Memory loss and dementia

1. Memory loss and dementia Chiadi U. Onyike, MD, MHS Assistant Professor, Neuropsychiatry Johns Hopkins School of Medicine

2. Acknowledgments • Kostas Lyketsos • Marilyn Albert • Peter Rabins • Crystal Evans • Tanwa Suma • MACAB • Johns Hopkins Neuropsychiatry • Alzheimer Association of Greater Maryland

3. What is dementia? • Is it “memory loss”? • Is it “old age”? • How is it different from Alzheimer disease?

4. What is dementia? • Loss of mental faculties • Orientation • Memory • Language • Object recognition • Executive functions • Praxis (learned skills)

5. Spectrum of Dementia N = 382 Barker WW, et al. Alzheimer Dis Assoc Disord. 2002;16:203-212.

6. Dementia in the population • Afflicts 4 - 5 million in the U.S. • 18 - 20 M worldwide • Over 12 M in U.S. (40 M worldwide) by 2050 • 70% live in the community • Costs $141 billion/year (1997 estimate) • Cost of care ≈ $50,000/patient/year

7. Causes of dementia • Alzheimer disease • Vascular dementia • Lewy body disease • Frontotemporal dementia • Mixed dementias • Others: • Trauma, PD, HD, NPH, CJD, others

8. Pathology

9. Pathology

10. Vascular Dementia • Many causes • Multiple “mini” strokes • Small strategic stroke • Large stroke • Leukoaraiosis • Focal motor and sensory symptoms

11. Strategic stroke • Sudden blindness, tongue numbness, slurring of speech • Transient LOC • Anterograde verbal and visual amnesias, impaired verbal fluency, hypophonia, dysarthria, and word agnosia

12. Stroke

13. Lacunar infarcts

14. Subcortical leukoencephalopathy

15. Age Family history CVD Trauma Lifestyle - diet, activity APOE genotype APP Presenilin-1 Presenilin-2 Trisomy 21 Risk factors for AD

16. Antecedents of dementia • Mild Cognitive Impairment • Mild cognitive syndromes (or CIND) • Late-life onset depression • Apathetic and other behavioral states

17. Loss of mental abilities 25 Loss of basic skills 20 15 Behavioral problems 10 Nursing-home placement 5 Death 0 0 1 2 3 4 5 6 7 8 9 Progression of AD 30 MMSE (points) Years Feldman H, Gracon S. In: Gauthier S, ed. Clinical Diagnosis and Management of Alzheimer’s Disease. Boston, Mass: Butterworth-Heinemann; 1996:239-252.

18. Pathologic emotionality Depression Apathy Catastrophic reactions Irritability Hallucinations Misinterpretations and delusions Paranoia Disinhibition Wandering Pacing Hoarding Sleep disturbance Overeating and new habits Sexual misdemeanors Resistiveness Aggression and violence Typical syndromes

19. DIAGNOSIS

20. Evaluation • History • Normal neurological exam • Normal laboratory tests

21. Evaluation • CT/MRI • SPECT/PET • MRA • MRS • Diffusion Tensor Imaging

22. Evaluation • Neuropsychological testing • Spinal tap and CSF analysis • EEG • Generalized slowing in most dementias • Biomarkers • Amyloid and tau staining • Gene tests

23. TREATMENT

24. “Four Pillars” of Dementia Care • Day-to-day support and/or supervision of IADLs and ADLs • Treat cognitive impairment • Treat behavioral disturbances • Provide family and caregiver support

25. Maximize functioning • Maintain general health • Optimize • Hearing • Vision • Gait • Use: • Cues • Prompts • Mechanical aides • Modified appliances • Restrictions

26. Medications for AD