Dementia and Aging

Steven Huege, M.DAssistant Professor of Clinical Psychiatry

Perelman School of Medicine at the University of Pennsylvania

Dementia and Aging

• Contrary to popular belief: Dementia and Memory loss are not part of normal aging

• Cognitive processing does slow down, but progressive short term memory loss is not normal and warrants a thorough work-up

Dementia

• Syndrome characterized by a deterioration of cognitive ability from a previous level leading to impairment in functioning.

• Can have many causes– Infectious (HIV, syphilis)– Toxic/Metabolic (Cu, Pb, ETOH, Folate, B12

deficiency)– Neurodegenerative/Vascular (Alzheimer’s,

Parkinson’s, Lewy Body, FTD, Prion)– “Structural” (Normal Pressure Hydrocephalus, Tumor)

Prevalence of Dementia

• Major health problem, especially as population ages

• 3-11% of community-dwelling adults age >65 have dementia

• 20-50% age >85 have dementia• In 2000, 4.5 million people had Alzheimer’s

Population with Alzheimer’s in U.SAlzheimer’s Association

Alzheimer’s Dementia

• Major health problem, especially as population ages

• 3-11% of community-dwelling adults age >65 have dementia

• 20-50% age >85 have dementia• In 2000, 4.5 million people had Alzheimer’s

NIA: Updated criteria for Dementia1. Interfere with the ability to function at work or at usual activities2. Represent a decline from previous levels of functioning and performing3. Are not explained by delirium or major psychiatric disorder4. Cognitive impairment is detected and diagnosed through a combination of

(A) history-taking (B) an objective cognitive assessment5. The cognitive or behavioral impairment involves a minimum of two of the

following domains:I. Impaired ability to acquire and remember new informationII. Impaired reasoning and handling of complex tasks, poor judgment.III. Impaired visuospatial abilitiesIV. Impaired language V. Changes in personality, behavior, or comportment

NIA: Alzheimer’s CriteriaMeets criteria for dementia +A. Insidious onset. Symptoms have a gradual onset over months to yearsB. Clear-cut history of worsening of cognition by report or observationC. The initial and most prominent cognitive deficits are evident on history

and examination in one of the following categories.

a. Amnestic presentationb. Nonamnestic presentations:

i. Language presentation ii. Visuospatial presentation: The most prominent deficits

are in spatial cognition, including object agnosia, impaired face recognition, simultanagnosia, and alexia

iii. Executive dysfunction: The most prominent deficits are impaired reasoning, judgment, and problem solving

Pathology of Alzheimer’s

• Senile (Amyloid) Plaques– Extracellular– Result from accumulation of proteins and an

inflammatory reaction around deposits of β-amyloid

• Neurofibrillary Tangles– Intracellular– Aggregates of hyperphosphorylated microtubular

protein tau

Tangles and Plaquesladulab.anat.uic.edu/images/ADstain.jpg

Symptoms of Alzheimer's at various stages of illness

• Mild• Moderate• Severe

Mild AD

• MMSE 20• Memory complaints-cardinal symptom!• Decreased knowledge of current events• Difficulty performing complex tasks• Impaired concentration• Less able to manage travel, finances• Disorientation• Word finding difficulty• Pt may not be aware of deficits

Moderate

• MMSE 15• Inability to recall address, names of family members• Some disorientation• Still retain major biographical info about self• Initially able to toilet, feed, but may become more

impaired as illness progresses• Worsening language and apraxia

Severe

• MMSE <5• Minimal verbal ability• Incontinent• Unable to perform even basic ADL’s• Immobile• Completely dependent on others for all

aspects of care

Mild Cognitive Impairment(MCI)

• Memory Impairment beyond normal limits• Performance < 1.5 SD on memory testing• No major impairment in functioning• Able to carry out all ADL’s• 70% of pts with MCI will progress to dementia

Biomarkers for Alzheimer’s DementiaSperling, et.al. 2011

Neuropsychiatric Symptoms of ADBased on Scores on MPI > 4, Lyketsos, C. JAMA 2002

Symptom MCI % AD%

Delusions 2 38

Hallucinations 4 18

Agitation 15 53

Depression 20 58

Anxiety 16 35

Disinhibition 1 25

Irritability 24 45

Sleep 28 72

Eating 20 57

Aberrant Motor Activity 7 43

Apathy 20 97

Pharmacological Treatments

• Cholinesterase inhibitors• Memantine• Antidepressants/Antipsychotics• None are disease modifying, preventative or

curative• Symptomatic treatments only

Survival by Dementia TypeFitzpatrick, et.al 2005

Conclusion

• Dementia can be thought of a “biopsychosocial” illness.

• The cognitive impairment from dementia requires pt, caregivers, and physicians to address all aspects of pt’s life.