DrBruceBomans alzheimers disease

 Percentage of elderly people living with their children has declined  More elderly people are either living with their spouse or living alone  Increased number of “skip-generation” h

Bruce Boman

 Median age in China is 35.5 years

 Median age in Australia is 38 years

 Median age in Singapore is 39 years

 Median age in Hong Kong is 42 years

 Median age Japan is 45 years

 Australia 12.8%

 Japan 18%

 Because of

 Reduced infant mortality

 Control of infectious diseases

 Higher living standards

 And so your country will age at a historically unprecedented rate

 More swiftly than even Thailand

 Percentage of elderly people living with

their children has declined

 More elderly people are either living with their spouse or living alone

 Increased number of “skip-generation”

households where grandparents are living with their grandchildren

 Males 70 years

 Females 75 years

 By 2034 your Ageing Index is projected to hit 100, meaning number of people over 60 years will outnumber children 15 years & under

 For every one hundred children & adolescents 15 & under

 There will be 160 people 60 & over

 AGE IS BY FAR THE BIGGEST RISK FACTOR FOR

DEVELOPING DEMENTIA

Millions with dementia in Thailand, Indonesia & Sri Lanka WHO data

 Psychiatrists in Vietnam understand how to recognise & treat dementia

 These three are the most common:

 Alzheimer’s disease 60%

 Vascular dementia 20%

 Dementia with Lewy bodies 10%

 But because we have limited time I will focus on Alzheimer’s disease

Alzheimer worked with the famous German psychiatrist Kraepelin who described schizophrenia & bipolar disorder

 People have trouble

1 Remembering new things AMNESIA

2 Speaking correctly APHASIA

3 Understanding what other people are saying to

them AGNOSIA

4 Working out how to put their clothes on

correctly APRAXIA

5 Recognising family & friends PROSOPAGNOSIA

6 Being able to organise & plan ahead EXECUTIVE

FUNCTION

 Here’s a practical way to assess a person for dementia

 Should take 25-30 minutes

 Requires two simple tests of cognition

 First talk to the person whom you think may

BECAUSE

 Cognitive difficulties

 Psychiatric symptoms

 Changes in behaviour

 Activities of daily living

 EACH OF THESE AREAS CAN BE EXPLORED WITH A FEW SIMPLE QUESTIONS

COGNITIVE

DIFFICULTIES

To patient:

Are you often having difficulties finding the right word?

To wife:

Is your husband getting frustrated

because he wants to say something

but just can’t find the right word?

To wife:

Are you having trouble

understanding what your

husband is saying?

Does he have having trouble understanding what you are saying to him?

out how to put on his clothes?

Does he put his trousers or

underclothes on the wrong way

round?

To wife:

Is your husband getting lost when out walking in your

neighbourhood?

Has he got lost & had to be

brought home by neighbours?

Visual hallucinations

Paranoid delusions

Behavioral changes

 To Patient: Are you seeing things you can’t

explain?

 To wife: Does your husband see things

that aren’t there?

Does he think his reflection in the

mirror is another person?

Does he think people on the TV are

real people?

 To patient: Are people stealing your things?

Do you worry your wife might be being unfaithful?

MORBID JEALOUSY IS DANGEROUS IN PEOPLE WITH DEMENTIA

 To wife: Has he been accusing people of

stealing his possessions? Has

he accused you of being unfaithful?

Always remember

to check Please don’t be embarrassed to ask

 To patient: Have you been feeling very sad recently?

 Is anything making you angry these

days ?

 To wife:

Has your husband been sad & tearful

recently? Has your husband been getting angry a lot? Are you frightened your husband

might hurt you when he gets angry?

 Can your husband still manage

finances & recognise value of bank notes

 Can your husband still work the TV remote control?

 To wife:

 Do you worry that your husband is no longer driving safely?

 Has he had an accidents recently?

 Would you worry if he wanted to take one of your grand children on the the back of his motor cycle?

 Dressing & grooming?

 Is there a movement disorder present?

 The Folstein Mini Mental State

Examination (Vietnamese translation)

 Clock Drawing Test

TOGETHER THEY PICK UP THE KEY AREAS OF

COGNITIVE DYSFUNCTION IN DEMENTIA

 Good for detecting problems with

orientation, attention, recall, language & praxis

 But not for frontal executive problems

 Quick & easy

 Good screening test for frontal executive

problems

 Plain sheet of A4 paper with a large circle

 Pretend the circle is a clock

 Please write the numbers around the dial of the clock

 Could you now put the hands on the clock for five -forty

 Before ordering investigations remember

 The diagnosis of Alzheimer’s disease is a

 Full Blood Count

 Serum B12 & folate level

MRI detects early atrophy around the hippocampus

18 FDG PET scan detects areas of reduced glucose metabolism in temporoparietal regions

 Gradual onset & relentlessly progressive

 Survival 8-10 years

 About 3 MMSE (or 7 ADAS-Cog) points

decline each year

 Psychotic symptoms associated with more rapid decline

 Pneumonia most common cause of death

 Apolipoprotein epsilon 4 (apo E-4) allele

 Less education, lower intelligence, blue collar work

 Vascular risk factors : hypertension, diabetes, raised cholesterol, high fat intake, high serum

homocystine

 Down’s syndrome

 Hormone replacement therapy

 Most people with

Down’s syndrome develop Alzheimer’s pathology by their 40’s

 Gene for amyloid

precursor protein on chromosome 21

 Down’s syndrome

has trisomy 21

increased amyloid production

 Over 95% cases Alzheimer’s disease are

sporadic

 Small number of early-onset autosomal

dominant cases due to mutations on a) chromosome 21 ( gene for amyloid precurser protein) b) chromosome 14 (gene for

presenilin-1) c) chromosome 1

(gene for presenilin-2)

 Most common cause early onset Alzheimer’s

 Also earliest onset & most rapidly progressive

 All autosomal dominant gene mutations lead to excess production of amyloid beta

42 (Ab42)

Normal brain

Severe Alzheimer’s

Neuron with fibrillary

tangles made of

tau protein

Central core of amyloid beta 42 Dystrophic neurites

 PIB scan

 CSF biomarkers

Decreased levels amyloid beta Increased levels tau

 Emotional support to patient & family

 Sensitive disclosure of diagnosis &

prognosis

 Seeing spouse or parent dement is very

distressing experience-like a slow

bereavement

 Treat depression & behavioural disturbances (details later)

 Aim to reverse deficiency of acetylcholine in the cerebral cortex found in Alzheimer’s

disease

 Medications work by inhibiting

acetylcholinesterase, the enzyme which

metabolises acetylcholine

 Acetylcholine pathways start in nucleus basilis

of Meynert & spread

out to most of cerebral cortex

Donepezil (Aricept)

Rivastigmine (Exelon)

Galantamine (Reminyl)

 All inhibit acetylcholinesterase & increase availability of acetylcholine in the cerebral cortex

 No difference in efficacy

 All need careful titration to avoid

gastrointestinal side effects

 Main action is to delay progress of the

dementia by about six to nine months

 Continue to work in advanced stages of the illness

 Do you have any questions?