Vascular Dementia (VaD)

• Processing speed, executive function impairment, insight, mood

• Multi-infarct dementia

• Subcortical vascular disease

Diffuse Lewy Body Dementia

• Prominent visual hallucinations• Parkinsonism (gait, balance, rigidity, bradykinesia- rest

tremor less common)• Falls or gait difficulties• Fluctuations in cognition/attention

• PDD- executive and visuospatial dysfunction• MSA- “Shy-Drager”

Frontotemporal Dementia

• Younger onset- 50-60s• Behavioral variant- R frontal• Primary Progressive Aphasias- L frontal or L temporal • Other tauopathies- PSP, CBS

Treatment Disclaimer

• Although there is currently no way to cure Alzheimer's disease or stop its progression, we are making encouraging advances in Alzheimer's treatment, including medications and non-drug approaches to improve symptom management.

Cognition Enhancing Drugs

Cholinergic Agents (AChEI)

- Donepezil/Aricept- Rivastigmine/Exelon- Galantamine/Razadyne

NMDA Antagonist- Memantine/Namenda

http://www.thefix.com/content/performance-enhancing-smart-drugs-olympics8838

Acetylcholinesterase InhibitorsMechanism of Action:• Inhibits centrally-acting acetylcholinesterase, making more

acetylcholine available• This compensates in part for degenerating cholinergic neurons

that regulate memory

FDA Approved Uses of AChEI

• Mild/Moderate AD• Moderate AD• Severe AD- for rivastigmine and donepezil only• Parkinson’s disease-related dementia- rivastigmine only

Off Label Uses

• VaD• DLB, MSA• Tauopathies

AChEI side effects • Diarrhea• Urination• Miosis/muscle weakness• Bronchorrhea• Bradycardia• Emesis• Lacrimation• Salivation/sweating

Muscle CrampsInsomnia/

incontinence Nausea Diarrhea

What about Namenda and Namenda XR (memantine)?

● regulates glutamate in the brain

● key role in processing information

● may delay the worsening of symptoms

● may allow patients to maintain daily functions• FDA approved as an addition to AChEI in mod/sev AD only

Off Label Use

• Anecdotally helpful in PPA• Trial and error

Behavioral Symptoms

• Insomnia• Weight loss• Home Safety• Agitation• Wandering

• Repetitive vocalizations

Weight Loss

• Possible causes• Forgetting to eat• Inability to prepare and eat foods• Impaired olfaction and taste• Behavior problems (restlessness, etc)• Depression• Comorbid medical illness• Medications (esp ACh-I, Antidepressants)• Inflammatory abnormalities (anorexia, procatabolic state)

Wang et al, J Neurol 2004, 251:314-320; Aziz NA et al, J Neurol 2008

Strategies

• Diet- liberalize it! No special diets!

• Environment• Eat with others• Pleasant, quiet

setting• Music may help

Tamura BK et al. Nutrition and the Institutionalized Elderly. 2007

More Weight Loss StrategiesFood Modifications

• Single items, presented one at a time

• Contrast color of food with the dish• Make food and setting look attractive• Make food portable for those who are restless• Sweet, hot/cold, juicy

Eating Schedule• AD pts ate more at breakfast than other meals• Frequent, small meals

Tamura BK et al. Nutrition and the Institutionalized Elderly. 2007

Behavioral Therapy

• Nonpharmacologic intervention• Antidepressants• Antipsychotics if necessary

Exercise!

Image from bodbot.com

Benefits of Exercise

Image from bodbot.com

Nonpharmacological Strategies

Advise caregiver(s) to:

1) Use scheduled toileting and prompted toileting for incontinence.

2) Offer graded assistance (as little help as possible to perform ADLs), role modeling, cueing, and positive reinforcement to increase independence.

3) Avoid adversarial debates; try to redirect conversation instead.

4) Maintain a calm demeanor.

5) Use services of caregiver support groups.

Depression in dementia

• Seen in up to 40% of AD patients; may precede onset of AD• Signs include sadness, loss of interest in usual activities,

anxiety, and irritability• Suspect if patient stops eating or withdraws• May cause acceleration of decline if untreated• Recreational programs and activity therapies have shown

positive results

Apathy v. depression in dementia

• High prevalence and persistence throughout course of AD• Causes more impairment in Activities of Daily Living than

expected for cognitive status• High overlap with depressive symptoms but lacks depressive

mood, guilt, and hopelessness

Agitation or aggression- What is it?

• Seen in up to 80% of patients with Alzheimer’s disease• A leading cause of nursing-home admission

Agitation- What do you do?

• Identify context of behavior (is it harmful to patient or others?)

• Identify environmental triggers (eg, overstimulation, unfamiliar surroundings, frustrating interactions)

• Exclude underlying physical discomfort (eg, pain or hunger)

Psychosis in dementia

• Seen in about 20% of Alzheimer’s disease (AD) patients• Delusions may be paranoid (eg, people stealing things, spouse

unfaithful)• Hallucinations (~11% of patients) are more commonly visual

Psychosis- what do you do?

• Determine whether delusions or hallucinations are interfering with function

Black box warning on antipsychotics in dementia

• [US Boxed Warning]: Elderly patients with dementia-related psychosis treated with antipsychotics are at an increased risk of death compared to placebo.

• cardiovascular or infectious (eg, pneumonia)

• quetiapine has a lower propensity to cause extrapyramidal side effects *

• risperidone not as sedating for daytime use

* APA, [Rabins 2007]

Resources for managing dementia

•Elder law attorney for will, advanced directives, conservatorship, estate planning

•Community: neighbors & friends, aging & mental health networks, adult day care, respite care, home-health agency

•Organizations: Alzheimer’s Association, Alzheimer’s of Central Alabama

•Services: Meals-on-Wheels, senior citizen centers, home care services

Educational Websites

• Alzheimer’s of Central Alabama- support groups and daycare programs- http://alzca.org/

• Alzheimer’s Association- advocacy and research info- http://www.alz.org/

• AlzOnline- patient and caregiver education- http://alzonline.phhp.ufl.edu/

• Association for Frontotemporal Degeneration- theaftd.org• Lewy Body Dementia Association- http://www.lbda.org/• The MSA Coalition- https://www.multiplesystematrophy.org/• www.uab.edu/alzheimers