1. General Dementia Knowledge:
Signs, Symptoms, Progression
Panelists:
Ellen Lindsey
Phipps Slaughter, PsyD
Moderator:
E. Ayn Welleford, MSG, PhD
May 9, 2011

2. CHANGES WITH AGING
TYPICAL CHANGES A-TYPICAL CHANGES
• Making a bad decision once in a • Consistent poor judgment and
while decision making
• Missing an occasional monthly • Loss of an ability to manage
payment money
• Forgetting which day it is and • Inability to keep track of the date
remembering later or the season
• Sometimes forgetting which word • Difficulty having a conversation
to use • Misplacing things and loss of the
• Losing things from time to time ability to retrace steps to find
them
• Trouble with visual and spatial
relationships
• Challenges in planning or solving
problems

3. DEMENTIA
Dementia
IS NOT a
specific
disease.
Dementia is a
Memory loss generally
GROUP OF SYMPTOMS
occurs in dementia, but
affecting intellectual and
memory loss alone does
social abilities severely
not imply you have
enough to interfere with
dementia. daily functioning.
DEMENTIA
Alzheimer's disease There are many
is the most common
cause of a progressive
causes of dementia
dementia. symptoms.

4. DEMENTIA
Per the Diagnostic Statistical Manual IV- Revised (DSM-IV-TR), dementias share a common symptom
presentation but are differentiated based on etiology, or cause.
The essential feature of any dementia is the development of multiple cognitive deficits
that include:
• memory impairment
and at least one of the following cognitive disturbances:
• aphasia (language disturbance),
• apraxia (impaired ability to carry out motor activities despite intact motor function),
• agnosia (failure to recognize or identify objects despite intact sensory function), and
• executive dysfunction (difficulty in planning, organizing, sequencing, abstracting).
The deficits must also be sufficiently severe and must represent a decline from a previously
higher level of functioning.
The diagnosis of dementia may be accompanied by subtypes and specifiers such as
• Early (before the age of 65) or Late Onset (after 65)
• With Behavioral Disturbance (e.g., wandering, striking out during care);
• With Delirium (if delirium is superimposed on dementia);
• With Delusions (if delusions are most prominent feature);
• With Depressed Mood (if depressed mood is most prominent feature); and
• Uncomplicated (if none of the aforementioned predominates the clinical presentation).

5. DEMENTIA CAUSES CHANGES IN
personality
memory
/ mood
behavior language
navigation thought

6. TYPES OF DEMENTIA
CORTICAL SUBCORTICAL
• Result from a disorder affecting the • Result from dysfunction in parts of
cerebral cortex (outer layers of the the brain that are below the cortex.
brain) playing a critical role in • Examples are dementias of the types
cognitive processes such as memory Huntington's disease, Parkinson's
and language. Disease, and AIDS dementia
• Alzheimer's and Creutzfeldt-Jakob complex
disease are two such forms. • Characteristics include changes in
• Characteristics include severe personality and attention span, with
memory impairment and aphasia a slowing down of thinking.
(inability to recall words or • Early symptoms include
understand common language). depression, clumsiness, irritability
or apathy. But the end stages of
subcortical dementia result in the
same breakdown of brain function
as in the cortical dementias.

7. FUNCTIONS OF THE CORTEX

8. CORTICAL DEMENTIAS
• Alzheimer’s disease
• Vascular dementia
• Frontotemporal dementia
• Creutzfeldt-Jacob disease

9. ALZHEIMER’S DISEASE
brain
disorder, most
common form
of dementia
ASSOCIATED RISK FACTORS:
• Age
• Family history
Affects 5% of
people at age • Down syndrome
65
• Incidence higher in women
• Alcohol use
• Atherosclerosis
Affects 50% of
people age • Blood pressure
85+
• Cholesterol
• Depression
Late-onset
• Diabetes (type 2)
(age 65+) is
most
common,
slowest-
progressing
Average
course of
DAT: 6-20
years

10. AD (cont.) – 10 WARNING SIGNS
Memory loss
that disrupts
daily Challenges in
Changes in functioning planning or
mood and
solving
personality
problems
Difficulty
Withdrawal completing
from work or familiar tasks at
social activities home, at work or
WARNING at leisure
SIGNS
Decreased or Confusion with
poor judgment time or place
Misplacing Trouble
things and understanding
losing the visual images
ability to retrace New problems and spatial
steps with words in relationships
speaking or
writing

11. Plaques Tangles
Acethylcholine Deficiency

12. AD – STAGES
It is important to keep in mind that stages are general guides, and symptoms vary greatly. Not
everyone will experience the same symptoms or progress at the same rate. This seven-stage
framework is based on a system developed by Barry Reisberg, M.D., clinical director of the New
York University School of Medicine's Silberstein Aging and Dementia Research Center.
Stage 1: No impairment (normal function)
The person does not experience any memory problems. An interview with a medical
professional does not show any evidence of symptoms of dementia.
Stage 2: Very mild cognitive decline (may be normal age-related changes or earliest
signs of Alzheimer's disease)
The person may feel as if he or she is having memory lapses — forgetting familiar words or the
location of everyday objects. But no symptoms of dementia can be detected during a medical
examination or by friends, family or co-workers.

13. AD – STAGES
Stage 3: Mild cognitive decline (early-stage Alzheimer's can be diagnosed in some,
but not all, individuals with these symptoms)
Friends, family or co-workers begin to notice difficulties. During a detailed medical interview,
doctors may be able to detect problems in memory or concentration. Common stage 3
difficulties include:
• Noticeable problems coming up with the right word or name
• Trouble remembering names when introduced to new people
• Having noticeably greater difficulty performing tasks in social or work settings
• Forgetting material that one has just read
• Losing or misplacing a valuable object
• Increasing trouble with planning or organizing

14. AD – STAGES
Stage 4: Moderate cognitive decline (Mild or early-stage Alzheimer's disease)
A careful medical interview should be able to detect clear-cut problems in several areas:
• Forgetfulness of recent events
• Impaired ability to perform challenging mental arithmetic
• Greater difficulty performing complex tasks, such as planning dinner for guests,
paying bills or managing finances
• Forgetfulness about one's own personal history
• Becoming moody or withdrawn, especially in socially or mentally challenging
situations
Stage 5: Moderately severe cognitive decline (Moderate or mid-stage AD)
Gaps in memory and thinking are noticeable, and individuals begin to need help with day-to-
day activities. At this stage, those with Alzheimer's may:
• Be unable to recall their own address or telephone number or the high school or
college from which they graduated
• Become confused about where they are or what day it is
• Have trouble with less challenging mental arithmetic; such as counting backward
from 40 by subtracting 4s or from 20 by 2s
• Need help choosing proper clothing for the season or the occasion
• Still remember significant details about themselves and their family
• Still require no assistance with eating or using the toilet

15. AD – STAGES
Stage 6: Severe cognitive decline (Moderately severe or mid-stage AD)
Memory continues to worsen, personality changes may take place and individuals need
extensive help with daily activities. At this stage, individuals may:
• Lose awareness of recent experiences as well as of their surroundings
• Remember their own name but have difficulty with their personal history
Remember:
It is difficult to place a person with Alzheimer's in a specific stage as stages may overlap.
• Distinguish familiar and unfamiliar faces but have trouble remembering the name
of a spouse or caregiver
• Need help dressing properly and may, without supervision, make mistakes such as
putting pajamas over daytime clothes or shoes on the wrong feet
• Experience major changes in sleep patterns — sleeping during the day and
becoming restless at night
• Need help handling details of toileting (for example, flushing the toilet, wiping or
disposing of tissue properly)
• Have increasingly frequent trouble controlling their bladder or bowels
• Experience major personality and behavioral changes, including suspiciousness
and delusions (such as believing that their caregiver is an impostor)or compulsive,
repetitive behavior like hand-wringing or tissue shredding
• Tend to wander or become lost

16. AD – STAGES
Stage 7: Very severe cognitive decline (Severe or late-stage Alzheimer's disease)
In the final stage of this disease, individuals lose the ability to respond to their environment, to
carry on a conversation and, eventually, to control movement. They may still say words or
phrases.
At this stage, individuals need help with much of their daily personal care, including
eating or using the toilet. They may also lose the ability to smile, to sit without
support and to hold their heads up. Reflexes become abnormal. Muscles grow rigid.
Swallowing impaired.

17. AD - TREATMENT
• No treatment is available to slow or stop the deterioration of
brain cells in Alzheimer's disease.
• The US Food and Drug Administration has approved five
drugs that temporarily slow worsening of symptoms for
about 6 - 12 months.
• These are effective for only about half of the individuals
who take them.
• Inconclusive research:
o Vitamin E
o Anti-inflammatory drugs
o Estrogen
o Vaccine
o Diet
www.alz.org/research/overview.asp

18. VASCULAR DEMENTIA
CAUSES:
• Untreated high blood pressure
The second most • Diabetes
common
dementia after • High cholesterol
Alzheimer's
disease • Heart disease
ASSOCIATED SYMPTOMS:
Result of a
damage to the • Confusion and agitation; depression
brain caused by
VaD can be cortical and
subcortical problems with • Unsteady gait
the arteries
serving the brain • Problems with memory
or heart.
• Urinary frequency, urgency,
incontinence
• Night wandering
Approx. 25-30%
of all dementias • Decline in ability to organize
are VaD
thoughts/actions, difficulty planning
• Poor attention/concentration
Prevalence of
VaD ranges from
TREATMENT:
1 to 4 percent in
people over the
Damage caused by infarcts cannot be
age of 65. reversed. Future cerebrovascular
incidents can be controlled (control of
cardiovascular risk factors)

19. FRONTOTEMPORAL DEMENTIA
CAUSES:
(Fronto-temporal areas
• Unknown
Group of
diseases
of the brain are
generally associated • Possible genetic mutations.
characterized by with personality,
the degeneration behavior and language). ASSOCIATED SYMPTOMS:
of nerve cells in In these dementias,
the F-T areas of portions of these lobes
atrophy.
• socially inappropriate behaviors
the brain
• loss of mental flexibility
• decline in personal hygiene
• language problems, and
Begins earlier
and progresses • movement disorders
faster than AD
• difficulty with concentration and
thinking.
TREATMENT:
• Irreversible dementing process
Occurs at ages
younger than
• Agitated symptoms respond to
AD, i.e., 40-70. antipsychotic meds
• Compulsive symptoms respond to
SSRIs (antidepressants)
• Some patients also benefit from
Pick's disease affects parts of
ADHD meds to stimulate frontal
One form of this
the brain that contain fibrous condition is lobe function
• Behavioral interventions may be
tangles made up of an Pick's disease.
abnormal protein called tau
protein
effective to encourage behavioral
control whenever possible

20. CREUTZFELDT-JAKOB DISEASE
CAUSES:
abnormal versions of a protein called a
CJD is a
degenerative brain prion.
disorder that leads
to dementia and,
ultimately, death. TRANSMISSION
(rapid progression)
Risk of CJD is low.
Cannot be transmitted through
coughing, sneezing, touching or
Variant CJD is
linked primarily to The "classic"
sexual contact.
eating beef infected Creutzfeldt-Jakob
with disease has not CJD DEVELOPS:
bovine spongiform been linked to
encephalopathy contaminated beef. • Spontaneously (majority of cases)
(mad cow disease.
• Genetic mutation (family history)
• Contamination. (very low number
of exposures to infected human
1 in 1 million
people are
tissue during a medical procedure)
diagnosed with
CJD per year
(usually older
ASSOCIATED SYMPTOMS:
adults). personality changes, anxiety,
depression, memory loss, impaired
thinking, blurred vision, insomnia
difficulty swallowing, motor issues.

21. MIXED DEMENTIAS
• AD and another type of dementia can exist at the same time
• This may account for nearly half of the cases where AD is present

22. SUBCORTICAL DEMENTIAS
• Dementia due to Parkinson’s disease
• Lewy body dementia
• Alcohol-induced persisting dementia
• Progressive supranuclear palsy

23. DEMENTIA DUE TO PARKINSON’S DISEASE
GENERAL PD SYMPTOMS:
• Movement problems (tremor, stiffness, slowness)
PD is a
• Walking problems (freezing, shuffling gait)
progressive • Speech problems (soft voice, trails off, monotonous)
disorder of the
CNS • Other oral problems (drooling, difficulty
swallowing)
• Fatigue
• Blank facial expression
Results from a DEMENTIA SYMPTOMS IN PD PATIENTS:
deficiency in the
neurotransmitter • Slowed reaction time
DOPAMINE • Impulse control problems
• Hallucinations or delusions
• Short-term memory problems (but with hints they
can recall info)
Affects more than
• Problems with recognizing emotions in others’
1.5 million people
in the US
speech or facial expressions
TREATMENT
There is no known treatment that stops or reverses
dementia due to PD
• Medications that increase dopamine production
20-40% have
more severe 50%+ of people help control movement aspects of PD (not cognitive)
symptoms/ with PD have
MCI. • Some surgeries can be helpful (e.g., Deep Brain
dementia
stimulation), but not for dementia symptoms
• Stem cell research is being conducted, results are

24. DEMENTIA WITH LEWY BODIES
CAUSES:
- Not known
Deposition of
Lewy bodies
- LB often found in the brains of people w/PD.
in both, SYMPTOMS:
cortical and
subcortical
• Core criteria (must have two):
o Fluctuating attention and concentration
o Recurrent, well-formed visual hallucinations
o Newly emerged PD-type motor problems
Has features • Suggestive features (these may be present):
of both PD
and AD
o History of REM sleep behavior disorder
(violent sleep behavior or sleepwalking)
o Sensitivity to neuroleptic (antipsychotic) meds
• Supportive clinical features (don’t have to be
Affects 1% of present):
those age 65, o Repeated falls, Syncope (fainting), Depression
5% over age
85 TREATMENT
• Older antipsychotics (e.g., Thorazine, Haldol) are
usually avoided because they can cause deadly
Usually reactions in LBD patients
progresses
more rapidly • Anti-dementia medications (e.g., Aricept, Reminyl)
than DAT have been found to be somewhat effective in
(average = 6
years) slowing cognitive decline and calming behavior
• Dopamine-enhancing drugs appear effective in
addressing motor symptoms

25. ALCOHOL-INDUCED PERSISTING DEMENTIA
ASSOCIATED SYMPTOMS:
Sometimes referred
to as Wernicke-
o Severe memory impairment
Korsakoff’s
syndrome o Inventing false memories (confabulation)
o Reduction in speech
o General apathy
o Gait problems (coordination)
A dementia
syndrome caused o Tremors
by many years of
heavy drinking o No insight into difficulties
o Hallucinations (in some patients)
Usually the result
of a combination of TREATMENT
malnutrition
(thiamine
deficiency) and
• Can be partially reversed if caught early and
brain damage
directly caused by
treated with high doses of thiamine
•
alcohol
Abstinence from alcohol is ESSENTIAL to stop
progression of dementia
o Support programs can help maintain
Accounts for < 5% abstinence
of all dementias
o Periodic blood tests, breathalyzers can also
be useful

26. ANOTHER WAY OF LOOKING AT
DEMENTIAS
REVERSIBLE IRREVERSIBLE
• Depression, delirium • Dementia of the Alzheimer’s
• Emotional disorders type
• Metabolic disorders (e.g., • Dementia of the Parkinson’s
hypothyroidism type
• Eye and ear impairments • etc.
• Nutritional (e.g., B12
deficiency)
• Tumors
• Infections
• Alcohol, drugs, medication
interactions

27. REVERSIBLE COGNITIVE IMPAIRMENT
COGNITIVE IMPAIRMENT DUE
PSEUDODEMENTIA DELIRIUM
TO MEDICAL CONDITION
• Dementia patients: bad guesses • Acute period of confusion brought • Malnutrition
• Pseudodementia patients: “I don’t about by many potential causes • Vitamin deficiency (e.g., B12)
know.” • Medical conditions • Electrolyte imbalance
• Medications (alone or in • Cardiac and/or pulmonary
• Dementia patients: slow onset, combination with one another) conditions
• Pseudodementia patients: • Altered sleep schedule (most • Insufficient oxygenation of blood
problems appeared rather often in dementia patients) to brain
suddenly • Intoxication by legal or illicit • Metabolic conditions
substances • Organ failure leading to
• Dementia patients: unaware of insufficient metabolization of
deficit • Always rule out delirium before nutrients, medications
• Pseudodementia patients: keenly diagnosing dementia
aware of deficits (and often • The cause of the delirium could
complain of distress) be deadly, must discover it early
• TREATMENT • TREATMENT
• Psychotherapy (if available and • consists of treating the
the patient is willing) underlying medical condition
• Antidepressant medications (e.g., • Rule of thumb: delirium lasts one
Zoloft, Wellbutrin, Celexa) week for each decade of the
• Maintaining physically active patient’s life (e.g., 65 y.o. = 7
daily regimen decades = 7 weeks)
• Regular sleep habits

28. PREPARING FOR A DOCTOR’S VISIT
If someone is experiencing symptoms, or is concerned about dementia it is
critical to GET EVALUATED.
The confusion or memory loss may be
treatable.
Why? If you have AD, you want to be involved
in your own planning for the future while
you are still able.
Current treatment is most effective when
started early.

29. PREPARING FOR A DOCTOR’S DIAGNOSIS POST DIAGNOSIS
VISIT
• Write a list of
symptoms, be
specific
Keep a log • Include when, how
often and where
• Develop list with
input from other
family members
Clinical
Examination Develop a
List Get legal Educate
Develop relationship Grow a
current and financial yourself
Neuropsychological long-term with your
issues in
support
about the
and Testing care plan healthcare
order
system
disease
previous team
health Blood Tests
problems
Brain Imaging Tests
• prescription,
vitamins
Bring all
medication • herbal supplements
and
• over the counter
medication

30. Alzheimer’s Association
Educational programs for
families and professionals
• 24-hour Helpline
• Information and referrals
1-800 272-3900 • Care consultation
The Alzheimer's Association is the leading voluntary • Support groups
health organization in Alzheimer’s, care, support and • Online community
research. Its mission is to eliminate Alzheimer’s disease
through the advancement of research; to provide and • Safety services
enhance care and support for all affected; and to reduce
the risk of dementia through the promotion of brain
health.
www.alz.org

31. VIRGINIA DEPARTMENT FOR THE AGING
www.vda.virginia.gov

32. VIRGINIA EASY ACCESS
Virginia Easy Access is a FREE resource providing a simple method to search for
specific services anywhere in Virginia. Virginia Easy Access is a gateway to
VirginiaNavigator (which lists over 21,000 programs and services throughout the
Commonwealth) and to the 2-1-1 Virginia Call Center.
easyaccess.virginia.gov

33. SENIOR NAVIGATOR
seniornavigator.org

34. VCU – Department of Gerontology
www.sahp.vcu.edu/gerontology/

35. Ellen Phipps Lindsey K. Slaughter, PsyD
VP Programs & Services Psychology Director
Alzheimer's Association, Licensed Clinical Psychologist
Central & Western VA Piedmont Geriatric Hospital
1160 Pepsi Place, Suite 306 P. O. Box 427
Charlottesville, VA 22901 5001 E Patrick Henry Highway
434-973-6122 Burkeville, VA 23922-0427
434-767-4424
E. Ayn Welleford, MSG, PhD, AGHEF
Gerontologist
Chair & Associate Professor
Department of Gerontology
PO Box 980228
Virginia Commonwealth University
Richmond, VA 23298-0228
804 828-1565
http://www.sahp.vcu.edu/gerontology/

36. DISCUSSION
and
Q&A

37. UPCOMING EVENTS
and SURVEY
• WEDNESDAY, MAY 11 – ELDER ABUSE, NEGLECT AND EXPLOITATION
– see registration at www.alzpossible.org
• TUESDAY, JUNE 21 – LIVEABLE COMMUNITIES & PERSON-CENTERED
CARE
• FRIDAY, JUNE 24 – PUBLIC POLICY AND DEMENTIA CARE
• TUESDAY, JUNE 28 – CULTURAL COMPETENCE AND DEMENTIA CARE
• A survey will be issued tomorrow to all attendees. In order to evaluate this
project for the General Assembly of Virginia we ask that this short
questionnaire be completed by everyone who participates in the GTE
initiative. Your answers are extremely valuable. This and any other forms
you complete related to this project are strictly confidential. Your responses
will not be linked with your name in any data base. The data will be used
only for the purposes of evaluation and all results will be grouped, so that
no single person or organization may be distinguished. Your participation is
voluntary. You have the right to withdraw at any time or refuse to answer
any questions. Estimated time to complete this survey is no more than 5 minutes.
THANK YOU!