dementia
Intermediate Dementia
Memory of remote events is reduced not totally lost. Patients require help with basic activities of daily living (eg, bathing, eating, dressing, toileting).
Personality changes- Patients become irritable, anxious, self-centered, inflexible, or angry more easily, or they may become more passive, with a flat affect, depression, indecisiveness, lack of spontaneity, or general withdrawal from social situations.
Behavior disorders - Patients wander or become suddenly and inappropriately agitated, hostile, uncooperative, or physically aggressive.
Late/Severe Dementia
End-stage dementia results in coma and death, usually due to infection.
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3 Minute Activity
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Diagnosing Alzheimer’s
History and physical examination
Formal mental status examination
Psychiatric examination / Mood assessment
Neuropsychological tests
(MMSE) Mini-mental state exam
(Cog Test) Cognitive impairment screen
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3 Min cog test
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Diagnosing Alzheimer’s
Laboratory testing
By ruling out all else
Minerals or chemicals in the blood,
Liver disease
Abnormal thyroid levels
Nutritional problems- folate or vitamin B12 deficiencies
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Diagnosing Alzheimer’s
Neuroimaging – Brain Scans
MRI, CT Scans
Autopsy
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The results show that the accuracy of brain imaging must be improved before it can be rolled out on a scale that could be useful to healthcare providers and patients. Image is for illustrative purposes only. Credit: NIH.
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Prevention of Alzheimer’s
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Preventing Alzheimer's Disease
Initial, observational evidence suggests that risk of Alzheimer disease may be decreased by --
Continuing to do challenging mental activities
(learning new skills, doing crossword puzzles) well into old age
Exercising
Controlling hypertension
Lowering cholesterol levels
Consuming diet rich in omega-3 fatty acids and low in saturated fats
Drinking alcohol in modest amounts
There is no convincing evidence that people who DO NOT drink alcohol should start drinking to prevent Alzheimer disease.
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Health, Environmental, & Lifestyle Factors
Mentally stimulating pursuits
- all been associated with helping people stay healthy as they age
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Nutrition – Prevent and delay any health issues
Physical – exercise helps them feel better, toilet habits, sleep habits,
-- 10 minute intervals
Social --
Mental
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Health, Environmental, & Lifestyle Factors
Nutritious diet
Healthy Weight
Prevent other complications
Diabetes, etc
Added stress to take medications
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Health, Environmental, & Lifestyle Factors
Physical Activity
Feel better, toilet habits, sleep habits, health weight
Water exercise
Music & Simple Dance
10 minute intervals – ‘mini-workouts’
Water and Juice
Issues
Depression
House chores
Soreness, Illness
Community garden, choral groups, volunteering
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Sweeping,
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Health, Environmental, & Lifestyle Factors
Social Engagement
Help improve
Thinking abilities, improve mood
Join senior Center
Try different Restaurants
Hobbies
Learn something new
Volunteer with disabled persons
Cooking class
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Health, Environmental, & Lifestyle Factors
Mentally Stimulating Pursuits
Research has found that keeping brain active seems to increase its vitality and may build its reserves of brain cells and connections
Low education levels have been related to higher risk of Alzheimer’s later in life.
This may be due to a lower level of life-long mental stimulation
Possibly because brain cells and their connections are stronger
Read & Write
Attend plays
Play games
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Health, Environmental, & Lifestyle Factors
On going research
Mentally stimulating pursuits
- all been associated with helping people stay healthy as they age
These factors might reduce risk of cognitive decline and Alzheimer’s disease
Clinical trials are testing some of these possibilities.
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Nutrition – Prevent and delay any health issues
Physical – exercise helps them feel better, toilet habits, sleep habits,
-- 10 minute intervals
Social --
Mental
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Controlling Alzheimer’s
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Treating Alzheimer’s
High-dose vitamin E (1000 IU po once/day )
Selegiline
NSAIDs
Ginkgo biloba extracts and
Statins
Estrogen therapy does not appear useful in prevention or treatment and may be harmful.
Efficacy is unclear for all above
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Alzheimer’s Treatment
Memantine – Cognition enhancing med
Appears to improve cognition and functional capacity of patients with moderate to severe Alzheimer’s disease
Cholinesterase inhibitors – blocks breakdown of acetylcholine
Modestly improve cognitive function and memory in some patients
Treatment should be continued if functional improvement is apparent after several months, but otherwise it should be stopped
Most common adverse effects are GI (eg, nausea, diarrhea).
Rarely, dizziness and cardiac arrhythmias occur
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Memantine, an N-methyl-d-aspartate receptor antagonist,
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Treating Alzheimer’s
Safety and supportive measures
Bright environment, cheerful, and familiar, should be designed to reinforce orientation
placement of large clocks and calendars in the room
Measures to ensure patient safety
signal monitoring systems for patients who wander should be implemented
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Alzheimer disease Statistics
The most common cause of dementia
Accounts for 60 - 80% of dementias in the elderly
In the US, an estimated 13% of people ≥ 65 and 45% of people ≥ 85 have Alzheimer disease
Twice as common among women as among men
Partly because women have a longer life expectancy.
Prevalence in industrialized countries is expected to increase as the proportion of the elderly increases.
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Recap
Impaired memory
Impaired thought and speech
Finally complete helplessness
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Resources
Alzheimer’s Disease – Merck Manual
http://www.merckmanuals.com/professional/SearchResults?query=ALZHEIMER
NIH Fact Sheet- https://www.nia.nih.gov/health/alzheimers-disease-fact-sheet
Stay Mentally Active http://www.alz.org/we_can_help_stay_mentally_active.asp
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