Dementia

Dementia

Dementia is our most-feared illness…Dr. David Perlmutter

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Definition:

Dementia is a common term used to describe a collection of symptoms, it is not a diagnosis.  The DSM, diagnostic and statistical manual for medical diagnosis uses the following definition.

Evidence from the history and clinical assessment that indicates significant cognitive impairment in at least one of the following cognitive domains:

  • Learning and memory
  • Language
  • Executive function
  • Complex attention
  • Perceptual-motor function
  • Social cognition

Furthermore, these conditions must be met:

  • The impairment must be acquired and represent a significant decline from a previous level of functioning
  • The cognitive deficits must interfere with independence in everyday activities
  • In the case of neurodegenerative dementias such as Alzheimer disease, the disturbances are of insidious onset and are progressive, based on evidence from the history or serial mental-status examinations
  • The disturbances are not occurring exclusively during the course of delirium (such as during an acute illness or intoxication)
  • The disturbances are not better accounted for by another mental disorder (eg, major depressive disorder, schizophrenia)

Manifesting as difficulty with one or more of the following:

  • Retaining new information (eg, trouble remembering events)
  • Handling complex tasks (eg, balancing a checkbook)
  • Reasoning (eg, unable to cope with unexpected events)
  • Spatial ability and orientation (eg, getting lost in familiar places)
  • Language (eg, word finding)
  • Behavior

Incidence/Prevalence/Costs:

  • 5.3 million Americans have dementia in 2015
    • Estimates for 2025 are 7.1 million
      • Nebraska has 33,000 cases
  • 5% of population in their 70’s have dementia
  • 25% of population in 80’s
  • 6th leading cause of death
  • 1 in 3 Americans have a demential condition at the time of their death
    • less than 1/2 of patients are aware they have a diagnosable dementia
  • most victims are over 65,
  • women have higher incidence at a ratio of 2:1.
  • higher incidence in hispanics and Black races.
  • Costs U.S. $226 billion in 2015.
  • Medicare costs are 300% higher for a senior with dementia than one without.

Types of Dementia:

Alzheimers Dementia, called AD

  • AD is responsible for 60-80% of dementia.

Vascular Dementia

  • Vascular disease is the second leading cause.

Dementia of Lewey Body, called DLB

  • manifests with hallucinations (visual and dramatic),
  • trouble walking,
  • tremor (like Parkinsonism)

Frontotemporal, FTD

  • manifest more as behavioral variant of dementia
    • change in personality,
    • lack of inhibition,
    • OCD behaviors,
    • apathy

Parkinson’s Disease with Dementia, PDD 

  • 30-40% of PD patients get dementia over course of their disease

 Cause:

 

Reversible: Minority of cases of dementia are from reversible causes (1%)

  • Thyroid disease
  • Vitamin Deficiencies
  • Hydrocephalus
  • CNS tumor
  • Depression
  • Alcohol or Drug abuse
  • Medications side effects:
    • pain pills,
    • sleeping pills,
    • sedatives,
    • anxiety meds,
    • depression meds,
    • anticholinergics (IBS, OAB meds),
    • antihistamines, benedryl, Tylenol PM
    • some Blood Pressure meds,
    • antipsychotics,
    • seizure meds.
    • Stress

Irreversible:

  • AD-protein tangles in the brain, Tau protein
  • LBD-amyloid proteins deposited in the brain, similar to AD
  • Creutzfeldt Jacob Disease, CJD
    • Prion infection in the brain, like Mad Cow Disease in cattle
  • Stroke, or combination of many mini-strokes over time
  • Parkinsons Disease, PD
  • Infections:
    • HIV,
    • Hepatitis
    • Meningitis/encephalitis(WNV, Syphilis)

Symptoms, differentiating dementia from forgetfulness or aging:

Dementia is characterized by:

  • Difficulty remembering recent events, familiar people.
  • Having to be told over and over.
  • Forgetting major events even happened, like a vacation.
  • Difficulty planning
  • Difficulty with following directions, like a recipe you’ve made several times.
  • Getting lost in familiar areas.
  • Difficulty balancing a check book.
  • The person doesn’t notice the issues, others do.
  • Become anxious, irritable with minor events or changes in routine.

Forgetfulness, or normal aging is more characterized by:

Diagnosis/Evaluation:

Your doctor can use several tools to determine if you have dementia.

  • MiniCog testing, can be given at home by family member or caregiver:
    • recall 3 familiar objects after 1 minute of time.
    • Draw a clock face with numbers and hands to display the correct time.
    • If fail MiniCog, further testing is needed.
  • MME: 30 point exam done at doctor’s office

Treatment:

There are treatments available for dementia.  First and foremost is to determine if there is a reversible cause.  Several non-medical strategies can be helpful for dementia.  Modification of vascular risk factors has a favorable outcome in slowing the progression of dementia.

  • Diet,
    • Heart healthy, Mediterranean diet
  • Exercise
  • Social engagement.
    • socializing with friends and relatives
    • games
    • reading
    • learning new skills
    • formal education
    • active hobbies
    • volunteerism

There are medical therapies available to help with dementia.

Medications:

1. Acetylcholinesterase inhibitors (Exelon, Aricept)

  • Can be used in all causes of dementia, score of 26 or less in MMSE.
  • First line treatment in early dementia.

2. Memantine (Namenda)

  • NMDA receptor antagonist, may be protective of neurons.  May have modest benefit in moderate to severe dementia.
  • Used in combination with AcetylCoA inhibitors for moderate to severe dementia.

 3. Vitamin E, 2000 U per day

  • May have some benefit in Dementia,
  • should not be used in combination with Memantine.

Prevention:

Several strategies have been found to delay the onset or slow the progression of dementia.

  • At the Alzheimer’s Association International Conference® 2014, a two-year clinical trial of older adults at risk for cognitive impairment showed that a combination of physical activity, nutritional guidance, cognitive training, social activities and management of heart health risk factors slowed cognitive decline.-1
  • Onion Model of cognitive decline:
    • Aging affects the brain like pealing the layers of an onion.
    • The more layers we build up over our lifetime the longer it takes to peal.
    • The core of the onion is equated to our ability to live independently with quality of life.
  • Learn a new skill (bilingualism delays the onset of dementia by 4 years), engage in formal education.  Stay socially engaged, volunteerism.  Active hobbies that require planning, thinking.
  • Practice Vascular health:
    • Good diet
      • Mediterranean diet:
        • fish, nuts, whole grains, fruits and veggies, olive oil, low in saturated fats (red meat, butter, cheese, sour cream, processed foods),
    • control weight, 
    • exercise, 
    • treat high blood pressure, 
    • control your cholesterol through diet, exercise and medications if necesary, 
    • aspirin may be appropriate 
      • (age > 65 with other vascular risk factors)
    • Don’t smoke,
    • get enough sleep,
    • manage stress (circle of influence vs circle of concern).
  • Avoid excess alcohol, 
  • evaluate and treat depression.

Research:

  • NIH spends $6B on cancer research,
  • $4B on heart disease research,
  • $3B on HIV,
  • but only $480M on AD.
  • Future research is focusing on the protein tangles in the brain and inflammation.
    • Immunizations
    • Antibodies against the proteins
    • Anti-Inflammatories

Conclusion/Call to Action:

Dementia is unfortunately very common.  As we live longer we will have increased incidences of health conditions related to aging.  Our actions, or lack thereof, when we are younger can influence the development and severity of dementia.  Be proactive about your health through preventive and protective habits.   Take action when you are healthy to diminish the impact of conditions associated with aging such as dementia, heart disease and cancer.

Resources:

An Unintended Journey, A Caregivers Guide to Dementia

Bible Verses-Alzheimer’s/Dementia/Memory Loss Activity Book for Patients and Caregivers

Shadowbox Press activity books for Dementia patients

http://www.alz.org

References:

1. Alzheimer’s Association,

2. Web MD

3.Up To Date

4.American Academy of Family Physicians

Skin Cancer

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Introduction:

Skin cancer is the most common type of cancer in the U.S.  3 million cases of skin cancer are diagnosed annually in the U.S.  1 in 5 Americans will be diagnosed with skin cancer over there lifetime.  Melanoma is the fastest growing preventable cancer in the U.S.

Types of Skin Cancer:

1. non-Melanoma, of which there are 2 kinds

  • Basal Cell Cancer (BCC ) and Squamous Cell Cancer (SCC)
  • BCC
    • 3 kinds: superfical, nodular, morpheaform
      • most common type of skin cancer
      • 1 in 3 in life
      • assoc. with sunlight or tanning or radiation exposure
      • 250,000 cases in U.S. per year
  • SCC
    • 2nd most common
    •  older individuals.
    • 2.1% mortality
    • treatment is shave, excise or desiccate

2. Melanoma, of which there are 5 kinds

  • superficial, nodular, lentigo, acral-lentiginous and amelanotic
  • Differential, or things that look like melanoma
    • Atypical nevi
    • seborrheic keratosis
    • AK, actinic keratosis
    • keratoacanthomas
    • Lentigo
    • dermantofibromas
    • sebaceous hyperasia
    • blue nevi
    • venous lakes800,000 individuals in U.S. have a history of melanoma.
  • fasting growing preventable cancer in U.S.
  • 9700 cases of Melanoma are related to tanning beds.
  • 8500 mortalities annually
  • related to sun, genetics, multiple nevi and atypical nevi individuals.
  • UVB is most potent ultraviolet light
  • 75% of adolescents, 33% of adults report at least one burn per year
  • UVA is also dangerous (tanning beds) and associated with photo aging, and cancer

Causes of skin cancer:

Tanning

  • 20% increased risk of melanoma if ever used a tanning device
    • Double the risk if age 35 or younger
  • 1:6 h.s. kids admit to tanning bed use.
    • risk is cumulative,
    • Group 1 Carcinogen to humans (definite link)

 

Prevention of skin cancer:

Screening for skin cancer:

  • USPSTF, the U.S. preventive services task force
    • No recommendation for doctors to screen everyone
    • if you are high risk, tell your doctor.
      • examine thyself, and family
  • ABCDE’s of melanoma
    • Asymmetry
      • right side different from left
    • Border
      • irregular
    • Color
      • change
      • irregular
    • Diameter
      • >6 mm
    • Evolution
      • changing, looks different than all others

Special Cases:

  • Large congenital nevi have 5 % lifetime risk of M.
    • >20 cm

 

References:
Dr. Rick Kellerman, Clinical Update
FP Essentials, Skin Cancer 10/2012
skincancer.org