The Aging Mind, The Aging Mind, Alzheimer’s and other Alzheimer’s and other

DementiasDementiasJulie O’Brien Julie O’Brien RN,MSN,CNL RN,MSN,CNL

Inova Neuroscience Inova Neuroscience Nurse Navigator Nurse Navigator

OutlineOutline Cognitive DomainsCognitive Domains A little neuroanatomy (very little)A little neuroanatomy (very little) Types of dementiaTypes of dementia

• Alzheimer’s DiseaseAlzheimer’s Disease• Vascular DementiaVascular Dementia• Parkinsonian DementiaParkinsonian Dementia

The Inova Memory CenterThe Inova Memory Center

Cognitive DomainsCognitive Domains RegistrationRegistration Recall (memory)Recall (memory) VisuospatialVisuospatial LanguageLanguage AttentionAttention Executive FunctioningExecutive Functioning

RegistrationRegistration The ability to encode information for The ability to encode information for

future usefuture use The information can come into the The information can come into the

brain through any of the five sensesbrain through any of the five senses The part of the brain that encodes The part of the brain that encodes

the memory is not the same as the the memory is not the same as the part of the brain that stores itpart of the brain that stores it

Recall (Memory)Recall (Memory) Verbal RecallVerbal Recall

• Immediate (attention)Immediate (attention) Tested with repetitionTested with repetition

• Short-term (working memory)Short-term (working memory) Phone numberPhone number

• Long-termLong-term Recall at five minutesRecall at five minutes

Recall (Memory)Recall (Memory) Visual RecallVisual Recall

• Figure or picture recallFigure or picture recall Motor RecallMotor Recall

• Ability to perform skilled tasksAbility to perform skilled tasks• Breakdown is called “apraxia”Breakdown is called “apraxia”

VisuospatialVisuospatial

The ability to use knowledge of The ability to use knowledge of where things are in spacewhere things are in space

Must have visual recall but then also Must have visual recall but then also be able to apply it to a situationbe able to apply it to a situation• Walking, drivingWalking, driving

In dementia manifests as getting lost In dementia manifests as getting lost while driving or walking in while driving or walking in neighborhoodneighborhood

VisuospatialVisuospatial

Test with Test with • Line bisectionLine bisection• Figure copyFigure copy• Delayed copyDelayed copy

LanguageLanguage

Receptive functionReceptive function• Understanding what is heard, read or Understanding what is heard, read or

seenseen Expressive functionExpressive function

• Being able to communicate by speaking, Being able to communicate by speaking, writing, or actingwriting, or acting

LanguageLanguage

NamingNaming• Proper names: grandchildren, object Proper names: grandchildren, object

names, generic namesnames, generic names• Word substitutionWord substitution

RepetitionRepetition Simple and complex commandsSimple and complex commands Category fluencyCategory fluency

AttentionAttention

Sustained effort to accomplish a taskSustained effort to accomplish a task Ability to manipulate information in Ability to manipulate information in

your headyour head• One step beyond rote memory and One step beyond rote memory and

automatic responsesautomatic responses• Something you have to think aboutSomething you have to think about

Ability to pick things out of a list or Ability to pick things out of a list or put something in reverse orderput something in reverse order

Executive FunctionExecutive Function PlanningPlanning Things that involve more than one Things that involve more than one

stepstep• How to prepare a mealHow to prepare a meal• How to balance a checkbookHow to balance a checkbook

Not just automatic activitiesNot just automatic activities

Neuroanatomy 101Neuroanatomy 101Lobes of the BrainLobes of the Brain

Neuroanatomy 101Neuroanatomy 101Function by areaFunction by area

Neuroanatomy 101Neuroanatomy 101Function by areaFunction by area

Dementia versus Normal AgingDementia versus Normal Aging Dementia must be:Dementia must be:

• A decline from premorbid functioning A decline from premorbid functioning beyond that expected for age and beyond that expected for age and education matched controlseducation matched controls

• Significantly impact lifestyle and Significantly impact lifestyle and function, e.g. ADL’sfunction, e.g. ADL’s

Dementia versus Normal AgingDementia versus Normal Aging Normal aging involves:Normal aging involves:

• Psychomotor slowing: decrease in speed Psychomotor slowing: decrease in speed of mental processingof mental processing

• Slower retrieval of informationSlower retrieval of information• Lower rate of learningLower rate of learning• Improved vocabularyImproved vocabulary• ““Crystalized intelligence”: more Crystalized intelligence”: more

practical and effective strategies in real practical and effective strategies in real world tasksworld tasks

Classification of DementiasClassification of Dementias Type of dementia is defined by the Type of dementia is defined by the

cognitive domain that it affects first cognitive domain that it affects first and worst:and worst:• MemoryMemory• LanguageLanguage• Attention and executive functionAttention and executive function• VisuospatialVisuospatial• BehaviorBehavior

Classification of DementiasClassification of Dementias Symptoms depend on the part of the Symptoms depend on the part of the

brain that is damagedbrain that is damaged• e.g. Alzheimer’s Disease is temporal e.g. Alzheimer’s Disease is temporal

lobes, giving mostly memory problemslobes, giving mostly memory problems Pathology of the damage does NOT Pathology of the damage does NOT

determine the symptoms, but some determine the symptoms, but some pathologies are more associated with pathologies are more associated with certain diseasescertain diseases

The Major DementiasThe Major Dementias Alzheimer’s Disease: 60% overall Alzheimer’s Disease: 60% overall

(80% of late onset dementias)(80% of late onset dementias) Vascular Dementia: 20%Vascular Dementia: 20% Parkinson’s related dementias: 10%Parkinson’s related dementias: 10%

• Parkinson’s Disease DementiaParkinson’s Disease Dementia• Lewy Body DementiaLewy Body Dementia

Frontotemporal Dementia: < 5%Frontotemporal Dementia: < 5%

Mild Cognitive ImpairmentMild Cognitive Impairment Cognitive decline beyond what is Cognitive decline beyond what is

expected for age but without expected for age but without meeting criteria for dementiameeting criteria for dementia

Different types, depending on Different types, depending on cognitive domaincognitive domain

Most are amnesticMost are amnestic Doesn’t interfere with lifestyleDoesn’t interfere with lifestyle

Alzheimer’s DiseaseAlzheimer’s Disease Degenerative disease of the brainDegenerative disease of the brain Initially affects memory, then Initially affects memory, then

spreads to other parts of brain. spreads to other parts of brain. There is no cure. Current meds only There is no cure. Current meds only

help memory. They do not slow help memory. They do not slow progression of disease. progression of disease.

Potential treatments useful only if Potential treatments useful only if begun early. begun early.

Alzheimer’s Disease Progression: Alzheimer’s Disease Progression: EarlyEarly

Alzheimer’s Disease Progression: Alzheimer’s Disease Progression: ModerateModerate

Alzheimer’s Disease Progression:Alzheimer’s Disease Progression:LateLate

Alzheimer’s Disease: SymptomsAlzheimer’s Disease: Symptoms Memory:Memory:

• Semantic memory: Word meanings, Semantic memory: Word meanings, categories, classescategories, classes

Naming is impaired earlyNaming is impaired early• Episodic memory: Events, Episodic memory: Events,

conversations, appointmentsconversations, appointments

Alzheimer’s Disease: SymptomsAlzheimer’s Disease: Symptoms Executive Function:Executive Function:

• Trouble organizing tasksTrouble organizing tasks• Doesn’t finish tasksDoesn’t finish tasks

Attention relatively preserved until Attention relatively preserved until later in diseaselater in disease

Alzheimer’s Disease: SymptomsAlzheimer’s Disease: Symptoms Visuospatial:Visuospatial:

• Trouble with spatial orientationTrouble with spatial orientation• Gets lost in familiar surroundingsGets lost in familiar surroundings

Neuropsychiatric:Neuropsychiatric:• DepressionDepression• ApathyApathy• DelusionsDelusions• Visual hallucinationsVisual hallucinations• AgitationAgitation

Alzheimer’s Disease: PathologyAlzheimer’s Disease: Pathology Nerve cells in brain cannot signal to Nerve cells in brain cannot signal to

each other properlyeach other properly PlaquesPlaques TanglesTangles Cell loss (atrophy)Cell loss (atrophy)

Alzheimer’s Disease Pathology: Alzheimer’s Disease Pathology: PlaquesPlaques

Interrupted communication between Interrupted communication between nerve cellsnerve cells

Made of Beta AmyloidMade of Beta Amyloid• Protein that forms clumps between cells, Protein that forms clumps between cells,

disrupting synaptic transmissiondisrupting synaptic transmission

Alzheimer’s Disease Pathology:Alzheimer’s Disease Pathology:TanglesTangles

Tau (hyperphophorylated)Tau (hyperphophorylated) IntracellularIntracellular Part of normal cytoskeletonPart of normal cytoskeleton

Symptomatic treatment versusSymptomatic treatment versusDisease modifying therapyDisease modifying therapy

Alzheimer’s Disease: TreatmentAlzheimer’s Disease: Treatment Pharmacological:Pharmacological:

• Cholinesterase Inhibitors:Cholinesterase Inhibitors: Exelon (Rivastigmine)Exelon (Rivastigmine) Aricept (Donepezil)Aricept (Donepezil) Razadyne (Galantamine)Razadyne (Galantamine)

• NMDA (glutamate) antagonistNMDA (glutamate) antagonist Namenda (Memantine)Namenda (Memantine)

Alzheimer’s Disease: TreatmentAlzheimer’s Disease: Treatment NutraceuticalsNutraceuticals

• Omega 3 fatty acids (DHA) 1000 mg Omega 3 fatty acids (DHA) 1000 mg dailydaily

• NSAIDS – ASA 81 mg qdNSAIDS – ASA 81 mg qd• Vitamin E – probably not helpfulVitamin E – probably not helpful• Ginko Biloba – definitely not helpfulGinko Biloba – definitely not helpful• Vitamin B complex Vitamin B complex

Alzheimer’s Disease: TreatmentAlzheimer’s Disease: Treatment Lifestyle:Lifestyle:

• Cognitive trainingCognitive training Effect of education levelEffect of education level

• Physical activityPhysical activity• Social activity and interactionsSocial activity and interactions

Vascular DementiaVascular Dementia Dementia caused by strokeDementia caused by stroke Can affect any cognitive domainCan affect any cognitive domain Does not have to involve memoryDoes not have to involve memory Slow thinkingSlow thinking

Vascular DementiaVascular Dementia Usually distinct or abrupt onsetUsually distinct or abrupt onset May be cumulative effect of multiple May be cumulative effect of multiple

small strokessmall strokes• ““small vessel disease” (microvascular)small vessel disease” (microvascular)• Subcortical white matter ischemic Subcortical white matter ischemic

diseasedisease

Vascular DementiaVascular DementiaTreatmentTreatment

Cholinesterase inhibitors (Aricept, Cholinesterase inhibitors (Aricept, Razadyne, Exelon)Razadyne, Exelon)• Treatment effect about as good as with Treatment effect about as good as with

Alzheimer’s diseaseAlzheimer’s disease Antihypertensive treatment, Antihypertensive treatment,

especially with ACE inhibitorsespecially with ACE inhibitors• May reduce incidence by 6-7%May reduce incidence by 6-7%

Parkinsonian DementiasParkinsonian Dementias About 5-10% of PD patients will have About 5-10% of PD patients will have

dementia at some pointdementia at some point Risk of dementia about 3x greater in Risk of dementia about 3x greater in

PD than general populationPD than general population Depression is common in PD with or Depression is common in PD with or

without dementiawithout dementia PD is more than just a motor diseasePD is more than just a motor disease

Parkinsonian DementiasParkinsonian Dementias Parkinson’s Disease Dementia:Parkinson’s Disease Dementia:

• Develops more than one year after Develops more than one year after onset of motor symptoms of PD (usually onset of motor symptoms of PD (usually many years later)many years later)

Dementia with Lewy Bodies (DLB)Dementia with Lewy Bodies (DLB)• Develops before onset of motor Develops before onset of motor

symptoms or within one yearsymptoms or within one year• Can happen before Parkinson’s Disease Can happen before Parkinson’s Disease

Motor symptoms are evidentMotor symptoms are evident

Parkinson’s Disease DementiaParkinson’s Disease Dementia Symptoms and signs:Symptoms and signs:

• Slow, progressive course in the setting Slow, progressive course in the setting of well established PD of more than a of well established PD of more than a year’s durationyear’s duration

• Can involve deficits of attention, Can involve deficits of attention, memory, language, and executive memory, language, and executive functionfunction

• Behavioral symptoms can include Behavioral symptoms can include depression, hallucinations and delusionsdepression, hallucinations and delusions

Lewy Body DementiaLewy Body DementiaCore FeaturesCore Features

Fluctuation of cognition and alertnessFluctuation of cognition and alertness• Sometimes near normalSometimes near normal• Other times confused, sleepy, forgetfulOther times confused, sleepy, forgetful• Periods may last hours to daysPeriods may last hours to days

Visual hallucinationsVisual hallucinations• Usually well formed: people, animals, Usually well formed: people, animals,

insectsinsects• Often realize they are not realOften realize they are not real

Lewy Body DementiaLewy Body DementiaOther featuresOther features

Delusions, often paranoidDelusions, often paranoid Depression is commonDepression is common Executive dysfunctionExecutive dysfunction

• Trouble with planning and executing Trouble with planning and executing taskstasks

Memory impairment: may develop Memory impairment: may develop laterlater

Lewy Body DementiaLewy Body DementiaTreatmentTreatment

May have significant response to May have significant response to dementia medicines: Aricept, dementia medicines: Aricept, Razadyne, ExelonRazadyne, Exelon

Atypical antipsychotics for behavior Atypical antipsychotics for behavior problems (Seroquel)problems (Seroquel)

Inova Memory Center:Inova Memory Center:PurposePurpose

Facilitate cooperation among the Facilitate cooperation among the broad range of clinicians and health broad range of clinicians and health professionals involved in the care of professionals involved in the care of dementia patientsdementia patients

Centralize services into one entity Centralize services into one entity and streamline sharing of clinical and streamline sharing of clinical informationinformation

Assure high level of careAssure high level of care

Inova Memory Center:Inova Memory Center:PurposePurpose

Standardized evaluation and Standardized evaluation and management according to American management according to American Academy of Neurology guidelinesAcademy of Neurology guidelines• Consensus on other aspects of careConsensus on other aspects of care• Knowledge and understanding of new Knowledge and understanding of new

developments in the fielddevelopments in the field

The Inova Memory Center:The Inova Memory Center:MembersMembers

Clinicians and allied health Clinicians and allied health professionals associated with Inova professionals associated with Inova who have interest and experience in who have interest and experience in treating dementia patientstreating dementia patients

Neurologists, psychiatrists, Neurologists, psychiatrists, geriatricians, radiologists, geriatricians, radiologists, neuropsychologists, social workers, neuropsychologists, social workers, researchersresearchers

Inova Memory Center:Inova Memory Center:Current StuctureCurrent Stucture

Patient makes an appointment to see Patient makes an appointment to see a clinician based on geographic and a clinician based on geographic and specialty needsspecialty needs

Patient is evaluated and referred for Patient is evaluated and referred for appropriate testing or other needed appropriate testing or other needed ancillary servicesancillary services

Can be given opportunity to Can be given opportunity to participate in a research studyparticipate in a research study