Alzheimer Disease Psychopathology, medical management and dental implications

1
Alzheimer DiseasePsychopathology, medical
management and dental implications

• Tom Sarna, DDS

2
JADA

• Clinical Practice
• September 2006
• Volume 137
• Arthur H. Friedlander, DMD Dean C. Norman, MD
  Michael E. Mahler, MD Keith Norman John
  Yagiela, PhD

3
Who?

• Most common after 60 years of age.
• Close to 50 of elderly 85 and older.
• 4.5 million Americans, estimated to increase to
  14 million in next 30 years.
• Average life span 8-10 years.

4
Stages of Alzheimer Disease

• I no noticeable changes
• 2 very mild cognitive decline/forgetful
• 3 mild cognitive decline/early confusion
• 4 - moderate cognitive decline/ late confusion
• 5 - mod-severe cognitive decline/early dementia
• 6 severe cognitive decline/middle dementia
• 7 very severe cognitive decline/ late dementia

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Stages

• Early
  Late
• 1 2 3 4 5 6
  7
• --------------------------------------------------
  ---?
• Cognitive decline incontinence
• ? Assisted Daily Living
• Forgetful
• ----------?
• Confusion
• -----------------------
  ------?
• Dementia

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Pathophysiology

• ß amyloid plaques and intracellular
  neurofibrillar tangles disrupt synaptic function
  and cause neuronal death.
• Photo taken from
  http//www.ahaf.org/alzdis/about/AmyloidPlaques.ht
  m
• Increased ß amyloid production in gray matter
• abnormal accumulation of tau protein in neurons

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Diagnosis

• Medical History, R/O depression
• Mini Mental State Examination
• orientation, registration, attention,
  calculation, and recall
• Laboratory tests to R/O drug toxicity,
  hypothyroidism,electrolyte imbalance, and
  cardiovascular accident.
• Imaging studies? MRI or PET scans? Definitive
  diagnosis cannot be made until autopsy

8
Treatment

• Pharmacotherapy
• Cholinesterase inhibitors
• For mild-moderate stage, transient improvements
  for lt5 yrs.
• Memantine
• For moderate-severe stage, delays progression,
  improves daily living and behavior episodes
• Antipsychotics, Haloperidol, Carbamazepine and
  divalproex sodium, SSRI, TCAs
• Assisted Daily Living Care

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Adverse orofacial reactions

• FDA advisory package insert in current Alzheimer
  medications.
• Cholinesterase inhibitors sialorrhea
• Memantine tinnitus, blurred vision
• Antipyschotics xerostomia, dysgeusia,
  stomatitis
• Haloperidol xerostomia, spasms of muscles of
  mastication, buccal ulcerations (leukopenia) and
  thrush (Candida)
• Antidepressants - XEROSTOMIA

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Factors leading to Oral Disease

• Disinterest or impaired ability to perform oral
  hygiene or remove prosthesis.
• XEROSTOMIA
• Difficult for caregivers to provide daily oral
  hygiene
• Extensive needs (Incontinence, feeding, bathing)
• Combative to invasive care
• Sundowning

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Dental Treatment

• Good communication (MD, caregiver, patient and
  DDS)
• Constant communication (DDS to patient)
• Realistic treatment plan (prioritize acute
  problems)
• Short appointments or OR
• Drug interactions
• Proactive Post-operative care

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Adverse Drug Interactions

• No diphenhydramine or amitriptyline antagonists
  to cholinesterase inhibitors.
• Avoid erythromycin and ketoconazole may cause
  hypercholinesteric effects (agitation,
  bradycardia, LOC)
• Avoid levonordefrin and greater than 3 cartridges
  of 2 Lido/1100,000 epi may cause cardiac
  stimulation
• Consult with MD before using NSAIDS, asp and
  codiene.

13
QUESTIONS?

• Who?
• Stages?
• Plaques and Tangles?
• Diagnosis?
• Treatment?
• Orofacial Reactions?
• Dental Treatment?
• Drug interactions?