CDM 4 Exam 2 Review Alzheimer s disease I Epidemiology A Most people with AD survive and average of 4 8 years after diagnosis but some as long as 20 years B 40 of a person s years with AD are spent in the most severe stage C By age 80 40 of Americans enter SNF skilled nursing facility But for people with ad 75 are in SNF by age 80 D SUPER EXPENSIVE DISEASE 1 Cannot be prevented cured or even slowed 2 Average spending person with dementia vs w o dementia a Medicare 3x higher Old SSDI Disabled social security disability have worked the certain number of work credits based on age and 65 after 2 years become Medicare eligible automatically enrolled in Part A and B b Medicaid 19x higher poor SSI disabled supplemental security income may or may not have worked usually eligible for Medicaid and food stamps asap E 1 in 6 Americans with Alzheimer s disease are women Breast Cancer risk is only 1 in 11 F More than 605 of Alzheimer s and dementia caregivers are women 2 5x more women than men providing intensive on duty care 24 hours a day 1 AGE people are living longer so Alzh prevalence 2 Down Syndrome 3 Genetics not 100 sure of MOA strength of genetic association is variable a APOE 4 chr 19 late onset Alz typical alz disease i 1 copy 2 3x risk ii 2 copies 12x risk b Presenilin 1 Chr 14 Early onset c Presenilin 2 Chr 1 Early onset 40s d Amyloid precursor protein Chr 21 3copies down s B Possible risk factors 1 CVD Risk Factors heavy smoking hypercholesterolemia Hypertension Diabetes Obesity II Etiology A Risk factors a BF to brain neuronal death 2 Head Injury Trauma Traumatic brain injury a Vets football players boxers III Pathophysiology A Amyloid Cascade 1 Formation of beta amyloid plaques some people have plaques without dementia plaques alzheimer s risk but not 100 diagnosable factor 2 Occurs ourside neuron 3 Amyloid precursor protein Prensenilin 1 Prensenilin 2 B Neurofibrilary tangles 1 Hyperphosphorylated tau protein 2 Microtubule collapse 3 Occurs within neurons cell death C Inflammatory Immunologic Hypothesis Inflammatory response to clear amyloid protein 1 2 Release of cytokines NO other free radicals anti inf agents NOT successful in tx 1 Amyloid Plaques Healthy Individual Small Residual Fragment Neurofibrillary Tangles Neurofibrillary Tangles con t Individual with Alzheimers Larger Residual Fragment D Cortex shrivels up 1 Thinking planning remembering are all E Ventricles grow larger F Hippocampus shrinks responsible in memory formation IV Diagnosis in DSM V A Neurocognitive disorder NCD replaced the term dementia but dementia still used today WILL NOT BE TESTED ON THIS B Mild modest decline in one or more cognitive domains does NOT interfere with independent living C Major significant decline in one or more cognitive domains substantial impairment that interferes with independent living 1 Specify mild moderate severe with or without behavioral disturbance D Cognitive domains 1 Complex attention multiple stimuli 2 Executive function plan and execute tasks required for daily function 3 Learning and memory 4 Language 5 Perceptual 6 Social Cognition E Major NCD etiology dementia is an umbrella term Alzheimer s 50 75 frontotemporal 10 15 Lewy body Parkinson s disease 10 25 vascular disease 20 30 traumatic brain injury substance medication use HIV infection prion disease Huntington s disease unknown prevalence of mixed dementia F Specific NCD Alzheimer s Diagnosis 1 Major NCD due to Alzheimer s disease APP cleaved by alpha secretase red and then gamma secretase aqua In Alzheimer s Disease APP is cleaved by beta secretase orange at a different site followed by gamma secretase aqua The longer fragment is called beta amyloid Tau proteins form insoluble filaments and tangles in axons Accumulation of tangles denotes severity of disease Beta amyloid fragments form oligomeres and then Loss of microtubules leads to synaptic congretate to form plaques failure cell injry and eventually in neuronal tissue neuronal death This causes oxidative and inflammatory injury and ultimately synaptic failure and cell death outside neuron but still in brain Microtubules transportation cell shape are composed of tubulin and stabilized by tau protein dark red In AD tau becomes hyperphosporylated red and insoluble therefore dissociating from tubulin Tau proteins form pair helical molecules which may be toxic 2 Interferes with independent living Insidious onset slow and gradual progression a b c Decline in one or more cognitive domains d Classify as probable or possible 2 Probable Alzheimer s disease a Genetic mutation obtained from family history or genetic testing OR b All 3 of the following i Decline in memory and learning and at least one other cognitive domain ii Steadily progressive gradual decline in cognition without extended plateaus iii No evidence of mixed etiology Warning Sign What s considered normal 1 Memory loss that disrupts normal life 2 Challenges in planning or solving problems 3 Difficulty completing familiar tasks at home at work or at leisure 4 Confusion with time or place 5 New problems with words in speaking or writing 6 Trouble understanding visual images and spatial relationships 7 Misplacing things and losing the ability to retrace steps 8 Decreased or poor judgment 9 Withdrawal from work or social activities 10 Changes in mood and personality V Clinical Presentation A A mix of all 3 Sometimes forgetting names or appointments but remembering them later Making occasional errors when balancing a checkbook Occasionally needing help to use the settings on a microwave or to record a television show Getting confused about the day of the week but figuring it out later Sometimes having trouble finding the right word Vision changes related to cataracts Misplacing things from time to time such as a pair of glasses or the remote control Making a bad decision once in a while Sometimes feeling weary of work family and social obligations Developing very specific ways of doing things and becoming irritable when a routine is disrupted 1 Cognitive memory loss 2 Behavioral personality changes 3 Functional being able to eat bath live for longest period of time B NCD etiology steady over time 1 Alzheimer s Memory language visual spatial disturbances delusions agitation slow 2 Vascular Abrupt onset stepwise deterioration executive dysfunction gait changes 3 Frontotemporal Personality changes executive dysfunction excessive eating drinking 4 Lewy Body parkinson s Visual hallucinations delusions