ALZHEIMER S DISEASE OVERVIEW Jeffrey Cummings, MD, ScD Cleveland Clinic Lou Ruvo Center for Brain Health
Prevalence AD: DEMOGRAPHY AND CLINICAL FEATURES Risk and protective factors Clinical features and course Differential diagnosis Current therapeutic approach
PREVALENCE
PREVALENCE OF ALZHEIMER S DEMENTIA Doubles in frequency every 5 years after age 60 50% of those over age 85-90 Most common cause of memory loss in the elderly
RISK AND PROTECTIVE FACTORS
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
CLINICAL FEATURES
The Journey of William Uttermohlen 1967
Blue Skies (1995) 1996
1996 1997
1998 1999
2000
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
History Past medical history Medications Family history CLINICAL ASSESSMENT OF THE AD PATIENT Medical / neurological examination Mental status examination
CLINICAL ASSESSMENT
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)
MOCA 30 items 10-15 minutes More challenging than MMSE Executive function included Multiple languages www.mocatest.org
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)
PET TAU IMAGING
OTHER CAUSES OF DEMENTIA
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
TREATMENT
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
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
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
SUMMARY
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