PROJECTION: Worlds dementia population is expected to triple by 2050

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1 DEMENTIA C L I S K C O N S U LTA N T P H Y S I C I A N I N A C U T E M E D I C I N E A N D G E R I AT R I C M E D I C I N E, B A R N E T H O S P I TA L, R O YA L F R E E N H S F O U N D AT I O N T R U S T A N D H E R T F O R D S H I R E C O M M U N I T Y N H S T R U S T

2 MENU Epidemiology of dementia Continum of Alzheimers dementia AD Pathological features of AD Clinical features Differential diagnosis Investigations Cognitive testing Management including Resources available and update in the clinical use of established therapies The future perhaps: agents in development Biomarkers Prevention of AD; is this achievable or a pipedream?

3 Alzheimers dementia Neurodegenerative disorder marked by cognitive and behavioural impairment that significantly interferes with social and occupational functioning. Incurable with long preclinical period and progressive course

4 PROJECTION: Worlds dementia population is expected to triple by 2050

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6 COSTS

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8 AD PREVALENCE

9 THE CONTINUM OF AD

10 Risk factors for AD

11 AD overview

12 PATHOLOGICAL FEATURES OF AD

13 Plaque deposition and AD pathology

14 Clinical signs and symptoms MILD AD Memory loss Confusion about the location of familiar places Taking longer to accomplish normal daily tasks Trouble handling money and paying bills Compromised judgement often leading to bad decisions Loss of spontaneity and sense of initiative Mood and personality changes; increased anxiety MODERATE AD Increasing memory loss and confusion Shortened attention span Problems recognising friends and family members Difficulty with language; problems with reading, writing, working with numbers Difficulty organising thoughts and thinking logically Inability to learn new things or to cope with new unexpected situations Restlessness, agitation, anxiety, tearfulness, wandering Repetitive statements or movement; occasional muscle twitches, Hallucinations, delusions, suspiciousness or paranoia, irritability Loss of impulse control Perceptual motor problems such as trouble getting out of a chair or setting the table

15 Clinical signs and symptoms (severe) Cannot recognise family or loved ones Completely independent for all ADLS Vanishing sense of self Weight loss Seizures, skin infections, difficulty swallowing Groaning, moaning, grunting Increased sleeping Lack of bladder and bowel control Death usually from aspiration pneumonia frequently

16 Other signs and symptoms Language disorders; anosmic, aphasia or anomia Visuospatial and executive functions impairment Less commonly right parietal lobe syndrome, spastic paraparesis.

17 Distinguishing AD from MCI

18 Physical examination Complete physical examination Mental status examination Attention and concentration Recent and remote memory Language Praxis (ability to perform skilled motor task without nonverbal prompting) Executive function Visiospatial function

19 Assessing language

20 Declining ability to function

21 RACHEL.

22 Mood and emotional changes

23 WHAT TESTS WOULD YOU ORDER FOR RACHEL?

24 Determining the level of impairment

25 Cognitive impairment

26 Differential diagnosis

27 Differential diagnosis

28 Workup and what next..

29 Cognitive testing

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32 AD 8

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34 Biomarker testing

35 Neuroimaging in AD

36 Hippocampal volume assessment

37 MRI IMAGING

38 MRI

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40 MANAGEMENT: CHOLINESTERASE INHIBITORS

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42 FDA APPROVED DRUGS FOR AD

43 Cognitive benefit of donepezil

44 Cognitive benefit of donepezil

45 Cognitive benefit of donepezil

46 Rivastigmine

47 Cognitive effects of rivastigmine

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49 Galantamine

50 Memantine

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52 Side effects of cholinesterase inhibitors

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56 Caide score for predicting risk of dementia

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62 Antihypertensives and AD

63 OBSTACLES TO RECOGNISING DEMENTIA

64 DETECTING COGNITIVE IMPAIRMENT IN PRIMARY CARE

65 DETECTING COGNITIVE IMPAIRMENT IN PRIMARY CARE

66 Conclusions