ALZHEIMER S DISEASE OVERVIEW. Jeffrey Cummings, MD, ScD Cleveland Clinic Lou Ruvo Center for Brain Health

Transcription

1 ALZHEIMER S DISEASE OVERVIEW Jeffrey Cummings, MD, ScD Cleveland Clinic Lou Ruvo Center for Brain Health

2 Prevalence AD: DEMOGRAPHY AND CLINICAL FEATURES Risk and protective factors Clinical features and course Differential diagnosis Current therapeutic approach

3 PREVALENCE

4 PREVALENCE OF ALZHEIMER S DEMENTIA Doubles in frequency every 5 years after age 60 50% of those over age Most common cause of memory loss in the elderly

5 RISK AND PROTECTIVE FACTORS

6 ALZHEIMER S IS A LIFE-LONG PROCESS AD Less Likely: Education Exercise Brain fitness Antioxidant diet Heart health AD More Likely: Age Genetics Female sex Hypertension Diabetes Homocysteine Cholesterol Head trauma Smoking

7 CLINICAL FEATURES

8 The Journey of William Uttermohlen 1967

9 Blue Skies (1995) 1996

10

11

12 2000

13 CLINICAL FEATURES She does not remember what I told her 5 minutes ago She keeps repeating the same question As the disease progresses Memory loss Language loss Loss of bladder control Loss of bowel control and walking Death 10 years from first symptoms to death

14 History Past medical history Medications Family history CLINICAL ASSESSMENT OF THE AD PATIENT Medical / neurological examination Mental status examination

15 CLINICAL ASSESSMENT

16 COMMONLY USED ASSESSMENT TOOLS Most clinicians do not do a mental status examination Most clinicians who perform mental status testing do not use a formal examination Common structured examinations Mini-Mental Status Examination (MMSE) Montreal Cognitive Assessment (MoCA)

17 MOCA 30 items minutes More challenging than MMSE Executive function included Multiple languages

18 CT or MRI CLINICAL ASSESSMENT OF THE AD PATIENT Laboratory tests including thyroid (TSH), B12 Contingent assessments Neuropsychological assessment in some FDG PET (for some) Apolipoprotein genotype (ApoE) Other laboratory tests (homocysteine, ESR, etc) Amyloid PET (for some)

19 PET TAU IMAGING

20 OTHER CAUSES OF DEMENTIA

21 Dementia Differential Diagnosis TSH; B12 Chronic Encephalopathies Focal Signs Vascular Dementia Parkinsonism Dementia with Lewy Bodies Tactless; Impulsive Frontotemporal Dementia Amnestic Memory Defect Alzheimer s Disease Atypical Syndrome Rare Disorders; Atypical Presentations

22 TREATMENT

23 Diagnosis AD: CURRENT THERAPY ALGORITHM Cholinesterase Inhibitor Progression or Moderate-Severe Disease Antidepressants, antipsychotics, sleep meds In some Memantine/High Dose ChE-I Late Stage Management: Infection Hydration Skin care

24 AD THERAPIES Useful, modest efficacy Temporary improvement (2-4 points on the ADAS-cog) Delay of decline (6-9 months) Side effects Cholinesterase inhibitors -> nausea, vomiting, diarrhea Memantine -> somnolence, dizziness, headache Combination therapy Well tolerated Additive benefit

25 Clinical Trials Cog Enhancers Behave Pharm CG Care Physical Exercise Comprehensive Integrated Care Pharm Asst d Disorders Medical Foods Cog Exercise Non-Pharm Tx Diet; Supplement

26 SUMMARY

27 SUMMARY AD is a relentlessly progressive disease with cognitive, functional, and behavioral disturbances AD begins with repeated questioning and progresses AD is under-recognized, under-diagnosed, and under-treated Current treatment involved cholinesterase inhibitors and memantine