Issues in Aging:Alzheimer’s Disease

What is Normal Aging?

■ Although we do experience minor changes in our memory and thinking as we age, these changes do not affect daily functioning or the ability to live independently.

■ Memory changes are a normal part of the aging process—it's common to have less recall of recent memories and to be slower remembering names and details.

!■ Alzheimer’s disease is not a normal part of aging or “just what happens when we get

old.” ■ If Alzheimer’s was part of the natural aging process, then every person over 65 years

of age would have Alzheimer’s disease.

Examples

■ A person might forget part of an experience.

!■ A person who forgets something will

eventually remember the information. !■ A person can follow instructions

without difficulty. !■ A person is able to use notes or

reminders. !■ A person can still manage their own

personal care (bathing, dressing, grooming, etc.).

!■ A person is able to manage their

finances.

■ A person with Alzheimer’s disease will forget the whole experience.

■ A person with Alzheimer’s won't recall the information at a later time.

!■ A person with Alzheimer’s disease is less

and less able to follow instructions over time. !

■ A person with Alzheimer’s gradually become less able to benefit from memory aids or forgets to use them.

!■ A person with Alzheimer’s loses the ability

to engage in these kinds of tasks. !■ A person is unable to track spending, pay

bills, manage savings/checking accounts.

Normal Aging Not Normal Aging

Brief History■ Alois Alzheimer, a German physician, is

credited with being the first to describe AD.

■ In 1906, Dr. Alzheimer observed a patient, Auguste Deter, in a local asylum who exhibited strange behaviors. He followed her care and noted her memory loss, language difficulty and confusion.

■ After her death at the age of 51 he examined her brain tissue. The slides showed what are now known as plaques and tangles that are recognized as Alzheimer’s disease.

■ In 1911, Doctors were using Dr. Alzheimer’s research to base diagnosis.

■ In the 1960’s British pathologists determined that AD was not a rare disease of the young but rather what had been termed “senility.”

■ In the 1990’s researchers identified that the beta amyloid protein was a factor in AD.

Alois Alzheimer

Auguste Deter

What is Alzheimer’s disease?

■ Alzheimer’s is a progressive, degenerative and incurable neurological brain disease that causes deterioration of brain nerve cells and ultimately death.

■ The deterioration is caused by: ■ a build up of abnormal substances called

amyloid plaques (an insoluble protein deposit);

■ And neurofibrillary tangles.

Plaques and Tangles■ Healthy neurons help guide nutrients

and molecules from the cell body to the ends of the axon and back.

!■ Plaques form when protein pieces

called beta-amyloid clump together. Beta-amyloid comes from a larger protein found in the fatty membrane surrounding nerve cells.

■ Beta-amyloid is chemically "sticky" and gradually builds up into plaques.

!■ Neurofibrillary tangles (NFTs) which are

found inside neurons, are abnormal collections of a protein called tau.

■ In AD, when NFT’s build up nutrients and other essential supplies can no longer move through the cells, which eventually die.

Source: Alzheimer’s Association: http://alz.org/alzheimers_disease_4719.asp Brain Tour

Axon – conducts nerve signal

Neuron-transmits to brain

Dendrites – signal receiver

Communication

Inside the Brain

In the Alzheimer brain: ■ The cortex shrivels up,

damaging areas involved in thinking, planning and remembering.

■ Shrinkage is especially severe in the hippocampus, an area of the cortex that plays a key role in formation of new memories.

■ Ventricles (cerebrospinal fluid-filled spaces within the brain) grow large

Source: Alzheimer’s Association: http://alz.org/alzheimers_disease_4719.asp Brain Tour

Cortex

Hippocampus

Ventricles

Source: Image from the Alzheimer’s Society of Saskatchewan with permission from Alzheimer’s Broken Brain.

Alzheimer’s Brain Normal Brain

So what is Dementia?!

■ Dementia is a set of signs and symptoms, not a disease. ■ Dementia is characterized by memory loss, changes in mood and

communication difficulties. !■ Types of diseases with the symptom of dementia are:

■ Alzheimer’s disease ■ Most common.

■ Vascular dementia ■ stroke related, 2nd most common type of dementia

■ Dementia with Lewy Body ■ Lewy bodies are deposits of a protein called alpha-synuclein that form

inside the brain’s nerve cells. Affects memory, concentration, speech. ■ Frontotemporal dementia

■ a rare disorder that affects the frontal lobes and the temporal lobes (sides) of the brain. Affects behavior, personality and memory later.

■ Wernicke-Korsakoff syndrome ■ most common cause is alcoholism, but the syndrome can also be

associated with AIDS, cancers.

Dementia…not

■ In a few cases, dementia is caused by a problem that can be treated. Once treated, the symptom of dementia often disappears. Examples include: !■ Having an underactive thyroid gland (hypothyroidism) can cause

difficulty with concentration and forgetfulness. ■ Vitamin B12 deficiency. B12 supports the function and development of

the brain, nerves, blood cells, and many other parts of the body. ■ Dehydration – severe dehydration causes confusion. ■ Malnutrition – prevents the brain from functioning properly. ■ Urinary Tract Infections – a type of infection that affects brain function. ■ In some, depression can cause memory loss; often referred to as

Pseudodementia. ■ Medications - Taking some medicines together may cause symptoms that

look like dementia. This includes prescribed, over the counter, herbals, vitamins and supplements.

Source: WebMD http://www.webmd.com/alzheimers/tc/dementia-topic-overview

Source: About.com http://alzheimers.about.com/od/diagnosisofalzheimers/a/reversible.htm

What is Mild Cognitive Impairment?

!■ Mild cognitive impairment (MCI) is a condition in which a person

has problems with memory, language, or another mental function severe enough to be noticeable to other people and to show up on tests, but not serious enough to interfere with daily life.

■ Individuals with MCI have an increased risk of developing Alzheimer’s disease over the next few years, especially when their main problem is memory.

■ Not everyone diagnosed with MCI goes on to develop Alzheimer’s.

■ There is currently no treatment for MCI approved by the FDA.

Source: Alzheimer’s Association: www.sanalz.org

Risk Factors

■ Age – Biggest risk factor ■ 10% of individuals over the age 65 will have AD. ■ After age 85, the risk reaches nearly 50 percent.

■ Family History ■ Research has shown that those who have a parent, brother or

sister with Alzheimer’s are more likely to develop Alzheimer’s. The risk increases if more than one family member has the illness.

■ Genetics – ■ Risk Genes ■ Deterministic Genes

Source: Alzheimer’s Association San Diego Chapter – www.sanalz.org

Risk Factors■ Risk Genes !

■ Risk genes increase the likelihood of developing a disease but do not guarantee it will happen. ■ APOE-e4 is one of three common forms of the APOE

(apolipoprotein) gene. ■ Everyone inherits a copy of some form of APOE from

each parent. ■ Those who inherit one copy of APOE-e4 have an

increased risk of developing Alzheimer’s. ■ Those who inherit two copies have an even higher risk,

but not a certainty. ■ In addition to raising risk, APOE-e4 may tend to make

symptoms appear at a younger age than usual.

Source: Alzheimer’s Association San Diego Chapter

Risk Factors

■ Deterministic Genes/Early Onset : ■ directly cause a disease, guaranteeing that anyone

who inherits them will develop the disorder. ■ Scientists have found rare genes that directly cause

Alzheimer’s in only a few hundred extended families worldwide.

■ This type is known as “familial Alzheimer’s disease”, and many family members in multiple generations are affected. True familial AD accounts for less than 5% of the cases.

Stages of AD

■ Mild or Early Stage ■ Friends, family or co-workers begin to notice

deficiencies. Some common difficulties include: ■ Word finding problems ■ Decreased ability to remember names ■ Performance issues in social or work settings ■ Reading a passage and retaining little material ■ Losing or misplacing a valuable object ■ Decline in ability to plan or organize

Source: National Alzheimer’s Association

Stages of AD

■ Moderate or Middle Stage ■ Major gaps in memory and deficits in cognitive function emerge. Some

assistance with day-to-day activities becomes essential. Some common difficulties include: ■ Inability to recall important details such as their current address, their

telephone number. ■ Confused about where they are or about the date, day of the week or

season. ■ Need help choosing proper clothing for the season or the occasion. ■ May have increasing episodes of urinary or fecal incontinence and need

assistance with toileting and personal care. ■ Lose most awareness of recent experiences and events as well as of their

surroundings. ■ Tend to wander and become lost. ■ Experience significant personality changes and behavioral symptoms.

■ including suspiciousness and delusions (for example, believing that their caregiver is an impostor)

■ hallucinations (seeing or hearing things that are not really there) ■ compulsive, repetitive behaviors such as hand-wringing or tissue shredding

Source: National Alzheimer’s Association

Stages of AD

■ Severe or Late Stage ■ This is the final stage of the disease when individuals lose the

ability to respond to their environment, the ability to speak and, ultimately, the ability to control movement. ■ Frequently individuals lose their capacity for recognizable speech,

although words or phrases may occasionally be uttered. ■ Need full assistance with eating and toileting and there is general

incontinence. ■ Individuals lose the ability to:

■ walk without assistance ■ sit without support ■ ability to hold their head up ■ Reflexes become abnormal and muscles grow rigid ■ Swallowing is impaired

Source: National Alzheimer’s Association

What is it like with AD?

■ Who was the story about? ■ Who were the characters

in the story? ■ What is the story about? ■ Where did the story take

place? ■ When did the story take

place?

When was the last time you needed help with…?

!■ Bathing ■ Personal care (toileting

and all that goes with it) ■ Getting dressed ■ Brushing your teeth ■ Combing your hair

Common Behaviors

■ Anxiety ■ Paranoia, suspicion ■ Depression ■ Outbursts – emotional,

verbal, physical aggression.

■ Rummaging ■ Poor grooming, dressing,

hygiene ■ Sexually inappropriate

behaviors

■ Refusal to eat ■ Eating non food items ■ Wandering, pacing ■ Hoarding ■ Repetitive behaviors such

as actions, word ■ Inappropriate social

behaviors such as undressing in public, inappropriate conversation with others.

How Do We Know it is AD?■ A process of elimination through testing. ■ 100% diagnosis for AD comes at autopsy when the brain can be examined. ■ Diagnosing AD

■ Physician will review your medical history ■ Mini Mental Status Exam administered (assesses mental function through a series of

questions) ■ A physical exam will be completed ■ Diagnostic tests will be ordered to rule out other illnesses or deficiencies that mimic

memory loss. Such as: Anemia, malnutrition or certain vitamin deficiencies, excessive use of alcohol, medication side effects, infections, diabetes, kidney or liver disease, thyroid abnormalities, problems with the heart, lung or blood vessels.

■ Neurological Exam which includes: Reflexes, coordination and balance, muscle tone and strength, eye movement, speech and sensation.

■ Brain Imaging through: ■ Structural imaging provides information about the shape, position or volume

of brain tissue. Structural techniques include magnetic resonance imaging (MRI) and computed tomography (CT).

■ Functional imaging reveals how well cells in various brain regions are working by showing how actively the cells use sugar or oxygen. Functional techniques include positron emission tomography (PET) and functional MRI (fMRI).

Treatments ■ There are 2 types of FDA approved drugs to treat the cognitive symptoms of

AD. These drugs affect the activity of two different chemicals involved in carrying messages between the brain’s nerve cells. ■ The first type are called Cholinesterase (KOH-luh-NES-ter-ays)

inhibitors and they prevent the breakdown of acetylcholine (a-SEA-til-KOH-lean), a chemical messenger important for learning and memory.

■ Cholinesterase inhibitors commonly prescribed: ■ Donepezil (Aricept) ■ Rivastigmine (Exelon) ■ Galantamine (Razadyne) ■ Tacrine (Cognex)

■ The second type is Memantine (Namenda) and this works by regulating the activity of glutamate, a different messenger chemical involved in learning and memory. ■ Memantine:

■ Approved in 2003 for treatment of moderate to severe Alzheimer's disease.

Source: National Alzheimer’s Association www.alz.org

Preserving Cognitive Function

■ Bad News: You cannot prevent Alzheimer’s disease

!■ Good News: You can help keep your brain sharp with regular social

activity; "mental exercise," such as doing crossword puzzles and reading; and physical activity, which increases blood and oxygen flow to the brain and a healthy diet.

Impact■ AD is the 7th leading cause of death in the U.S. (Heart Disease is #1) ■ Length of the disease is 3 – 20 years !■ Currently, there are 5.4 million with AD; SD/Imp Cty=90,000 !■ By 2029 all Baby Boomers (1946-1964) will be at least 65 – 10 million of the

78 million are predicted to develop AD. !■ More women than men will develop AD

■ Avg life expectancy in 2010 – Women 80.8; Men 75.7 (US Census projection)

!■ 2010 Cost of Care is estimated at $172 billion (Healthcare and Long Term

Care) ■ Skilled Care:$6K/mo; In Home Care: $3,800/mo; Daycare:$1,500/mo ■ Cost to businesses – lost work time, absenteeism, leaves of absence, quitting

work. !

■ In 2009 there were an estimated 10.9 million unpaid caregivers (family, friends ■ Several studies show hours of caregiving range from 21-40; higher number of hours

as the disease progresses. ■ Average age of the caregiver is 51. ■ 60% of the caregivers are female.

Source: National Alzheimer’s Association http://www.alz.org/documents_custom/report_alzfactsfigures2010.pdf

For More Information on Research/Clinical Trials

■ What is a clinical trial? ■ According to clinical trials.gov, clinical trials are biomedical or health-

related research studies in human beings that follow a pre-defined protocol. Clinical trials can include both interventional and observational types of studies. ■ Interventional studies are those in which the research subjects are assigned by

the investigator to a treatment or other intervention, and their outcomes are measured.

■ Observational studies are those in which individuals are observed and their outcomes are measured by the investigators.

■ http://adrc.ucsd.edu/trials.html ■ What Research is going on? ■ Studies investigate treatments designed to improve thinking and daily

functioning as well as studying ways to slow decline or delay the onset of Alzheimer’s’ disease. ■ http://adrc.ucsd.edu/research.html

Source: UCSD Shiley Marcos Alzheimer’s Disease Research Center http://adrc.ucsd.edu

Additional Resources

■ Alzheimer’s Disease Education and Referral Center (ADEAR) – www.nia.nih.gov/Alzheimers

■ Alzheimer’s Association- San Diego Chapter – www.sanalz.org ■ Family Caregiver Alliance – www.caregiver.org ■ Southern Caregiver Resource Center –

www.caregivercenter.org ■ UCSD Shiley Marcos Alzheimer’s Disease Research Center –

www.adrc.ucsd.edu ■ Joe Bouthillier - Alzheimer’s Awareness

http://www.josephbouthillier.com/