Opening video

DEATH OF THE NEURON FOREST

An in depth look at Alzheimers Disease and it progression

Presented by:
Kaila Williams Alexis Puente-Smith Michelle Olive Dave McClure Lauren Goodman Jason Cardiff Anjana Mitter Dori Nelsen Terry Smiley

We will cover
Stats and info About the brain Dementia Alzheimers The stages of AD Risk factors / Diagnosis Treatment and Medications Your Alzheimer s patient Wrap it up

What is Alzheimer s Disease?

Dementia is a syndrome characterized by multiple cognitive deficits AD is the most common form of Dementia (estimated 60%-80% of all cases)

 An estimated 5.4 million Americans have Alzheimer s disease 1 in every 8 people age 65 or older has Alzheimer s Expected to be as high as 16 million by 2050

 Estimated 3.5 million formally trained health care professionals will be needed by 2030 to meet the needs of the dementia population alone
National Academy of Sciences, 2010

Cerebellum It controls coordination and balance.

Cerebrum Involved in remembering, problem solving, thinking, and feeling. It also controls movement.

Brain stem It connects the brain to the spinal cord and controls automatic functions such as breathing, digestion, heart rate and blood pressure.

Further divided into lobes that house the various areas of function and cognition

 An adult brain contains about 100 billion nerve cells (neurons) that connect at more than 100 trillion points. Signals traveling through the neuron forest form the basis of memories, thoughts, and feelings. Neurons are the chief type of cell destroyed by Alzheimer's disease.

 Signals move through an individual nerve cell as a electrical charge. Nerve cells connect at synapses. Charge reaches a synapse, triggering the release of neurotransmitters. Neurotransmitters travel across the synapse, carrying signals to other cells (neurons).

Dementia
A progressive, irreversible decline in mental function The onset is slow and can range from months to years Highest in those older than 85 at 24-47%

Early signs and symptoms

Mild memory loss Forgetting words or names Difficulties in
registration comprehension learning task execution language use

Later terminal stage symptoms

Memory impairment, Deficits in reasoning and judgment, Loss of ability in regard to abstract thought and clouding of consciousness.

 AIDS, Alzheimer s Vitamin B12 deficiency Carbon monoxide poisoning Subdural hematoma and multiple brain infarcts

Dementia in regard to Alzheimer s is a symptom while Alzheimer s is the disease causing the condition.

Alzheimer's disease leads to nerve cell death and tissue loss throughout the brain.

Over time, the brain shrinks dramatically, affecting nearly all its functions.

 The cortex shrivels up, damaging areas involved in thinking, planning and remembering. Shrinkage is especially severe in the hippocampus, an area of the cortex that plays a key role in formation of new memories. Ventricles (fluidfilled spaces within the brain) grow larger.

 Alzheimer's tissue has fewer nerve cells and synapses than a healthy brain. Plaques, abnormal clusters of protein fragments, build up between nerve cells. Dead and dying nerve cells contain tangles, which are made up of twisted strands of tau protein.

Plaques form when protein pieces called beta-amyloid (BAY-tuh AM-uh-loyd) clump together. Beta-amyloid is chemically "sticky" and gradually builds up into plaques.

The small clumps may block cell-to-cell signaling at synapses and may also activate immune system cells that trigger inflammation and devour disabled cells.

In healthy areas: The transport system is organized in orderly parallel strands somewhat like railroad tracks. Food molecules, cell parts and other key materials travel along the "tracks." A protein called tau (rhymes with wow) helps the tracks stay straight. In areas where tangles are forming: Tau collapses into twisted strands called 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.

Plaques and tangles (shown in the blue-shaded areas) tend to spread through the cortex in a predictable pattern as Alzheimer's disease progresses.

Overview of AD Staging

Original criteria created 1984 2011 recommendations provide for 3 major stages and consolidate previous stages into one Dementia stage Staging is difficult: AD is a continuous process and boundaries can be difficult to define Better diagnosis during Preclinical and Mild Clinical Impairment Stages may result in lifetime savings of 50%

Alzheimer s Disease Stages

Disease Phases Preclinical MCI Alzheimer's Disease Dementia

Level of Disability

Biomarkers ADLs No clinical Unimpaired

Mild or Stage I

Moderate or Stage II

Severe or Stage III

Based on 2011 NIA-AA Workgroups Recommendations

Based on 2011 NIA-AA Workgroups Recommendations

Preclinical Stage

Biomarkers appear an average of 10 years before mild cognitive impairments Amyloid- peptide accumulation proposed as key early event Neurodegeneration accelerates process, resulting in subtle cognitive decline

Mild Cognitive Impairment (MCI) Stage

Concern regarding a change in cognition Impairment in one or more cognitive domains Preservation of independence in functional abilities No dementia

Alzheimer s Dementia: Mild or Stage I

Difficulty with new learning and making new memories. Trouble finding words. Easily loses way going to familiar places. Has trouble organizing and thinking logically. Loses judgment about money.

Moderate or Stage II
Changes in behavior, concern for appearance, hygiene, and sleep become more noticeable. Mixes up identity of people. Has restless, repetitive movements in late afternoon or evening. Has trouble following written notes or completing tasks. Needs help finding the toilet, using the shower, remembering to drink, and dressing for the weather or occasion.

Severe or Stage III

Doesn't recognize self or close family. May refuse to eat, chokes, or forgets to swallow. Loses control of bowel and bladder. Forgets how to walk or is too unsteady or weak to stand alone. Needs total assistance for all activities of daily living.

Risk Factors: Non-modifiable

Age is the greatest known risk factor ->65 years old -doubles every 5 yrs ->85 years old, 50% chance -woman live longer Family history: -close family member -increases more if multiple family members are affected.

-Risk genes
apolipoprotein E-e4 (APOEe4) Found in 1993

-Deterministic genes
amyloid precursor protein (APP), presenilin-1 (PS-1) and presenilin-2 (PS-2). Autosomal Dominant Alzheimer s Disease (ADAD) Will develop around ages 40-50.

Risk Factors: Modifiable

Heart Health Blood pressure Heart disease High cholesterol Diabetes

Head Trauma Repeatedly or involves loss of consciousness Safety precautions

Reducing your risk:

Exercise Don t smoke Control blood pressure Control cholesterol Manage diabetes well Mental Stimulation Stay socially interactive Healthy weight Avoid excess alcohol

Diagnostics
Assessment Patient history
Symptoms
Duration Progression Course

Changes
Memory Forgetfulness Behavior/Personality Sense of smell

 Physical assessment
Changes in cognition
Folstein s Minimental exam Set test

Changes in mood Self-management skills

 No definitive diagnosing lab test Genetic testing

Apolipoprotien E4 (Apo E4) Amyloid beta protein precursor (soluble) (sBPP)

Laboratory Tests

Other lab tests

To rule out other causes of dementia or delirium
CBC, Electrolytes, ETOH screening, Thyroid and liver function test, and Syphilis screening

Imaging and Other Diagnostics

Imaging
CT PET SPECT MRI

Neuropsychological tests
Showing progression of disease

Treatment Goals for AD

Slow the progression of the disease Manage behavior problems, confusion, sleep problems, and agitation Modify the home environment Support family members and other caregivers

Drug classes for treatment of Alzheimer s

Cholinesterase inhibitors Donepezil ( Aricept) Galantamine (Reminyl) Rivastigmine (Exelon) Tacrine (Cognex)

NMDA( N-methyl-Daspartate) receptor antago Memantine(Namenda)

Antidepressants which are not anticholinergics Sertraline(Zoloft), paroxentine(Paxil) Psychotropic Drugs- Used for behavioral problems Risperdal (risperidone) Quetiapine(Seroquel)

Generic
donepezil

Brand
Aricept

Approved For
All stages

Side Effects
Nausea, vomiting, loss of appetite and increased frequency of bowel movements.

galantamine

Razadyne

Mild to moderate

Nausea, vomiting, loss of appetite and increased frequency of bowel movements.

memantine

Namenda

Moderate to severe

Headache, constipation, confusion and dizziness. Nausea, vomiting, loss of appetite and increased frequency of bowel movements.

rivastigmine

Exelon

Mild to moderate

tacrine

Cognex

Mild to moderate

Possible liver damage, nausea, and vomiting.

Non-Pharmacologic Therapy For Alzheimer and Dementia Patients

Meaningful therapy CAN enrich patient & caregivers lives Consider patient interests and abilities Boost patients self esteem & reduce stress Instill sense of stability Keep it simple

Music Therapy
Self Expression Improve mood, promote relaxation Decrease wandering and restlessness Slows decline in physical, psychological and cognitive processes Stimulates recollection of memories

Animal Therapy
Stimulate social interaction Ease agitation Companionship Promote physical activity

 Connect patient to nature Reduce stress; Lower Blood Pressure Maintain circadian cycle (sleep/wake cycle) Vitamin D = Healthy Bones Physical exercise Most important establish a routine Increase stability

Garden Therapy

Improving Quality of life

Always consider patients interests and abilities Structure & routine is important Encourage and give praise often Compassion and patience a must

Caring for your Alzheimer s Pt.

Use simple words Speak slowly Show what you are saying Smile

Activities of daily living Bathing Dressing Eating Safety

Bathing

Plan the bath or shower for the time of day when the person is most calm and agreeable. Tell the person what you are going to do, step by step, and allow him or her to do as much as possible.

 Try to have the person get dressed at the same time each day Encourage the person to dress himself or herself to whatever degree possible. Allow the person to choose from a limited selection of outfits.

Dressing

Eating & Nutrition

View mealtimes as opportunities for social interaction Aim for a quiet, calm, reassuring mealtime atmosphere

Safety

Identification or medical bracelet Alzheimer s Association Safe Return program Environment Plan ahead
Notify neighbors and local authorities

The biggest issue with AD Pt s

Sundowners Syndrome
End-of-day activity Fatigue Low light

How to calm your pt

Establish a routine Monitoring diet Controlling noise

Caregivers
Family most prominent Respite Care Understanding that caring for themselves is primary Accepting the role as caregiver

Possible Nursing Diagnosis

Chronic confusion R/T disease progression (AD) Risk for Injury R/T wandering, elder abuse or mistreatment Compromised Family coping and Caregiver Role Strain R/T patient s prolonged progression of disability and increasing care needs Self-care Deficit R/T cognitive deficit Imbalance Nutrition Less than Body Requirements R/T self-care deficit and/or anorexia

Let s Review
What are plaques made of? Beta amyloid polilopoprotiens What are tangles made from? Detached tau protien s Who is most at risk for Alzheimer s? People over 65 What are the cognitive affected by Alzheimer s? Primary motor function, symantic s vision and speech, establishment of new memories, and regulation of unconscious muscle activity Can neurons be regenerated? NO

Questions???

Thank you for your time and attention