Download AD Research: the Search for Causes

GERIATRIC NEUROLOGICAL CHANGES
 Hillcrest EMS
 March, 2013
OBJECTIVES
 Discuss normal/abnormal changes with
aging of the nervous system.
 Discuss various nervous system diseases
that are associated with aging.
 Review various symptoms related to the
nervous system.
 Review types medications in use for these
problems.
GERIATRIC FACTS
 Per 2010 – 40 million >65 USA (13%)
 By 2030 - 72 million (20%)
 By 2050 – 87 million (17%)
 In 1990 – Very Old >85 = 100,000
 In 2010 – 5.5 million
 Married -72% of men vs. 42% of women (majority are
widows)
 Women outnumber men at 23 million to 17 million men.
 About 30% (11.3 million) of non-institutionalized older
persons live alone 8.3 million women, 3.0 million men.
 Half of older women (49%) age 75+ live alone.
GERIATRIC FACTS
 Healthcare:
 In 2010, 95.5% non-institutionalized persons 65+
were covered by Medicare.
 5% of the non-institutionalized elderly were covered by
Medicaid.
 For Medicare beneficiaries residing in nursing homes,
over half (62%) were covered by Medicaid.
Normal Changes with Age
Not everyone has these changes to the same
degree, and the resulting affects may be
very different.
 PHYSICAL
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Declining endurance
Increased health concerns
Vision changes
Hearing loss
 MENTAL
 Slowed learning speed
 Memory loss
 SOCIAL/EMOTIONAL
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Retirement
Personal loss
Loneliness
New roles
 FINANCIAL
 Limited income
 Higher health care cost,
cost of living
 Lifestyle change
Normal Changes with Age
 Physiological aging changes in the Brain:
 Brain and spinal cord lose nerve cells and weight.
 Transmission of messages (synapses) slows down.
 Waste products from nerve cell breakdown may
accumulate in the brain creating plaque and tangles to
be formed.
 A fatty brown pigment (lipofuscin) can also build up in
nerve tissue.
Geriatric Mental Health -Anxiety
 Generalized anxiety disorder is characterized by
persistent worry about major or minor concerns.
 Others — such as panic disorder, obsessive-
compulsive disorder (OCD) and post-traumatic
stress disorder (PTSD) — have more-specific
triggers and symptoms.
 Anxiety is the most prevalent mental health
problem for people over 50.
Geriatric Mental Health - Anxiety
 Anxiety may happen as a normal part of life. It can
be useful when it alerts you to danger.
 For some - anxiety persistently interferes with
daily activities such as work, school, sleep
relationships, and enjoyment of life.
 Medications to treat anxiety are very successful
along with an understanding of what anxiety is.
Geriatric Mental Health - MCI
Mild Cognitive Impairment is an intermediate stage
between the expected cognitive decline of normal
aging and the more serious decline of dementia.
MCI can involve problems with memory, language,
thinking and judgment that are greater than normal
age-related changes.
A person with MCI may be aware that their memory or
mental function has "slipped.“ Family and close friends
also may notice a change.
Mild Cognitive Impairment (MCI)
 Mild cognitive impairment may increase the
risk of later progressing to dementia, caused by
Alzheimer's disease or other neurological
conditions.
 In general, cognitive function is preserved
and activities of daily living, social
relationships, and occupational
responsibilities are not affected.
 Some people with mild cognitive impairment
never get worse, and a few eventually get
better. Treatment usually optional.
Geriatric Mental Health - Depression
 IS NOT A NORMAL PART OF AGING estimated 6% > 65
(over 2.4 million)
 An illness that affects mind & body
 Can be dangerous
 Is not a sign of weakness
 Is often overlooked
 Can’t just snap out of it – need treated – one of the most
successfully treated
Geriatric Mental Health -Depression
 Common signs
 Deep sadness
 Hopelessness
 Loss of interest in old





activities
Significant + or –
weight
Inability to sleep
Loss of energy
Inability to concentrate
Thoughts of death
Geriatric Mental Health -Depression
 NEGATIVE FEELINGS
Feel empty
 Sense of hopelessness
 Lack of feelings
 Loss of sexual desire
 Feel worthless
 Feel guilty
 Thoughts of death or
suicide

 CHANGES IN BEHAVIOR,
THINKING & ATTITUDE
 Trouble concentrating
 Irritability
 Poor memory
 Not care about
appearance
 Withdrawing from
family & friend
 PHYSICAL COMPLAINTS
 Unexplained aches/pains
 Sleep problems
 Fatigue
Geriatric Mental Health -Depression
 Major depression – can be mild, moderate or severe; be
triggered by a loss, crisis or change; make it hard to
function day to day; continue for months or years if not
treated
 Dysthymia –mild form, can last for years, may not
remember what it feel like to be happy, can function day to
day, but work and relationships suffer
 Bipolar disorder – periods of depression followed by periods
of mania (unusually high energy, insomnia,
overconfidence, racing thoughts, impulsive and reckless
behavior (Manic depression)
 Seasonal Affective Disorder (SAD) – depression occurring in
fall or winter – caused by seasonal change
Geriatric Mental Health -Depression
 Once identified and treated, 80% return to
their normal lives
 Common treatments include:
 Psychotherapy – for mild depression
 – Treat 10-20 weeks
 Antidepressant meds – work on the balance of
neurotransmitter chemicals in the brain
 Treat ~ 6 months
 ECT (electroconvulsive therapy)– for life
threatening depression not responsive to meds
Depression & Suicide
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Rate is 50% higher than for any other age group
For those >85 - highest of all
Men >65 have a 7x higher rate than women
Women’s rate goes up after 75
Most have seen PMD 20% (one day) – 40% (1
week)
 More than 30 percent of victims diagnosed &
suffering from major depression.
 6-9% living in primary setting report suicidal
ideation
Geriatric Mental Health - Dementia
 Dementia is not a specific
disease. It's an overall term
that describes a group of
symptoms caused by
various diseases or
conditions.
 Dementia is a general term
for a decline in mental
ability severe enough to
interfere with daily life.
Alzheimer's is the most
common type of dementia.
Geriatric Mental Health - Dementia
Forgetfulness
Confusion
Withdrawl
Can progress over
years or within weeks
– depending on cause
 Irreversible conditions
 Alzheimers
 Stroke
 Rare viruses
 Parkinson’s
 Aids
 Reversible conditions
 Thyroid
 Alcohol
 Poor nutrition
 Mental problems
 Reactions to meds
Geriatric Mental Health - Dementia
 Can be difficult to determine as neurologic
symptoms may be the result of multiple
causes.
 Use VITAMINS C & D mnemonic to help
recall potential causes
Vitamins C & D
 Vascular
 Inflammation
 Toxins, trauma,


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tumors
Autoimmune
Metabolic
Infection
Narcotics
Systemic
• Congenital
• Degenerative
Geriatric Mental Health - Dementia
 Symptoms can vary greatly. At least two of the
following core mental functions must be
significantly impaired to be considered
dementia:

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
Memory
Communication and language
Ability to focus and pay attention
Reasoning and judgment
Visual perception
Geriatric Mental Health - Dementia
 People with dementia may likely have
problems with:
 Short-term memory
 Keeping track of a purse or wallet
 Paying bills
 Planning and preparing meals
 Remembering appointments
 Traveling out of the neighborhood.
Dementia Criteria
Other signs & symptoms:
1. Impairment of Long Term Memory
2. Impairment of Abstract Thinking Ability
3. Impairment of Judgment
4. Personality Change
5. Disruption of High Cortical Function
 Aphasia – Speech
 Ataxia – Motor Function
 Agnosia – Object Recognition
Dementia – Delirium Syndrome
 Considered a syndrome since symptoms come
from various underlying causes
Symptoms:
 Sudden onset
 Usually temporary & reversible
 Oriented to person – not time or place
 Disorganized thought process – can’t keep
attention, cooperation
 Speech can be loud and argumentative/ can’t
More Symptoms of Delirium Syndrome
 Altered perceptions, visual
illusions/hallucinations – misinterpret the
environment
 Lucid/confusion alternating
 Most are restless, agitated/ combative
 Emergency situation requiring attention now.
Causes of Delirium Syndrome
 Systemic:
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Exacerbation of chronic illness/new disease process
Infections – respiratory/UTI
Drug toxicity/interactions
Elimination problems
 Mechanical:

– CVA, cardiac dysfunction, ca, brain tumor
 Psychosocial/environmental:
 Losses – loved one, possessions
 Sensory deprivation/overstimulation
 Treatments – based on symptoms.
Geriatric Mental Health - Alzheimers
 The most common (50-60%) form of dementia
among older people. About 5 .4 million
Americans suffer from this condition.
 Is it genetic? Maybe - research has turned up
evidence of a link between Alzheimer's disease
and a number of genes .
 There is no proof it is caused by aluminum, zinc,
a virus, or toxic food. Studies on-going.
Dementia - Alzheimer’s Disease (AD)
 AD Statistics….
• One in eight over 65 have AD.
 Estimated 4 percent are
under age 65, 6 percent are
65 to 74,44 percent are 75 to
84, and 46 percent are 85or
older.
• Chance of getting it doubles
every 5 years after 65.
6th leading cause of death, only
one that can’t be prevented,
cured of slowed
 By 2050, 13.2 million older
Americans are expected to
have AD if the current
numbers hold and no
preventive treatments
become available.
Dementia - Alzheimer’s Disease (AD)
 Where are people with
AD cared for?
• 80% family @home
The national cost of caring for
people with AD is about $200
billion every year. $140 billion
by Medicare,Medicaid.
(add’l $210 B. in
donated care)
• Assisted living facilities
(those in the early
stages)
• Nursing homes (special
care units)
Alzheimers
vs. Normal Aging
Signs of Alzheimer's
Typical age-related changes
 Poor judgment and
 Making a bad decision
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
decision making
Inability to manage a
budget
Losing track of the date or
the season
Difficulty having a
conversation
Misplacing things and
being unable to retrace
steps to find them

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
once in a while
Missing a monthly
payment
Forgetting which day it is
and remembering later
Sometimes forgetting
which word to use
Losing things from time to
time
10 Warning Signs of Alzheimers
1. Memory loss that disrupts daily life.
2. Unable to do planning or complete project.
3. Difficulty completing familiar tasks at home, at
work or at leisure.
4. Confusion with time or place.
5. Trouble understanding visual images and spatial
relationships.
10 Warning Signs of Alzheimers
6. New problems with words in speaking or
writing.
7. Misplacing things and losing the ability to
retrace steps.
8. Decreased or poor judgment.
9. Withdrawal from work or social activities.
10.Changes in mood and personality
Inside the Human Brain
Brain’s Vital Statistics
• Adult weight:
about 3 pounds
• Adult size:
a medium cauliflower
• Number of neurons:
100,000,000,000
(100 billion)
• Number of synapses
(the gap between
neurons):
100,000,000,000,000
(100 trillion)
Inside the Human Brain
The Three Main Players
1. Cerebral Hemispheres (cerebrum)– where sensory information
received from the outside world is processed; this part of the
brain controls voluntary movement and regulates conscious
thought and mental activity:
•
accounts for 85% of brain’s weight
•
consists of two hemispheres connected by the corpus
callosum
•
is covered by an outer layer called the cerebral cortex
Inside the Human Brain
The Three Main Players
2. Cerebellum – in charge of balance and coordination:
•
takes up about 10% of brain
•
consists of two hemispheres
•
receives information from eyes, ears, and muscles
and joints about body’s movements and position
Inside the Human Brain
The Three Main Players
3. Brain Stem – connects the spinal cord with the brain
•
relays and receives messages to and from muscles,
skin, and other organs
•
controls automatic functions such as heart rate, blood
pressure, and breathing
Inside the Human Brain
The Three Main Players
• Hippocampus: where short-term memories are converted
to long-term memories
• Thalamus: receives sensory and limbic information and
sends to cerebral cortex
• Hypothalamus: monitors certain activities and controls
body’s internal clock
• Limbic system: controls emotions and instinctive behavior
(includes the hippocampus and parts of the cortex)
Inside the Human Brain
The Brain in Action
Hearing Words
Speaking Words
Seeing Words
Different mental activities take place in
different parts of the brain. Positron
emission tomography (PET) scans can
measure this activity. Chemicals tagged
with a tracer “light up” activated regions
shown in red and yellow.
Thinking about Words
Neurons
• The brain has billions of
neurons, each with an
axon and many
dendrites.
• To stay healthy, neurons
must communicate with
each other, carry out
metabolism, and repair
themselves.
• AD disrupts all three of
these essential jobs.
Plaques and Tangles: The Hallmarks of AD
The brains of people with AD have an abundance of two
abnormal structures:
• beta-amyloid plaques, which are dense deposits of protein and cellular material
that accumulate outside and around nerve cells
• neurofibrillary tangles, which are twisted fibers that build up inside the nerve cell
An actual AD plaque
An actual AD tangle
Beta-amyloid Plaques
Amyloid precursor protein (APP) is
the precursor to amyloid plaque.
1. APP sticks through the neuron
membrane.
2. Enzymes cut the APP into
fragments
of protein, including
beta-amyloid.
3. Beta-amyloid fragments come
together in clumps to form plaques.
In AD, many of these clumps form,
disrupting the work of neurons. This
affects the hippocampus and other
areas of the cerebral cortex.
Neurofibrillary
Tangles
Neurons have an internal support structure partly made up of microtubules.
A protein called tau helps stabilize microtubules.
In AD, tau changes, causing microtubules to collapse, and tau proteins clump
together to form neurofibrillary tangles.
The Changing Brain in Alzheimer’s
Disease
No one knows what causes AD to begin, but we do
know a lot about what happens in the brain once
AD takes hold.
Pet Scan of Normal Brain
Pet Scan of Alzheimer’s Disease
Brain
Preclinical AD
• Signs of AD are first
noticed in the entorhinal
cortex, then proceed to the
hippocampus.
• Affected regions begin to
shrink as nerve cells die.
• Changes can begin 10-20
years before symptoms
appear.
• Memory loss is the first
sign of AD.
Mild to Moderate AD
• AD spreads through the brain. The
cerebral cortex begins to shrink as
more and more neurons stop working
and die.
• Mild AD signs can include memory
loss, confusion, trouble handling
money, poor judgment, mood
changes, and increased anxiety.
• Moderate AD signs can include
increased memory loss and
confusion, problems recognizing
people, difficulty with language and
thoughts, restlessness, agitation,
wandering, and repetitive statements.
Severe AD
• In severe AD, extreme shrinkage
occurs in the brain. Patients are
completely dependent on others
for care.
• Symptoms can include weight
loss, seizures, skin infections,
groaning, moaning, or grunting,
increased sleeping, loss of
bladder and bowel control,
malnutrition.
• Death usually occurs from
aspiration pneumonia or other
infections. Caregivers can turn to
a hospice for help and palliative
care.
AD Research: the Search for Causes
• AD develops when genetic,
lifestyle, and environmental
factors work together to cause
the disease process to start.
• In recent years, scientists have
discovered genetic links to AD.
• They are also investigating other
factors that may play a role in
causing AD
AD Research: the Search for Causes
Genetic Studies
The two main types of AD are
early-onset and late-onset:
• Early-onset AD is rare, usually
affecting people aged 30 to 60
• Late-onset AD is more
common. It usually affects
people over age 65.
Researchers have identified a
gene that produces a protein
called apolipoprotein E (ApoE).
Scientists believe this protein is
involved in the formation of
beta-amyloid plaques.
• Researchers have identified
mutations in nine genes that
are implicated in AD.
Studies at the Cellular and Molecular Level
• Oxidative damage from
free radical molecules can
injure neurons.
• Homocysteine, an amino
acid, is a risk factor for
heart disease. A study
shows that an elevated
level of homocysteine is
associated with increased
risk of AD.
• Scientists are also looking
at inflammation in certain
regions of the brain and
strokes as risk factors for
Epidemiologic Studies
 Scientists examine characteristics,
lifestyles, and disease rates of groups
of people to gather clues about
possible causes of AD.
 Two of the studies focus on religious
communities. Yearly exams of physical
and mental status, and studies of
donated brains at autopsy. Some early
results indicate:
• Mentally stimulating activity protects the
brain in some ways.
• In early life, higher skills in grammar and
density of ideas are associated with
protection against AD in late life.
AD Research: Diagnosing AD
Physicians today use a number of tools to
diagnose AD:
• a detailed patient history
• information from family and
friends
• physical and neurological
exams and lab tests
• neuropsychological tests
• imaging tools such as CT scan,
or magnetic resonance imaging
(MRI). PET scans are used
primarily for research purposes
AD Research: NIA Study
Neuroimaging and Biomarkers of AD Initiative, to
study how the brain changes in Mild Cognitive
Impairment (MCI) and AD.
• Using MRIs and PET scans conducted at regular intervals, researchers
hope to learn precisely when and where in the brain problems occur.
• Researchers will also examine blood samples to check for higher levels
of abnormal substances that could be considered “biomarkers” of AD.
• Also studying CSF markers.
• Looking for subtle changes that may indicate the changes of AD
Alzheimer’s Treatments
 Current medications cannot cure Alzheimer’s or stop it
from progressing, they may help lessen symptoms,
such as memory loss and confusion, for a limited time.
 The FDA has approved two types of medications
 These drugs treat the cognitive symptoms (memory
loss, confusion), and problems with thinking and
reasoning to help lessen or stabilize symptoms for a
limited time by affecting certain chemicals involved
in carrying messages among the brain's nerve cells.
Alzheimer’s Treatments
 Cholinesterase
inhibitors
(Aricept,
Exelon,
Razadyne,
Cognex)
Alzheimer’s Treatments
 NMDA
/receptor
blocker,
(Namenda or
memantine
HCL)
Alzheimer’s Treatments
 Non-drug approaches may be used for behavior and
personality changes such as:
 Irritability ,Anxiety
 Depression
 Agitation & Aggression
 Emotional distress, physical or verbal outbursts
 Restlessness, pacing, shredding paper or tissues
 Hallucinations (seeing, hearing or feeling things that are not really there)
 Delusions (firmly held belief in things that are not true)
 Sleep disturbances
 Monitor their conditions, anticipate their needs.
 Drugs used: Antidepressants (for mood), Anxiolytics (for
anxiety/restlessness), Antipsychotic medications (for
hallucinations)
Managing Symptoms
 70 to 90% of people with AD eventually
develop behavioral symptoms: sleeplessness,
wandering and pacing, aggression, agitation,
anger, depression, hallucinations and
delusions. Experts suggest coping strategies
for managing difficult behaviors:
• Stay calm and be understanding.
• Be patient and flexible. Don’t argue or try to
convince.
• Acknowledge requests and respond to them.
• Try not to take behaviors personally. Remember:
It’s the disease talking.
Experts encourage caregivers to try non-medical coping strategies first. However,
medical treatment is often available if the behavior has become too difficult to
handle.
Helpful Hints to Reduce Agitation
 Decrease environmental stimulation
 Break down tasks into simple steps
 Provide choices, try humor/not demanding
 Be prepared to repeat yourself
 Ask one question at a time/ simple answers
 Be non-confrontational – limit number of
people communicating to ONE
Basic Patient Management
 For any patient with altered mental status,
airway and breathing support have priority.
 Supplemental oxygen at a minimum
 Consider need for positive pressure ventilations.
 Monitor ECG, pulse Ox, and blood sugar.
 Determine dementia diagnosis, establish
baseline and be slow, and supportive.
Basic Patient Management
 Medical problems
 Medications – polypharmacy is common, need to know
ALL meds including herbal/ OTC
 Psychological state; find out what is normal from family
members
 May need nothing more than your presence and
attention while taking to hospital
 Take note of the environment (possible abuse)
Resources
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GEMS
Medscape
Web MD
Alzheimer’s Association
Cleveland Clinic/ CCF EMS
Mayo Clinic
 National Institute on Aging, part of the
 National Institutes of Health (NIH)
 CDC