3/13/2018 ALZHEIMER S DISEASE IN ADULTS WITH DOWN SYNDROME

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1 ALZHEIMER S DISEASE IN ADULTS WITH DOWN SYNDROME Sigan L. Hartley, Ph.D. Waisman Center Investigator 100 Chair Human Ecology Associate Professor, School of Human Ecology University of Wisconsin-Madison ALZHEIMER S DISEASE Most common type of dementia progressive deterioration of cognitive functioning that ultimately prevents performance of everyday activities Dementia vs. Alzheimer s disease: Alzheimer s disease affects the brain and causes the observed changes in dementia ALZHEIMER S DISEASE Accounts for 70% of cases of dementia Difficulty in language, memory, perception, behavior, persaonlity, and cognitive skills 1

2 ALZHEIMER S DISEASE 5.3 million Americans; 110,000 in Wisconsin Prevalence will increase; ~ 10,000 Baby Boomers turn 65 per day 7 th leading cause of death ALZHEIMER S DISEASE No cure Treat symptoms; temporarily slow the progression of disease Critical need to find ways to treat the disease, delay onset, and prevent DOWN SYNDROME Reprinted from Shaw,

3 DOWN SYNDROME 1 in 800 live births worldwide; ~255,000 children in US Intellectual disability Impairments in language, motor, and cognitive skills Facial appearance - flat face, short neck, slanting eyes, etc. Physical features - low muscle tone, loose joints Health conditions - problems with thyroid, heart, intestines, hearing loss DOWN SYNDROME AND ALZHEIMER'S DISEASE General population: Rare before age 50; 5-10% of adults aged 65+ yrs; 15-30% of those aged 80+ yrs Down syndrome: 9% of adults in 40; 33% of adults in 50s; 50% of adults in 60s+ yrs WHY THE HEIGHTENED RISK? Chromosome 21 codes for the amyloid-β precursor protein (APP) gene APP Accumulation of amyloid-β plaques in brain plays key role in development of Alzheimer's disease 3

4 NEUROPATHOLOGY IN ALZHEIMER'S DISEASE Healthy Alzheimer s Disease Neurofibrillary tangles Amyloid-β plaques Image: Jannis, Dempsey, & Fredenburg; Jannis Productions/NSF PROGRESSION OF ALZHEIMER S DISEASE Healthy Mild Cognitive Early Middle Late Impairment Alzheimer s Disease Reprinted from Tarawneh & Holtzman, 2010 PROGRESSION OF ALZHEIMER S DISEASE Healthy Mild Cognitive Early Middle Late Impairment Alzheimer s Disease Reprinted from Tarawneh & Holtzman,

5 PROGRESSION OF ALZHEIMER S DISEASE Healthy Mild Cognitive Early Middle Late Impairment Alzheimer s Disease Reprinted from Tarawneh & Holtzman, 2010 NEURODEGENERATION IN AGING DOWN SYNDROME Track early brain changes associated with Alzheimer s disease in adults with Down syndrome in order to more broadly understand early neuropathology and course of disease How does Alzheimer's disease develop? When could we intervene? Why do symptoms progress faster in some individuals than others? Can we come up with accurate early screeners? University of Pittsburgh University of Cambridge, UK Waisman Center, University of Wisconsin-Madison BRAIN IMAGING Magnetic resonance imaging (MRI) Positron emission tomography (PET) 5

6 PIB PiB Status Tissue ratios calculated for cortical regions-of-interest (ROI) and normalized to cerebellum (SUVR) PiB+ = above the cutoff (>1.5) in 5 cortical areas defined using the iterative outlier approach AGE AND PIB % PiB positive subjects generally increased with age PiB positivity of the striatal components with the value of the whole striatum represented as the black line. NEUROPSYCHOLOGICAL TESTS 6

7 SCREEN AND DIAGNOSIS ALZHEIMER'S DISEASE IN DOWN SYNDROME SCREEN AND DIAGNOSIS ALZHEIMER'S DISEASE IN DOWN SYNDROME Baseline assessment of adult functioning by age 35 years documents cognitive abilities, memory, motor functioning, everyday living skills, and social and behavioral functioning Consider medical conditions COMPLICATING THE PRESENTATION AND/OR NEED TO BE RULED OUT Vision loss/impairment Hearing loss Hypothyroidism Obstructive sleep apnea Osteoarthritis Atlantoaxial instability and cervical spine disease Osteoporosis Celiac disease 7

8 SCREEN AND DIAGNOSIS ALZHEIMER'S DISEASE IN DOWN SYNDROME Baseline assessment of adult functioning by age 35 years documents cognitive abilities, memory, motor functioning, everyday living skills, and social and behavioral functioning Consider medical conditions Consider life transitions Transfer of care to siblings Death of parents Work or staff transitions ALZHEIMER S DISEASE PROGRESSION Mild Cognitive Impairment Early Stage Alzheimer's Disease Mild problems remembering recent information Mild difficulty in planning (slowed) Mild impairments in reasoning or judgement Still completing activities of daily living Memory of recent information/events impaired Misplace items Word finding difficulties Difficulty tracking conversation Problems processing visual information Slower at grasping new ideas Confused or lose track of the day or date Social withdrawal EARLY STAGE ALZHEIMER'S DISEASE Normal Aging Making a bad decision 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 Signs of Alzheimer s disease Poor judgment and 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 8

9 ALZHEIMER S DISEASE PROGRESSION DIFFERENCES IN DOWN SYNDROME Other groups, found some evidence that behavior and personality may occur earlier on in course of Alzheimer s than in general population But, our group s findings suggest that early brain changes are more strongly linked with memory and cognitive declines Episodic memory Visuospatial coordination Change Cycle 1 to Cycle 2 in Cognitive Score by PiB group (Amyloid-β) Free and Cued Recall PiB- to PiB- PiB+ to PiB+ PiB- to PiB+ 1 2 Cycle Change in Episodic Memory by PiB group (Amyloid-β) Cued Recall Intrusions Cycle PiB- to PiB- PiB+ to PiB+ PiB- to PiB+ 9

10 SCREENING TOOLS National Task Group Early Detection Screen for Dementia (NTG-EDSD) Dementia Scale for Down Syndrome (DSDS) DIRECT ASSESSMENTS Dementia symptoms Adaptive behavior Behavior and emotion IQ MEMORY 10

11 MEMORY Rivermead Behavioral Memory Test Sally and Kevin have been friends for 30 years. Every Tuesday morning they meet at Rosie s Restaurant where they have coffee and donuts. Then they go for a walk near Mirror Lake. 11

12 VISUOSPATIAL ORGANIZATION EXECUTIVE FUNCTIONING ALZHIEMER S DISEASE PROGRESSION Middle Stage Alzheimer s disease Late Stage Alzheimer s disease need support in day-to-day life confusion with day/time disorientation and wondering off forget names repeat questions fail to recognize people easily upset, angry or aggressive, seek reassurance dependent on others for care unable to recognize familiar objects, people, or surroundings unable to walk; incontinence difficulty eating and, sometimes, swallowing gradual loss of speech restless, distressed or aggressive 12

13 TIPS FOR PROFESSIONALS ANDCAREGIVERS COMMUNICATING WITH SOMEONE WITH ALZHEIMER'S DISEASE Address the adult directly, even with diminished cognitive capacity Sit in front of them and at same level and gain in order to help gain their attention Try to speak clearly and at a natural rate of speech. Avoid speaking too loudly, unless earing is an issue Provide information to help orient the adult. For example, explain who you are and what you are going to be doing Consider having a family member or caregiver present and try to be in a familiar surrounding when possible COMMUNICATING WITH SOMEONE WITH ALZHEIMER'S DISEASE Adults with dementia may have difficulty with open-ended questions. Consider using a yes-or-no or multiple-choice format. Break down activities into a set of simple instructions When needed, distract and redirect Not worth arguing Can still find ways to enjoy life! 13

14 DO ALZHEIMER S DISEASE MEDICATIONS WORK FOR ADULTS FDA has not approved any drugs specifically to treat dementia associated with Down syndrome In the United Kingdom, cholinesterase inhibitors are approved to treat dementia in people with Down syndrome But, to date, international experts concluded that not enough evidence to reach a conclusive judgment about the benefit of cholinesterase inhibitors for people with Down syndrome DO ALZHEIMER S DISEASE MEDICATIONS WORK FOR ADULTS Early evidence from clinical study that memantine is not effective in adults with Down syndrome Currently studying effect of scyllo-inositol in adults with Down syndrome ARE THEIR WAYS TO REDUCE RISK AND/OR STAY HEALTHIER LONGER? Growing evidence that healthy lifestyles can reduce risk for dementia In other words, there may be lifestyle choices that can promote cognitive and physical health in adults with Down syndrome 14

15 CARDIOVASCULAR EXERCISE Regular exercise that rises heart rate can help promote healthy brain activity NOT SMOKING A link between smoking and increased risk for Alzheimer's disease has been found in general population LOWER RISK FOR HEART DISEASE Obesity, high blood pressure, high cholesterol, diabetes 15

16 DIET Mixed evidence SOCIALLY ENGAGED MENTALLY ENGAGED 16

17 Acknowledgements THE WONDERFUL FAMILIES IN OUR STUDY!! Ben Handen Brad Christian William Klunk Iulia Mihaila Renee Makuch Julie Price Patrick Lao Annie Cohen Darlynne Devenny Peter Bulova Sarah Clayton Travis Doran David Maloney Patty Jo Murray Michael Bergnic Christy Matan Chester Mathis Marsha Mailick Tami Hogg Sterling Johnson Regina Hardison Tobey Betthaus Ansel Hillmer Andrew Higgins Rameshwari Tumuluru Dhanabalan Murali Todd Barnhart National Institute of Heath (AG031110; P30 HD03352, AG033514, AG029479, U01AG051406) Friends of the Waisman Center The Morse Society 17