Health

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Health IllnessAssessment of Dementia

• Jenny Wilson
• Wilsonj1_at_hope.ac.uk

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Dementia What is it?

• Dementia is a generic label used to describe a
  progressive decline of cognitive function,
  severe enough to impair the daily functioning of
  an individual, leading to long term care.
• Many diseases can result in dementia, the most
  common one being Alzheimers disease

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DSM IV Criteria for Dementia

• A person suffers from dementia when multiple
  cognitive deficits develop manifested by
• 1.  Memory impairment (inability to learn new
  information or recall previously learned
  information)
• 2. Cognitive disturbances of One (or more) of the
  following
• (a) aphasia (b) apraxia (c)agnosia
  (d) disturbance in executive function .
• 3.   Cognitive deficits in 1 and 2 cause
  significant impairment in social and occupational
  functioning and represent decline from previous
  level of functioning.
• 4. The cognitive deficits in 1 and 2 are not due
  to any of the following
• Other central nervous conditions that cause
  progressive deficits in memory and cognition.
• Systemic conditions that are known to cause
  dementia.
• Substance- induced conditions.

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Dementia Prevalence Rates

• Dementia currently affects over 750,000 people in
  the UK
• 18,500 people with dementia are aged under 65
  years
• Dementia affects one person in 20 aged over 65
  years and
• one person in five over 80 years of age

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Alzheimers Disease

• Single most common cause of dementia
• Can occur from age of 45
• typically an age-associated disease,
• Prevalence up to the age of 65 years, only 1
  person in 1000 is affected.
• This figure increases sharply to 1 in 20 over the
  age of 65.
• 1 in 5 over the age of 80 years

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On a Peculiar Disease of the Cerebral Cortex. A.
Alzheimer (1907)

• A woman, 51 years old, showed jealousy towards
  her husband as the first noticeable sign of the
  disease.  Soon increasing loss of memory could be
  noticed.  She couldnt find her way around her
  own apartment.  She carried objects back and
  forth and hid them. 
• At times she would think that someone wanted to
  kill her.She was totally disoriented to time and
  place At times she greeted the doctor like a
  visitor.Periodically, she was delirious, dragged
  her bedding around, called  her husband and
  daughter, and had auditory hallucinations. Frequen
  tly, she shrieked for many hours
• Her ability to remember was severely disturbed. 
  If one pointed to objects, she named most of them
  correctly, but immediately afterwards she would
  forget everything again When talking she
  frequently used perplexing phrases and some
  paraphrasic expressions She seemed no longer to
  understand the use of some objects The
  generalized dementia progressed After 4 1/2
  years of the disease, death occurred.

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Symptoms

• People with Alzheimers disease suffer from
• impaired memory orientation,
• limitations of concentration, planning and
  judgement
• personality changes
• perceptual, speech and walking disorders
• And in the final stage, various other body
  functions such as swallowing and the excretion
  process are affected.

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Early indications of dementia

• Forgetfulness in daily life
• Most people sometimes forget names or
  appointments or forget where they put keys.
• In dementia this happens frequently and
  inexplicable states of confusion also occur,

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Early indications of dementia

• Difficulties with familiar activities
• People who are very busy are sometimes
  absent-minded and for example forget the pie in
  the oven.
• People with dementia not only forget the pie in
  the oven but also that they have cooked at all.

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Early indications of dementia

• Language problems
• We all sometimes experience difficulties in
  finding the right words.
• Dementia sufferers often cannot remember simple
  words and instead they use inappropriate fillers
  (paraphrasic expressions)which makes it difficult
  to understand the sentences

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Early indications of dementia

• Problems with spatial and temporal orientation
  Dementia sufferers frequently do not know what
  day of the week it is.
• They get easily lost, even in their own street
  they may no longer know where they are, how they
  got there and how to get home again.

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Early indications of dementia

• Impaired capacity of judgement
• Dementia sufferers have difficulty making
  rational and appropriate judgements.
• For example, they wear a bathrobe while shopping
  or several blouses on top of each other on a hot
  summer day.

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Early indications of dementia

• Problems with abstract thinking For many
  people running a bank account is a challenge.
  Dementia patients can often neither recognise
  numbers nor carry out simple calculations.

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Early indications of dementia

• Mood swings and behavioural changes People with
  dementia may have very sudden mood swings, often
  without discernible cause.
• Personality changes People affected by
  dementia may experience a very pronounced
  personality change suddenly or over a longer
  period of time. Somebody who is generally
  friendly, for example, becomes unexpectedly
  angry, jealous or timid.

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Stages of Alzheimers disease

• Alzheimer's disease can take very different
  courses.
• It is a slowly unfolding, progressive disease
  which is accompanied over time by changes in the
  appearance of the patient.
• The disease is typically divided into three
  stages. In medical terms, Alzheimer's disease is
  divided into
• Mild, Moderate and Severe OR early-stage,
  mid-stage and late-stage Alzheimer.
• The individual course of the disease is, however,
  very variable.

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Three stages of Alzheimers

• Mild stage
• Typically characterised by impairments of mental
  abilities as well as mood swings.
• Moderate stage
• Confusion Behavioural disturbances usually
  increasingly develop,
• Advanced stage
• Totally dependent state. physical problems are
  dominant

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Alzheimer brain Gross anatomy

• Alzheimer's disease attacks nerve cells in
  several regions of the brain 
• A) Cerebral Cortex Involved in conscious
  thought and language.
• B) Basal forebrain Has large numbers of neurons
  containing acetylcholine, a chemical important in
  memory and learning.
• C) Hippocampus Essential to memory storage.

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A
c
B
Image courtesy Alzheimer's Disease Education and
Referral Center,
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Alzheimers disease pathology

• Alzheimer's disease disrupts each of the three
  processes that keep neurons healthy
• communication, metabolism, and repair.
• This disruption causes certain nerve cells in the
  brain to stop working, lose connections with
  other nerve cells, and finally, die.
• The destruction and death of nerve cells causes
  the memory failure, personality changes, problems
  in carrying out daily activities.

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Tangles Plaques

• The brains of AD patients have an abundance of
  two abnormal structures beta amyloid plaques
  and neurofibrillary tangles.
• Plaques are dense, deposits of protein and
  cellular material outside and around the neurons.
• Tangles are twisted fibres that build up inside
  the nerve cell.

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Healthy neurons are marked by red arrows tangles
and plaques by the blue arrows.Courtesy Toshi
Kinoshita, Department of Pathology, University of
Wisconsin Medical School
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Alzheimers Disease Pathology Summary

• Acetylcholine loss
• hippocampus
• Amyloid proteins
• senile plaques
• Neurofibrillary tangles of tau protein
• These represent death of neurons
• Brain shrinks

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Risk Factors for Alzheimers

• AGE
• Chances of getting AD increase with age. 1 in 50
  (2) between 65 70. This raises to 1 in 5 (20)
  over 80 years.
• Gender
• Women more likely to develop AD. (possibly due to
  lack of oestrogen after menopause)
• Genetics
• ApoE predisposition. Link with Downs Syndrome
• Education
• Lower levels of Eduction associated with
  increased risk
• Head Injury inconclusive (males only)
• Environment Aluminium, not definite link
  established

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Current Diagnostic Methods

• The only definite way to diagnose AD is to find
  out whether there are plaques and tangles in
  brain tissue.
• To look at brain tissue, doctors must wait until
  they do an autopsy, which is an examination of
  the body done after a person dies.
• During life, doctors make a diagnosis of
  "possible" or "probable" AD.
• At specialized centers, doctors can diagnose AD
  correctly up to 90 percent of the time. Doctors
  use several tools to diagnose "probable" AD

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Current Diagnostic Methods

• Medical tests
• E.g. tests of blood, urine, or spinal fluid
  Allows other possible diseases (that may be
  causing the symptoms) to be excluded.

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Current Diagnostic Methods

• Neuroimaging
• Brain scans can also be used to gain information
  about blood flow and metabolic activity in
  various parts of the brain.

PET
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Clinical Assessment

• A complete medical history includes information
  about the person's general health, past medical
  problems, and any difficulties the person has
  carrying out daily activities.
• Neuropsychological tests measure memory, problem
  solving, attention, counting, and language. For
  example MMSE, RBMT

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Major disorders mistaken for Alzheimers Disease

• Depression
• Subcortical dementia
• Non-AD dementia syndromes

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In class Exercise The MMSE

• Take some time familiarising yourself with the
  questions.
• One person is the examiner the other is the
  client
• The aim is to give you the opportunity to
  experience using this screening tool

• Clients you may or may not be presenting with
  dementia.
• Examiner its your job to decide if performance
  is considered cognitively impaired possibly due
  to dementia.
• NB in the real world not just rely on the
  MMSE.