normal aging, brain injury and alzheimer’s disease

Normal Aging, Brain Injury and Alzheimer’s Disease

Annual Conference for Professionals in Brain InjuryApril 11, 2013

Presenters

• Jean Wood, Minnesota Board on Aging

• Mark Kinde, Minnesota Department of Health

• Michelle Barclay, Alzheimer’s Association

Overview of Session

• Normal brain changes with age• Brain injuries in older adults

– Prevalence, causes and comorbidities• Alzheimer’s Disease and other dementias

– Prevalence, identification and management• Falls prevention to reduce risk for brain injury

– community interventions

Demographics of Aging

• The baby boomers started turning 60 in 2006.• According to the 2010 Census -

In 2010, there were 683,000 Minnesotans age 65 and older.in 2030, there will be 1.3 million Minnesotans age 65 and older.

• The 85+ population is the fastest growing.

Normal Brain Changes with Aging

• Brain and spinal cord lose nerve cells and weight.

• Nerve cells may transmit messages more slowly.

• Reduced or lost reflexes or sensation may occur in some people.

• Some slight slowing of thought, memory and thinking is natural.

Brain Injury Epidemiology, MN

• When & where do brain injuries happen?• To whom?• What are the leading causes?• What other illnesses or injuries occur in

conjunction with brain injury?• What do we know about outcomes?• How much do brain injuries cost?• Who pays?

ED TBI by age-group

N

Year

Hospitalized TBI by age-group

N

Year

ED TBI by gender

N

Year

Hospitalized TBI by gender

N

Year

Seasonal incidence of TBIseen in the ED

Year

N

Seasonal incidence of hospitalized TBI

What causes unintentional TBI?(ED treated)

N

Year

What causes unintentional TBI?(Hospitalized)

N

Year

Where do brain injuries happen? (ED TBI)

N

Year

Where do brain injuries happen? (Hospitalized TBI)

N

Year

Co-morbidity: ED treated TBI

Co-morbidity Hospitalized TBI

What about drugs & alcohol?

ED Treated Hospitalized

Is income related to brain injury? (Median Income by Zip)

ED Treated Hospitalized

Centers for Disease Control and Prevention , National Center for Health Statistics. Multiple Cause of Death 1999-2010 on CDC WONDER Online Database, released 2012. Data are from the Multiple Cause of Death Files, 1999-2010, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/mcd-icd10.html on Feb 13, 2013 5:58:52 PM

TBI Mortality by year, Minnesota, 55+

ALZHEIMER’S DISEASE AND RELATED DEMENTIA

Dementia is a loss of mental function in two or more areas such as

language, memory, or judgment severe enough to impact daily life.

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Alzheimer’s disease is the most common cause of dementia.

Dementia

Common UncommonAlzheimer’s DiseaseVascular Dementia

Dementia with Lewy bodiesParkinson’s Dementia

Frontotemporal dementiaCorticobasal Degeneration

Progressive Supranuclear PalsyJakob-Creutzfeldt Disease

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Causes of Dementia in People 71+

Adams, 2002

Alzheimer’s Prevalence with Age

Hebert et al 2000

85+(42%)

65-74 years (1.6%)

75-84 years (19%)

Alzheimer’s Disease Risk Factors

Age Family history

Patients with a 1st degree relative have a 10-30% increased chance of developing AD (van Duijn 1991)

Genetic factors Mild Cognitive Impairment (MCI) Vascular risk factors Head injury Amyloid in the brain (PET Scan)

TAUIST

BAPTIST

Progression of Alzheimer’s Disease

Early Stage: 2 - 4 years in duration

Middle Stage: 2 - 10 years in duration

Late Stage: 1 - 3 years in duration

Early Stage AD

Symptoms Interfere with everyday functioning Forgetfulness Trouble with time/sequence relationships More mental energy needed to process Trouble multi-tasking Writes reminders, but loses them Personality changes Shows up at the wrong time or day Changes in appearance Preference for familiar things

Middle Stage AD Fluctuating disorientation Diminished insight Learning new things becomes difficult Restricted interest in activities Declining recognition of acquaintances,

distant relatives, then more sig. relationships

Mood and behavioral changes Functional declines Alterations in sleep and appetite Wandering

Late Stage AD

Severe disorientation to time and place No short term memory Long-term memory fragments Loss of speech Difficulty walking Loss of bladder/bowel control No longer recognizes family members Inability to survive without total care

Alzheimer’s Disease: Course, Prevention, Treatment Strategies

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INTERVENTION Primary Prevention

Secondary

Prevention

Treatment

CLINICAL STATE NormalPre-

symptomatic AD

Mild Cognitive Impairme

ntAD

Numbers of people ??? 20 to 60 mil 10 to 15 mil 5.3mil

BRAIN PATHOLOGIC STATE

No diseaseNo symptoms

Early AD brain changesNo symptoms

AD brain changesMild symptoms

Mild, moderate or severe impairment

STRATEGIES

Identify at-riskPrevent AD

Prevent or delay emergence of symptoms

Stimulate memorySlow progression

Treat cognitionTreat behaviorsSlow progressionDISEASE PROGRESSION

ALZHEIMER’S DISEASE IMPACT

Nearly 90,000 Minnesotans have Alzheimer’s disease.

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5.4 million Americans have the disease.

Number of people over 65 with AD in MN38

2000 2010 2025 Change

% increa

se

88,000 94,000 110,000 22,000 25%Alzheimer’s Association Facts & Figures Report 2012

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Alzheimer’s disease is the sixth leading cause of death

in the United States.

AD is the fifth leading cause of death for those aged 65 and older.

% change in leading causes of death: 2000 - 2008

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Alzheimer’s Association Facts & Figures Report 2012

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Nearly 240,000 Minnesotans are caregivers for someone with Alzheimer’s disease.

Seventy percent of people with Alzheimer’s disease live at home.

Economic Value of Caregiving in MN42

Number of ADRD Caregive

rs

Hours of Unpaid

Care

Economic Value of Unpaid Care

237,441 270,397,947 $3,225,847,510Alzheimer’s Association Facts & Figures Report 2011

Age of Alzheimer’s Family Caregivers43

*Average age = 52 years

Alzheimer’s Association Facts & Figures Report 2012

Impact on the Caregiver’s Health

33% of Alzheimer’s family caregivers have symptoms of depression

Alzheimer’s family caregivers are more likely than non-caregivers to: Report that their health is fair to poor. Have high levels of stress hormones, reduced

immune function, slow wound healing, new hypertension and new coronary heart disease.

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45

People with Alzheimer’s disease are high users of healthcare

and long-term care services.

Total cost was three times higher for Medicare beneficiaries age 65+ with AD in 2004.

Average Medicare payments per person for beneficiaries age 65+ with and without ADRDs in 2008 (2011 dollars)

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Alzheimer’s Association Facts & Figures Report 2012

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More than seventy thousand Minnesota nursing home residents

have cognitive impairment.

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Current data suggests that less than 35% of people with Alzheimer’s and other dementias have a diagnosis of the condition in their medical record.

Boise et al., 2004, Boustani et al., 2005, Ganguli et al., 2004, Valcour et al., 2000

Impact of Co-Existing Medical Conditions:Percentage of Medicare beneficiaries 65+ with ADRD and a co-existing medical condition in 2009

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Alzheimer’s Association Facts & Figures Report 2012

COMMUNITY INTERVENTIONS TO IMPROVE IDENTIFICATION & MANAGEMENT OF AD

Benefits of Early Identification

Rule out other causes of cognitive impairment Start treatment early Better manage co-existing conditions Understand the symptoms and how to manage them Make decisions and future plans Build a support system Lower anxiety Avoid crisis-driven care Participate in clinical trials or other research

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Provider Practice Tools

Cognitive Impairment ID Flow Chart

Dementia Work-Up / Provider Checklist

Intervention Checklist

www.alz.org/documents/mndak/pagetrifold.pdf

Early Intervention Goal 1: Educate about medications Goal 2: Reduce excess disability

Treat conditions that worsen symptoms or lead to poor outcomes (depression, uncontrolled diabetes or blood pressure, etc.)

Make safety part of the plan Goal 3: Educate about the disease, common pitfalls,

and actions that lead to success Taking Action Workbook

Goal 4: Encourage lifestyle changes that may reduce disease symptoms or slow symptom progression Living Well Workbook

Medical Interventions: Cognitive & Behavioral Symptoms Cholinesterase Inhibitors (early- late) -

Cognex®, Aricept®/ Donepezil, Exelon®, Razadyne®

Side Effects: nausea, vomiting, increased bowel frequency

Glutomate blocker (NMDA receptor antagonist: mid/late) - Namenda®

Goal: to maintain function and reduce impact of symptoms

Medical Treatment – Co-morbid Conditions and Behavioral Symptoms Co-morbid medical conditions

Diabetes, cholesterol, blood pressure, sleep dysregulation

Psychiatric / Behavioral Symptoms Depression Anxiety Aggression / Agitation Hyper-sexuality

Reducing Excess Disability Treat conditions that worsen symptoms or lead to poor outcomes

Depression Co-existing medical conditions (diabetes, blood pressure, sleep

dysregulation) Stop smoking, limit alcohol

Address Safety Issues Medication management Fall risk Home modification / simplification Driving assessment Gun safety Financial safety Medical emergency Employment Issues, when applicable

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Early Stage

Current Services in Minnesota

Medical Evaluation / Diagnosis / Pharmacological Treatment*Research / Clinical Trials*Care Coaching / ConsultationInformation / Education Early Stage Support Groups* Engagement Programs (arts, social, creativity)*Exercise / Nutrition / Cognitive Habilitation* Home Care / Companion Services* Assisted LivingMedic Alert Safe Return® * limited

availability

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Middle Stage

Current Services in Minnesota

Medical Evaluation / Diagnosis / Pharmacological TreatmentResearch / Clinical Trials*Care Coaching / Consultation / CounselingInformation / Education Caregiver Support Groups* Adult Day Services* Meals on Wheels*Home Care / Home Health Care / Respite Services*Medic Alert Safe Return®

Assisted Living / Nursing Facility * limited availability

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Late Stage

Current Services in Minnesota

Medical Evaluation / Diagnosis / Pharmacological TreatmentCare Coaching / Consultation / CounselingInformation / Education Caregiver Support Groups* Adult Day Services* Meals on Wheels*Home Care / Home Health Care / Respite Services*Medic Alert Safe Return®

Assisted Living / Nursing FacilityHospice* * limited

availability

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Minnesota Resources

Telephone / Internet Resources Alzheimer’s Association 800.272.3900 alz.org/mnndSenior LinkAge Line 800.333.2433 MinnesotaHelp.infoACT on Alzheimer’s ACTonAlz.org

Falls in Older Adults

• Falls are the leading cause of injury for children and for adults 35-years and older.

• Falls and fall-related injuries among adults over age 65 are on the rise.

• MN ranks 5th among states in number of fall-related deaths.

Proven Steps to Reduce Fall Risk• Ask fall risk screening questions of the adults

you work with.• Refer individuals at risk for falls to their

physician for a comprehensive assessment.• Know your community resources. Connect

individuals to the resources that can help them take steps to reduce their risks.

www.mnfallsprevention.orgwww.minnesotahelp.info

Contact Information

Jean Wood, Minnesota Board on Aging651-431-2563, jean.wood@state.mn.us

Mark Kinde, Minnesota Department of Health651-201-5447, Mark.kinde@state.mn.us

Michelle Barclay, Alzheimer’s Association952-857-0524, mbarclay@alz.org