Alzheimer's Disease- Neuro Quiz 2

Alzheimer's Disease

A progressive, neurodegenerative disease leading to severe dementia and usually death

The most important risk factor for Alzheimer's is?

Age

Genes Affected in AD

ApoE4, APP, Presenilin 1&2

PT implications of AD

Cognitive rehab program: designed to teach the patient structured tasks. Patients should be able to attend an activity for at least 5 minutes and the session should not provide more stimulation than tolerable. Exercises should be short, simple and done in the same order and at the same time each day.

Severe/Advanced Stages of AD

Cortex and hippocampus shrink, and new memories are unable to be formed. Ventricles enlarge

Dementia

Decline in intellectual functioning severe enough to interfere with a person's relationships and ability to carry out ADLs. Most commonly caused by Alzheimer's disease A hallmark sign is significant decline in memory

Lewy Body Dementia

Early dementia, rigidity more prominent, hallucination, fluctuating cognitive status, and falls. Initial Parkinsonism unresponsive to standard medication. Lewy bodies, tangles, and plaques. Progresses to deteriorization of cognition. Asymmetrical gait, speed apraxia, "alien hand" syndrome, rigidity, myoclonus, cortical sensory loss.

Early Alzheimer's

Learning, memory, thinking, planning

Mild to Moderate Alzheimer's

Speaking, understanding speech, proprioception

Clinical Course/Progression of AD

There is no cure. Progression is usually continuous and does not fluctuate or improve.

Risk Factors fo Alzheimer's Disease

-*Age -Female gender after 80 years of age -Cardiovascular risk factors: HTN, diabetes, obesity, hypercholesterolemia. -Family history -Genetic markers such as: ApoE4 gene, Mutations in amyloid precursor protein (APP) gene, Trisomy 21(down syndrome), Mutations in presenilin 1&2 which account for most cases of early-onset inheritied AD. (appear to accelerate B-amyloid plaque formation and apoptosis)

AD etiology

Appears to be a relationship between a genetic predisposition, the abnormal processing of a normal cellular substance, amyloid, and advanced age. Mutations in the genese previously mentioned provide strong support for the "amyloid cascade hypothesis"

Alzheimer's Disease and Gender

As we age, women have a higher chance of developing AD than men due to the fact that women live longer than men.

Etiologic Hypothesis behind AD: Senile Plaques

B-amyloid protein: natural substance required to maintain fibroblasts and cell funciton; usually dissolved and reabsorbed by brain tissue. Individuals with AD: B-amyloid remains in fluid surrounding neurons>>B-amyloid protein deforms>> many stick together>> sheet of connected proteins=senile plaques

AD and mortality

Between 2000 and 2008, deaths attributed to AD increased 66%, while those attributed to the #1 cause of death, heart disease, decreased 13%.

Patients with AD have a higher incidence of falls and are more seriously injured when they fall; why is this and what can we do?

Caused by an interaction of medications, capacity overload because of decline in cognition and wandering. We can modify the living area. Perform strengthening and ROM to prevent falls. Assistive device usage is controversial. Some say it gives the patient a sense of safety, some say that because of limited dual task processing, it adds to the problem.

Alzheimer's Disease

Characterized in the brain by abnormal clumps (amyloid plaques) and tangled bundles of fibers (neurofibrillary tangles) composed of misplaced Protein

Neurofibrillary Tangles

Chemical changes in the neuron produce structural changes in the tau protein which results in twisting and tangling

Alzheimer's Dementia

Clinical dementia in people who also have Alzheimer neuropathology.

Based on what we have learned in motor behavior, what type of memory does "structured tasks" target? and what dkind of practice do you think would be best?

Implicit memory: be repetitive, use minimal instructions with more visual than verbal and just do it. Spend most of the treatment showing them and performing the task. Basically they learn subconsciously (without awareness) through repetitions. Therefore, constant and not variable practice is best for learning. (same thing over and over again)

MMSE and AD

Mini Mental Status Exam is a valid and reliable instrument widely used to screen for cognitive impairment in older adults.

Severe Alzheimer's

Most of the cortex is damaged (brain shrinks secondary to cell death)

Other Key points on Alzheimer's

Remember that exercises should be simple, repetitive, and done in the same order each day. Identify yourself and use the patient's name. "Hi Mr._____ I'm _____, your physical therapist. Do exercise earlier in the day and at the same time each day. DO NOT interrupt routine.

Diagnosis of AD

The most important diagnostic step is determining if it's truly AD. It could be interactions of medications, or possibly a reversible encephalopathy. Requires complete medical assessment. Definition of true diagnosis: a decline from previous levels of functioning and impairment in MULTIPLE COGNITIVE DOMAINS BEYOND JUST MEMORY. (jot just memory but spatial relationships, inability to plan, and unable to solve problems)

AD is thought to mainly affect cognition early on and spare motor until later, but this school of thought is changing. Why?

Walking is often viewed as an automatic task, but as we have studied, it may be more of a cognitive process requiring higher level control, and researchers are observing that changes in cognitive function are contributing to gait disturbances and increased fall risk (motor changes).

Alzheimer's Disease and Down Syndrome

by the age of 40, symptoms of AD can be seen in almost everyone with down syndrome.

AD and the United States

one of top 10 leading causes of death, mortality rates are on the rise.

Alzheimer's Disease (AD)

the disease process that ultimately results in Alzheimer's Dementia. Atypically the patient has progressive aphasia or progressive ataxia rather than dementia.

Primary Signs/Symptoms of AD

-Memory loss that disrupts daily life(most common) -Challenges in planning or solving problems -Difficulty completing familiar tasks at home, at work or at leisure -Confusion with time or place -Trouble understanding visual images and spatial relationships -New problems with words in speaking or writing -Misplacing things and losing the ability to retrace steps -Decreased or poor judgement -Withdrawal from work or social activities -Changes in mood and personality

Epidemiology of Alzheimer's

5.4 million in US currently diagnosed. Without a cure these numbers will increase by almost threefold by 2050. Prevalence: 13% of people over 65, 43% of people over 85%. Lifetime risk of developing AD is between 12-17%.

Sundowning

Complication of AD that includes: restlessness, wandering, increased confusion, delusions, anxiety and paranoia. Symptoms surface when the sun goes down. Late afternoon or early evening, at about the same time every day. Increased incidence in fall and winter. Gets worse if something interferes with patient's routine. Exercise is though to be beneficial in management.

Senile Plaques

Composed of B-amyloid deposits, usually contained in the extracellular space of individuals with AD -Trigger an inflammatory response>> increased free radicals>> damage to nervous system

Frontotemporal Dementia

Describes several progressive disorders that have a tendency to effect the frontal lobes. Cellular neuropathology is variable (sometimes seems to be the frontal lobe manifestation of AD, Pick's Disease, and Lewy Body Dementia

Earliest Stages of AD

Deterioration in the earliest stages can begin as early as 20 years before diagnosis Affected Regions: Hippocampus (learning and memory), Frontal lobe (thinking and planning)

Prognosis of AD

Disease cannot be stopped or reversed. Treatment is based on early institution of drugs used to slow progression. Time from onset to death is about 7-11 years. Death is usually due to dehydration or infection. Fourth leading cause of death in adults.

Alzheimer's Disease

Eventually will destroy cognition, personality, and the ability to function

Pick's Disease

Frontal inhibition of socially unacceptable and previously suppressed behavior emerges early in the disease, often overshadowing the memory disturbance. Cortical atrophy occurs in the frontal and temporal lobes. Inclusions known as Pick bodies, and no tangles or plaques. Much less common than AD.

Mild to Moderate Stages of AD

Progression of initial stages. Spread of Plaques and tangles to effect more regions of the brain. Affected Regions: Temporal Lobe (speaking and understanding) Also see deficits in the sense of where their body is in relation to objects around them

Severe Stages of AD

Progression of the moderate stage affects. Spread of plaques and tangles throughout most of the cortex. Brain shrinks due to cell death, and patient loses ability to recognize loved ones and ability to care for themselves

Etiologic Hypothesis: Neurofibrillary Tangles

Senile plaque comes into contact with a neuron and causes changes that lead to destruction and destabilization of microtubules. Tau protein, which normally holds microtubules together detaches and causes the microtubules to disintegrate. Neurofibrillary tangles form and remain in the system. Overall effects are decreased cell division and loss of axonal transport of neurotransmitters.

7 Stages of AD according to NYU School of Medicine Aging and Dementia Research Center

Stage 1: no impairment Stage 2: very mild decline; may be normal age related changes or earliest signs of AD. Stage 3: mild decline Stage 4: moderate decline; early stage AD Stage 5: moderately sever decline; 506 are mid stage AD Stage 6: severe decline Stage7: very severe decline; late stage AD