What About Dementia? Module 8, Part B (With Dr Allison Lamont) Slide 1 Module 8 Part B will address the question What about dementia? Several surveys of older people both in the UK and USA have shown that older people fear dementia and the subsequent loss of memory and independence more than they do death, itself. Slide 2 Class attendees often ask questions about dementia many come to the classes because they have close relatives who have experienced dementia. Very often there is fear around the most common memory lapses because of the worry that it is the start of something far more sinister. We will look at the symptoms of dementia and how they differ from the sort of memory lapses that people experience as part of the ageing process. The latest research is clear it is possible to guard against Alzheimer s disease, the most common form of dementia, and there is compelling evidence that the sort of lifestyle changes and cognitive exercise in Brain Fit for Life will do much to counter the risk factors for this dreadful disease. Module 8, Part B Transcript 1
Slide 3 Very often people use the terms dementia and Alzheimer s disease interchangeably. This is not the case. DEMENTIA is a chronic, terminal disorder of the mental processes caused by brain disease or injury, and is marked by memory disorders, personality changes, and impaired reasoning. Alzheimer s, or any of the other types of dementia, are the CAUSE of the dementia. As you can see on the slide, there are many other causes of dementia, too. Slide 4 These are the most common causes of dementia. As you can see, dementia of the Alzheimer s type, sometimes written as DAT or more commonly by the initials AD, is by far the most diagnosed cause of dementia. Second most common is Vascular Dementia, followed by mixed types, and a lot less common are dementia with Lewy Bodies, and Fronto-temporal dementia. Other, rarer, causes of dementia include Korsakoff s syndrome (associated with alcohol use), Huntington s disease, and dementia caused by inoperable tumours and injury. We will take a look at some of these, and then move to a more in depth understanding of Alzheimer s disease. Slide 5 Vascular Dementia is the second most common cause of dementia. This group of conditions is caused by poor blood supply to the brain as a result of a stroke or several mini-strokes. Vascular dementia symptoms can begin suddenly after a stroke or gradually as disease in the blood vessels worsens. Some people can have both vascular dementia and Alzheimer s disease and will then be in the category of mixed dementias. Module 8, Part B Transcript 2
Slide 6 Lewy Body Dementia is characterised by the presence of Lewy Bodies abnormal clumps of protein in the brain. These develop within the cells. The Lewy Bodies cause changes in movement, thinking, behaviour and alertness. People with Lewy Body dementia can fluctuate between almost normal functioning and severe confusion within short periods of time, and may also have hallucinations, seeing things that aren t really there. Lewy body dementia happens when the Lewy Bodies are present within the cerebral cortex. Slide 7 There is sometimes confusion about Lewy Bodies, as Lewy Bodies are also present in Parkinson s disease. However, in Parkinson s the Lewy Bodies appear in only in the substantia nigra a brain structure in the mid-brain that is important to movement. Slide 8 Here we see that if the location of Lewy Bodies is within the cerebral cortex, then the outcome is Lewy Body dementia (LBD). Parkinson s disease is a disease of movement the primary cause is related to lack of dopamine a neurotransmitter. For some Parkinson s patients, Lewy Bodies also develop in the cerebral cortex, leading to both the characteristic Parkinson s movement problems and dementia (PDD) Module 8, Part B Transcript 3
Slide 9 In this slide you can see the devastating damage done to the frontal and sometimes temporal lobes in Frontotemporal lobe dementia. This disease (also known as Pick s disease) is a group of conditions which affect the frontal and/or temporal lobes of the brain. If a person has affected frontal lobes they will have increasing difficulty with motivation, planning and organising, controlling emotions and maintaining socially appropriate behaviour. If temporal lobes are affected the person will have difficulty with speaking and/or understanding language. Although it is a less common cause of dementia, symptoms often begin in a person s 50s or 60s. Module 8, Part B Transcript 4
Slide 10 Alzheimer s disease is the most common form of dementia. It is not part of normal ageing, although the greatest known risk factor is increasing age and the majority of people with Alzheimer s are 65 and over. However, Alzheimer s is not just a disease of old age. Up to 5% of the people with the disease have early onset Alzheimer s which can appear when someone is in their 40s or 50s. The early-onset of Alzheimer s is the type most affected by a genetic component. Alzheimer s is a progressive disease, where dementia symptoms gradually worsen over a number of years. In the early stages, memory loss is mild, but with late-stage Alzheimer s, individuals lose the ability to carry on a conversation and respond to their environment. Survival is usually somewhere between 4 and 20 years after the onset of noticeable symptoms, depending on age and other health conditions. Slide 11 Module 8, Part B Transcript 5
Defining characteristics of Alzheimer s are the presence of amyloid plaques and neurofibrillary tangles. Plaques form when protein pieces called beta-amyloid clump together. Beta-amyloid comes from a larger protein found in the fatty membrane surrounding nerve cells. It is sticky and gradually builds up into plaques. It is thought that these may block cell-to-cell signalling at synapses and may also activate immune cells which devour disabled cells. Tangles destroy a vital cell transport system. Slide 12 This electron microscope picture shows a cell with some healthy areas and some others areas where tangles are forming. The transport system is organised in orderly parallel strands a bit like railway tracks. Food molecules, cell parts, and other key materials travel along these tracks. A protein called tau helps keep the tracks straight. In areas where tangles are forming, tau collapses into twisted strands these are the tangles. The tracks can no longer stay straight. They fall apart and disintegrate. Nutrients and other essential supplies can no longer move through the cells, which eventually die. Slide 13 One of the difficulties of diagnosis of Alzheimer s is that there isn t one pathway along which the symptoms must travel. It may attack in a different order of brain areas although it is known to usually start within the hippocampal area. This is, however, a typical track for the disease to take. The formation of the plaques and tangles start here, in the hippocampus, the part of the brain where memories are first formed. Over years, the plaques and tangles slowly kill the cells within the hippocampus and it becomes harder and harder to form new memories. Simple recollections from a few days or moments ago we would take for granted are simply not there. Module 8, Part B Transcript 6
Slide 14 Then the plaques and tangles spread into different regions of the brain, killing cells and compromising function wherever they go. From the hippocampus, the disease often spreads to the area of the brain where language is processed. When that happens it becomes harder and tougher to get the right word. Language becomes less elaborate and it is harder to take part in conversations. Slide 15 Then the disease creeps towards the front of the brain where logical thought takes place. Very gradually, the person begins to lose the ability to solve problems, grasp concepts, and make plans. Slide 16 When the plaques and tangles invade the brain area where emotions are regulated the person gradually loses control of moods and feelings. There can be angry outbursts or the person acts in a way or has moods that seems out of character to earlier days. Slide 17 When the disease spreads to the area where the brain makes sense of what it sees, hears and smells, Alzheimer s wreaks havoc on a person s senses and can spark hallucinations. At this stage the characteristics and behaviours associated with severe Alzheimer s are usually all too apparent. Slide 18 Eventually the disease erases a person s oldest and most precious memories stored towards the back of the brain. Near the end, the disease compromises a person s balance and coordination, and in the very last stages it destroys the part of the brain which regulates breathing and the heart. The progression from mild forgetting is slow and steady. It takes place over a number of years. It is relentless, and for now, it is incurable. Slide 19 Alzheimer s looks very different to the memory lapses we may experience during healthy ageing. Alzheimer s does begin with mild loss of memory, but this is usually accompanied by loss of other cognitive abilities as well. Alzheimer s as it progresses has some distinctive changes, and these are not part of normal ageing. Typical changes as the disease progresses, although they can appear in any order, are: Forgetting biographical information such as your address, or what your home looks like. Module 8, Part B Transcript 7
Having difficulty learning new things such as where the bathroom is in a house being visited, no matter how often the person is shown. Profound difficulty in recalling objects, places, times, dates, names. Forgetting how to do everyday things you have done many times before making a cup of tea, for example. Not recognising family or friends. Forgetting how to maintain personal hygiene. Repeating phrases, questions or stories in the same conversation. Trouble making choices or handling money. Unable to find your way even in familiar surroundings. Forgetting where the bathroom is in your own home. Tendency to wander aimlessly. Slide 20 Noticeable language and intellectual decline. Poor judgement. A growing sense of distrust. Unusual irritability and/or aggression. Noticeable change of personality in later stages of the disease. Inability to keep track of day to day events. General loss of social graces. Inability to follow simple instructions or to concentrate. Feeling more depressed, confused, restless and anxious. Delusions or hallucinations in later stages of the disease. Care must be taken to make sure that these are not a result of delirium rather than Alzheimer s. Slide 21 Module 8, Part B Transcript 8
The most burning question today is Can Alzheimer s disease be prevented? Professor A. D. Smith and his team from Oxford University give a resounding yes, following the results of their study in the United Kingdom. In 1991, based on the expected population growth, the team predicted the number of cases of Alzheimer s disease there would be in the United Kingdom 20 years later, in 2011. Astonishingly, when the statistics were analysed in 2011, there were 214,000 fewer cases of AD than predicted from the 1991 data. The researchers, after a lot of investigation, believe this is most likely to be because during that 20 years, a lot more was known about healthy lifestyle factors which would reduce the likelihood of cardiovascular events heart attacks and so on, and a large proportion of the population paid more attention to health in general particularly diet and exercise. Moderating these risk factors certainly lowered the risk of heart attacks, but has also reduced the prevalence of Alzheimer s disease. All risk cannot, at present, be mitigated, but as we have discovered throughout the modules there is much we can do to help prevent, or at least push back the symptoms of this terrible disease. The work you will be doing with your classes is vitally important. It is a message that people are desperate to hear. We certainly can t prevent all Alzheimer s, but we can eliminate as many of the risk factors as we can. Slide 22 In your Answer Book we would like you to consider how the fear of dementia, especially of Alzheimer s disease as it is the most commonly encountered, raises anxiety and worry for many people. Please review both this and earlier modules and think about what Module 8, Part B Transcript 9
reassurance you could give your classes that in coming to the Brain Fit for Life they are taking positive steps to reducing the risk of the disease. What can they do? If you have met or visited someone with dementia, what did you notice? Module 8, Part B Transcript 10