lena smith ernst, ph.d
TRANSCRIPT
Lena Smith Ernst, Ph.D.
By 2050 a new American will develop Alzheimer’s disease
Every 33 seconds!
Facts & Figures, 2013, Alzheimer's Association
2001: 24.3 Million cases 2020: 42.3 Million cases 2040 81.1 Million cases
Ferri, C. (2005). Lancet
“Quality of life for people with dementia is strongly
influenced by communication and social
relationships”
Language deficits and difficult behaviors increase caregiver burden
Caregiver communication skills simultaneously impact a patient’s difficult behaviors
(bi-directional)
Haberstroh, p. 405
The #1 Risk Factor for Dementia is AGE
746
301
164
35
100+
85+
65+
All ages
Percent Change in the World's Population: 2005 to 2040
Figure 3-7.
Source: United Nations Department of Economic and Social Affairs, 2007.
AD overtook diabetes as the 6th leading cause of death in the United States in 2006
In 2009 heart failure, strokes, and cancer dropped in total numbers while AD increased!
Centers for Disease Control
A syndrome of acquired intellectual impairment produced by brain dysfunction
Mendez & Cummings, 2003.
“Dementia is a shift in the way a person experiences the world around him/her”
G. Allen Power, MD, FACP
Domains of Cognition
Language Memory Calculations Attention/Orientation Praxis Judgment Personality Visual-Spatial Abilities Emotional Awareness Conceptual Knowledge
Alzheimer’s disease Vascular dementias Lewy body dementia Parkinson’s disease Frontotemporal dementia ETOH dementia
Alzheimer’s Disease is the most common cause of dementia (60-80% of cases).
Growing awareness that AD is often mixed with other dementia etiologies.
Accumulation of protein plaques (beta-amyloid) and tangles (tao) that interfere with communication between brain cells and cause the cell to eventually die
1906: Dr. Alois Alzheimer describes AD 1906-1970’s: General assumption that this is an
unusual & untreatable degenerative disease of middle age
1976: Dr. Robert Katzman editorial: “ The Prevalence and Malignancy of Alzheimer’s Disease “
Late 1970’s Cholinergic hypothesis suggests treatment possibilities
1985: First positive treatment study 1993: Tacrine is approved; 3 other similar drugs follow 2003: Memantine is approved, representing a second therapeutic class for AD
NOTHING SINCE 2003
Negative pivotal trials: Xaliproden (neuroprotection) Tramiprosate (amyloid anti-aggregation) Tarenflurbil (gamma secretase modulator) Rosiglitazone (metabolic, anti-inflammatory) Leuprolide (endocrine) Dimebon (mitchondrial) Semegacestat (gamma secretase inhibitor Avagacestat (Ph II, gamma secretase inhibitor) Bapineuzumab (anti-amyloid antibody) IGIV (pooled human immunoglobulin) Solanezumab (Mild AD) (anti-amyloid
antibody)
Alzheimer’s vs. Frontotemporal
Taken from: Agamandis, D.P. Neuropathology: An illustrated interactive course for medical students and residents.
At some point during the course of illness 75%-85% of persons with dementia demonstrate a behavioral expression indicative of distress
Weiner & Lipton, 2003; Dementia Initiative ,2013
Preferred term for “behavioral problem” is behavioral expression
Behavioral expressions can occur at any stage.
Dementia Initiative, 2013, p 25
“Behavioral Expressions can be broadly conceptualized as a response to unpleasant internal or external cues that are interpreted as threatening”
Bradford et al., 2012, Am Jrn of AD
Behavioral Expression may represent a cry for help, a result of unmet needs, or an inadequate attempt to fulfill those needs.
Great range of behaviors Who is defining “problem” behavior Variation in settings (context) may change the perception of the behavior
Cohen-Mansfield, J. (2000). Alz Care Quar 1(4)
1. Screaming or Shouting 2. Unwarranted requests for help
3. Uncooperative with care 4. Cursing, threatening insulting
5. Verbally bossy
6. Restlessness 7. Pacing 8. Hoarding 9. Hiding objects 10. Expressions of Anger
Tractenberg et al., 2001, Int Jrn of Geriatric Psych
How do we provide interventions that results in
reduced distress and increased daily joy?
Singing Looking at Pictures Discussing a favorite food Giving a hand massage Going for a short walk Brushing hair Reading a bible passage together
Walking outside Oreos in the shower Pad and pencil Let’s make a call Music Prayer Activities 1:1 time
EMPATHY buys you time for creativity in approach
“Non-pharmacological interventions have potential to
reduce frequency and severity of neuropsychiatric behaviors with effect sizes equaling those of
pharmacotherapy”
Brodaty & Arasaratnam, 2012, Amer Jrn of Psych, 169
There is a role for medications when non-pharmacological interventions on their own are unsuccessful or there is a significant safety risk
Steinberg & Lyketsos, 2012, Am Jrn of Psych, 169
1. Delusions 2. Hallucinations 3. Agitation/Aggression 4. Depression/Dysphoria 5. Anxiety 6. Euphoria
7. Apathy 8. Disinhibition 9. Irritability/lability 10. Motor disturbances 11. Sleep disturbances 12. Appetite/eating changes
Cummings, J. (1997). NPI, Neurology, 48.
New or rapidly worsening behavioral symptoms in a
patient living with dementia indicates the presence of a
medical problem until proven otherwise
“Cure sometimes,
Treat often, Comfort always.”
-Hippocrates
Lena Smith Ernst, Ph.D.
Clinical Director/COO
Retreat Healthcare Rio Rancho, New Mexico