The American Society on Aging (asaging.org) hosted a webinar on Monday, November 21st on the topic of “Understanding the Different Forms of Dementia.” The speaker was Teepa Snow (teepasnow.com), a dementia education specialist.
Though I think Teepa Snow is typically an incredible presenter, the one-hour webinar format didn’t suit her. She raced through the material, and didn’t cover many slides. I thought her discussion of Alzheimer’s and mixed dementia were very good. For Lewy Body Dementia, I think she would’ve done better by looking at the diagnostic criteria. I thought she was very unclear on FTD (frontotemporal dementia). And I think she under-rates the challenge of diagnosing dementia.
She said two things about Lewy Body Dementia that were new to me:
* “This is not AD plus PD.”
* “About 50% of those with LBD can’t get into REM sleep.”
You can find an online recording of the webinar here:
Put your mouse over the “11-21-11” area. Click on the file folder that appears below the word “Understanding.”
And, I’ve copied my notes from the webinar below. (In some cases, I’ve combined my notes with Teepa Snow’s slides, particularly for the many slides that she didn’t cover in full.)
Robin’s Notes from
Understanding the Different Forms of Dementia
Speaker – Teepa Snow, a dementia education specialist
Recording will be posted on asaging.org (American Society on Aging) within a week.
Learning objectives of this webinar:
* Distinguish the difference between normal and abnormal changes in brain functions associated with the aging process.
* Describe similarities and differences among dementia, delirium, and depression.
* Compare various dementias regarding initial symptoms, progression patterns, and management and treatment strategies.
* Discuss the importance of the role of the care partner in helping to effectively manage the care plan and treatment of individuals living with various dementias.
Dementia is caused by changes in the brain:
* Structural changes: permanent; cells are shrinking and dying
* Chemical changes: variable; cells are producing and sending less chemicals; people can “shine” when least expected (“chemical rush”)
“Dementia” – umbrella term that covers 70-80 different disorders, such as Alzheimer’s Disease (50-60%), vascular dementias, Lewy body dementia, fronto-temporal lobe dementias, other dementias. The “other dementias” category includes genetic syndromes, drugs/toxin exposure, white matter diseases, and Parkinson’s. Most of AD co-occurs with other dementias. These are terminal disorders. These are life-altering disorders.
Alzheimer’s has two forms — young onset (used to be called “early onset”; younger than 65), and late onset (or “normal onset”; more common; after age 65; average onset is 75). People in their 20s have AD!
Over 65, 5-10% of population has AD. At 85, closer to 50% of population has AD. Dramatic increase between 65 and 85!
With AD, brain shrinks by one-third.
PET scans of glucose activity by Gary Small, MD, at UCLA. Most with “Early Alzheimer’s” don’t have an AD diagnosis. Person and family might be aware of subtle changes. Similarities in PET scans between 90 YO with late AD and a child!
Young onset AD: genetics can be involved or lifestyle (high stress; sedentary; not socializing) can be involved. Many have young families (children in the house). Misdiagnosis (including psychiatric illnesses; mid-life crises; menopause; substance abuse) and non-diagnosis are common. Work may be the first place to notice changes (may be fired). Relationships are strained early. Services can be a problem. Finances are often problematic.
Down Syndrome: beta-amyloid plaques are in the brain at birth; young onset.
Late onset AD: New info is lost. Recent memory worse. Problems finding words. Misspeaks. More impulsive or indecisive. Gets lost in time and place. Notice changes over 6 months to 1 year. Can last 8-12 years, on average.
Problems not due to disease. Damage is related to blood supply, not primary brain disease. White spots on CT scan indicate dead cell areas — mini-strokes. Symptoms depend on where the dead areas are.
Sudden changes, known as stepwise progression.
Treatment can plateau. Treatment involves managing vascular health.
Other conditions: diabetes, hypertension, heart disease.
Picture varies by person (blood/swelling/recovery).
Can have bounce back and bad days.
Least-predictable of all the dementias.
Judgment and behavior is “not the same”
Spotty loss (memory, mobility).
Emotional and energy shifts. Person is very labile: go from one extreme to another pretty quickly. Example: ask someone “how are you doing?” and they start crying and say “I don’t know.” Advice: leave the room, come back with Kleenex. This distraction solves problem. Another situation is that the person is very apathetic.
Can last 3-30 years.
LEWY BODY DEMENTIA
Important to know about. This is not AD plus PD. This is a different phenomenon.
Most mis-diagnosed and missed as a diagnosis.
Can be misidentified as PD. It does involve movement problems (especially frequent falls) early in the disease. Often falls are in bathrooms and bedrooms.
Can have visual hallucinations. Almost always involve animals, children, or people. Usually in the late afternoon and evening. Some people have insight into their hallucinations.
Can have fine motor problems — hands and swallowing.
Don’t often have rest tremor. The person is often awkward due to an intention tremor. (This is a distinguishing characteristic.)
Episodes of rigidity. The person might get stuck. They are NOT getting stuck on purpose!
Episodes of syncope.
Can have nightmares. Think dreams are real. Can have a dark edge of the dreams.
Can have insomnia. About 50% of those with LBD can’t get into REM sleep.
Fixed delusional thinking.
Fluctuations in abilities.
Drug responses can be extreme and strange. This is probably the most important thing. Often, MDs, if they are thinking PD, will prescribe Sinemet. Sinemet can make the hallucinations worse. Often the drugs used to treat hallucinations are antipsychotics. 50% of those with LBD have a seriously strong reaction (extrapyramidal side effects) to antipsychotics. This is one of the reasons for a black-box warning on antipsychotics.
Often drugs used to treat agitation can make the problem worse.
Average: live 7-9 years with symptoms.
* Frontal – loses impulse and behavior control (no memory issues). Says unexpected, rude, mean, odd things to others. Disinhibited with food, drink (so serious the person can get hyponatremia), sex, emotions, actions. OCD-type behaviors. Hyperorality.
* Temporal – language loss. Cannot speak or get words out. Cannot understand what is said. Sounds fluent but using nonsense words.
Those with frontal lobe dementias: can end up arrested. Highest risk: genetic and head injury.
“PPA (Primary Progressive Aphasia) Nonfluent” – older term for temporal dementia
* FvFTD – frontal variant of FTD
* FTD – frontal-temporal lobe dementia
* TLD – non-fluent aphasia
* TLD – fluent aphasia
[Robin’s note: yes, those last two both say “TLD”]
Temporal Lobe Non-Fluent Aphasia: very frustrating; locked-in dementia; cannot name items; hesitant speech; not speaking; worsening of speech production over time; echolalia; misspeaking; word salad; receptive inability; other skills intact — early; 25% never develop global dementia
FTD (Pick’s Disease)
* Frontal Issues: poor decision making; problems sequencing; reduced social skills; lack of self-awareness; hyperorality; egocentric; disinhibited (food, drink, words, actions); OCD behaviors early; excessive emotions
* Temporal Issues: reduced attempts to talk; reduced content in speech; poor volume control; public use of “forbidden words”; sing-song speech; cannot understand others’ words
Could be atypical dementia, other dementia, or mixed dementia
40% of those with PD will develop dementia
Up to 50% of those with depression will develop dementia late in life.
Those with toxic exposure (drugs, heavy metals) or pesticide exposure can develop dementia
* genetic syndromes: Huntington’s Chorea
* ETOH related
* white matter diseases: MS
* mass effects: tumors and NPH
* infections that cross the blood brain barrier: Creutzfeld-Jakob, HIV/Aids
Some progress very rapidly. Some are unique while some follow more traditional patterns.
In a mixed picture, it is possible to:
* have multiple forms
* start with one and add another
* have some symptoms, but not all
* have other life-long issues and then develop dementia (Down syndrome, mental illness, personality disturbances, substance abuse)
SEEING A DOCTOR
If you begin to notice changes, what should you do?
* Get it assessed
* Go see the doctor!
Why see a doctor?
* Future plans: progression and prognosis; finances; health
* Being in control
* Medications can make a difference in quality of life
* Get educated about the disease
* Take advantage of the right support services
Old screening option is the MMSE. It’s short but helpful.
New screening options:
* AD8 interview
* SLUMS: 7 minute screen; short but helpful
* Animal fluency: # of animals that can be named in one minute
* Clock drawing: 2 step
* Full neuropsychological testing panel
AD8 dementia screening interview:
* Does your family member have problems with judgment?
* Does your family member show less interest in hobbies/activities?
* Does your family member repeat the same things over and over?
* Does your family member have trouble learning how to use a tool, appliance, or gadget?
* Does your family member forget the correct month or year?
* Does your family member have trouble handling complicated financial affairs?
* Does your family member have trouble remembering appointments?
* Does your family member have daily problems with thinking or memory?
AD8 score: Changed, Not Changed, Don’t Know
If the screening identifies concern:
* Review current medications
* Complete work-up and follow up OR Send for a full neuropsychological evaluation
* Then, follow up with you OR Refer to a specialist
MIMICS OF DEMENTIA
Depression: cannot think; cannot remember; not worth it; loss of function; mood swings; personality change; change in sleep
Delirium: swift change; hallucinations; delusions; on and off response; infection; toxicity; dangerous
WHEN YOU NOTICE SOMETHING
* If person is aware and cooperative, partner and support
* If person is not aware and not interested or willing, look for authority figure to help. Be willing to change how you talk about your concern. Weigh the cost-benefit. Ask for the person’s help FOR you….not about them. Do you have a healthcare POA?
GETTING A DIAGNOSIS
What should happen?
* A complete physical, medical, and psychological history
* A good history from the person and the family of the situation
* A thorough PE neurological and cardiac exam with blood work
* A complete medication review
* Imaging study (CT, MRI, PET)
* Neuropsychological testing – what works and what does not
* Follow-up and counseling or at least a referral
When should you get a second opinion?
* When what we talked about did not happen
* When you feel un-listened to about concerns
* When you are not offered options that seem reasonable
* When you think or feel that the doctor is not skilled enough to do a good job of managing this
* When it is an atypical dementia
How you can help?
* Be supportive
* Be an advocate
* Work out healthcare support (HC-PoA)
* Check with your doctor – raise your concern
* Consider a neuropsychological assessment
* Consider seeing a specialist — geriatrician, neurologist, gero-psychiatrist
QUESTIONS & ANSWERS (45:00)
Question: How do we interact with someone with FTD?
Answer: For frontal lobe dementia, the most important thing to know is that the person can be impulsive, and although the person may know they are not supposed to do something, they are still going to do it. We need to quit creating opportunities where the impulse will create a bad outcome.
You can’t stand in front of the door and say “you can’t go out and drive,” as you will get hurt. You want to remove the car keys from the immediate vicinity, and let someone else be the bad guy.
This person needs a controlled environment early on.
When someone is doing something, use positive social engagement. Rely on automatic responses.
If it’s a temporal lobe problem, stop using so many words. Slow down your speech. Don’t get too close. Don’t put your hands on them. Repeat a few of the words they said.
If it’s a fluent aphasia, go along with their speech.
If it’s a nonfluent aphasia, say: “You are a very smart person. I’m so sorry but I can’t understand what you are saying.” Don’t say “It’s OK, it’s OK.”
Q: Meds for AD?
A: AChEIs (Aricept, Exelon, Razadyne) – help with symptom management. Don’t help with the disease. Helps brain produce more acetylcholine in some people. Can only help living cells. Most effective early in the disease. Late in the disease, acetylcholine may be helping your brain to remember to put food in your mouth and chew. We don’t know when this medication becomes ineffective. It’s not for everyone. Always consider giving it a dry. These drugs are for AD, but not necessarily for FTD.
There’s also Namenda. Controls glutamate in brain. Can keep brain on an even keel.
We don’t know if people are short on acetylcholine and need to have their glutamate level moderated. Must weigh downsides (GI, may bother heart, may bother gut).
Q: Tool to tell difference between these conditions?
A: What were the very first symptoms anyone noticed? The first symptoms tell us where the disease started. Where the disease started is important. This helps identify the primary dementia.
Upon brain autopsy, for those cases where we got a really good history, 90% of the time we are accurate.
AD – memory; immediate recall
LBD – movement; hallucinations; delusional thinking
FTD – behaviors or language
Benson’s – visual processing (we haven’t talked about this one)
Q: We are seeing more LBD and vascular dementia diagnoses these days. Is the frequency increasing?
A: We are diagnosing people better.
For the first time, Alzheimer’s is no longer a diagnosis of exclusion.