Screening, evaluation and treatment of dementia in the elderly Asian population

Transcription

1 Screening, evaluation and treatment of dementia in the elderly Asian population Aimee Kao, MD, PhD Associate Professor of Neurology UCSF Asian Health Symposium No disclosures Outline of talk Introduction Dementia definition and syndromes Case study Special issues in the Asian community UCSF Chinese Outreach Clinics Why is dementia important? Rapidly aging population Alzheimer Disease is the 6 th leading cause of death in the U.S. 5.4 million individuals affected 1 in 8 Americans aged 65 and older is affected by Alzheimer s Disease In 2013, Americans provided provided 17.7 billion hours of unpaid care to people with AD and other dementias In 2014, AD cost Medicare and Medicaid ~$150 billion Public health impact of deaths from Alzheimer s disease Percentage change in cause of death 2000 to 2013 Alzheimer's & Dementia: :

2 Rates of dementia in Asian Americans Recent studies suggest rates of dementia in Chinese are comparable to those in U.S. 8% in Hong Kong 10% in China ~11% in US Asians in US, average annual rate: 15.2 per 1,000 for Asian Americans (included Japanese) 19.3 per 1,000 for Caucasians Little data comparing dementia in Asians vs. other Americans Sources: Fei et al., Alz Dis Assoc Disord, 2009; Lam et al., Int Psychogeriatr, 2008; Mayeda et al. Alzheimers Dement, 2016; 2000 U.S. Census Data; 2009 American Community Survey Data What is dementia? An acquired, progressive, persistent impairment in cognition or behavior Involves 1 or more cognitive domains Sufficient to cause a decline from a previous level of functioning Dementia is no longer a diagnosis of exclusion Pre frontal: Executive function and behavior Temporal: Memory Frontal and subcortical: Motor Parietal/temporal: Language and visuospatial Risk and protective factors Risk Factors Increased age Vascular disease Genetics (ie ApoE4) Head injury Lower education Chronic inflammation Protective Factors Physical exercise Social engagement Mental activity Education Careful phenotyping of dementias is critical for appropriate treatment Lewy Body Disease Frontotemporal dementia Progressive supranuclear palsy Corticobasal degeneration Multiple system atrophy Amyotrophic lateral sclerosis Triplet repeat disease (ie Huntington s Disease) Paraneoplastic disorders Hashimoto s encephalopathy CNS lymphoma Rapidly progressive dementias (ie Creutzfeld Jakob disease) Adapted from Courtesy Plassman Howard et al., Rosen

3 The Mini Mental Status Exam (MMSE) for dementia screening Very good screening tool Can be administered rapidly (<5 min) and reproducibly Covers basic cognitive domains (memory, language, visuospatial, executive, motor) Normal is 29/30 (as long as 1 is from word memory) Case Study: A 76 yo Chinese American woman with forgetfulness CC: My memory is not as good as it used to be, but overall it s fine. HPI: (from patient and informant) Insight? Over last 2 years, has forgotten to take her pills and missed appointments Family is concerned about her riding buses in the city by herself as she got lost and was missing for several hours. Has had several falls in the last 1 2 years Family worries that she is depressed Depression as a sx? PMH: Hypertension, hyperlipidemia Neurological exam: Socially intact but with a paucity of spontaneous speech Cogwheel rigidity in arms L>R (parkinsonism) Gait instability Fall risk MMSE: 21/30 missing points for orientation, memory, copy of pentagons Executive, memory and visuospatial What is the diagnosis? A. Normal aging B. Alzheimer Disease (AD) C. Vascular dementia (VaD) D. Alzheimer Disease + Vascular dementia Answer: It depends on the MRI For vascular dementia, look on T2 or FLAIR sequences for Lacunar infarcts Periventricular white matter (PVWM) changes (FLAIR image) 3

4 In AD, look for hippocampal atrophy Alzheimer Disease (AD) Normal hippocampus Atrophy of hippocampus 1 st symptom: Difficulty encoding new memories (due to hippocampal atrophy) Will spread to include other cognitive domains Usually social graces and motor functions are spared until late in disease AD symptoms mirror its spreads through connected neuronal circuits Vascular Dementia (VaD) Example of sub cortical fibers Early Middle Late 1 st symptom: Difficulty retrieving memories (sub-cortical pattern of memory impairment) Stepwise progression Oftentimes accompanied by executive dysfunction, parkinsonism, psychiatric disturbance (paranoia, hallucinations) Vascular dementia is distinct from stroke 4

5 Diagnosis of vascular dementia Amyloid imaging is an early biomarker for AD Can be difficult Symptoms and impairments similar to AD Research shows that physicians don t always agree Presence of PVWM changes on MRI does not rule out AD Absence of PVWM changes makes AD more likely Problems with balance and walking are more common in early vascular dementia Differs from stroke in non acute onset and progressive impairment without recovery over time Amyloid Plaques PET Imaging + Pittsburgh Compound B (PIB) HO S NH 11 CH 3 N PIB binds fibrillar amyloid in a reversible fashion Helpful in distinguishing AD from other dementias Can help to predict who will convert from MCI to AD Is not a screening tool for asymptomatic individuals Courtesy of William Klunk, UCB Amyloid is Also Detectable in Normal Older Adults 15%-30% of cognitively normal older adults are Aβ- PET+ More common in ApoE4+ and older age Treatment of AD and VaD are similar Acetylcholinesterase inhibitor (ie donepezil) SSRI for depression and/or irritability Exercise regimen +/ physical therapy Home safety evaluation to prevent falls, accidents Planning for the future Caregiver support Rabinovici and Jagust 5

6 AD and VaD: Take home points By age 90, >50% of individuals have AD plaques and tangles, so overlap syndromes are common Loss of insight is common in dementia affecting frontal lobes Depression can be a presenting symptom of a neurodegenerative disorder Special considerations in an Asian population Because of family support, presentation to healthcare tends to be later in disease Family interviews may need to be conducted separately out of respect to affected individual Potential stigma against psychiatric disorders can make the diagnosis of co existent depression challenging Compliance with medications, especially antidepressants, may be an issue Chinese Outreach Clinics 華人外展計劃診所 Goals of Chinese Outreach Program Chinatown Public Health Center 華城公共衛生局 AM Thursdays PM Chinese Hospital 東華醫院 Address the underrepresentation of Asian Americans in dementia research Establish outreach to overcome geographical, resource and transportation barriers Conduct community lectures to provide dementia education in appropriate cultural context 6

7 UCSF Chinese Outreach Team 外展團隊 Multilingual and multicultural staff Dr. Howard Rosen (Neurologist) 羅森醫師, 神經內科 English 英文 Dr. Richard Tsai (Neurologist) 蔡孟鈞醫師, 神經內科 Mandarin, English 國語, 英文 Marian Tse (Clinical Outreach Coordinator) 謝譚敏兒, 研究助理 Cantonese, Toishanese, Mandarin, English 廣東話, 台山話, 國語, 英文 Contact info: Phone 415/ Fax 415/ UCSF Sandler Neurosciences Center Thank you Purpose of Chinese Outreach Program 華人外展計劃宗旨 UCSF Chinese Outreach Program: UCSF 創立華人外展計劃 : Address the underrepresentation of Chinese Americans in dementia research 針對華人在失智症 / 老人癡呆症研究領域代表性不足 Establish outreach clinics to overcome geographical, resource and transportation barriers. 創立華人社區診所, 客服地理, 資源, 交通困難 Conduct community lectures to provide dementia education in appropriate cultural context. 為華裔美國人提供語言, 文化適當的失智症 / 老人癡呆症教育與支持 7