Alzheimer's Disease

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ALZHEIMER’S DISEASE Unraveling the Mystery

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Although the risk of developing AD increases with age – in most people with AD, symptoms first appear after age 60 – AD is not a part of normal aging. It is caused by a fatal disease that affects the brain. Alzheimer’s disease is an irreversible, progressive brain disease that slowly destroys memory and thinking skills. What is AD?

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AD Statistics…. AD is the most common cause of dementia among people age 65 and older. Scientists estimate that around 4.5 million people now have AD. For every 5-year age group beyond 65, the percentage of people with AD doubles. What is AD? By 2050, 13.2 million older Americans are expected to have AD if the current numbers hold and no preventive treatments become available.

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What is AD? Where are people with AD cared for? home assisted living facilities (those in the early stages) nursing homes (special care units) The national cost of caring for people with AD is about $100 billion every year.

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To understand Alzheimer’s disease, it’s important to know a bit about the brain… The Brain’s Vital Statistics Adult weight: about 3 pounds Adult size: a medium cauliflower Number of neurons: 100,000,000,000 (100 billion) Number of synapses (the gap between neurons): 100,000,000,000,000 (100 trillion) Inside the Human Brain

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The Three Main Players 1. Cerebral Hemispheres – where sensory information received from the outside world is processed; this part of the brain controls voluntary movement and regulates conscious thought and mental activity: accounts for 85% of brain’s weight consists of two hemispheres connected by the corpus callosum is covered by an outer layer called the cerebral cortex Inside the Human Brain

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2. Cerebellum – in charge of balance and coordination: takes up about 10% of brain consists of two hemispheres receives information from eyes, ears, and muscles and joints about body’s movements and position The Three Main Players Inside the Human Brain

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3. Brain Stem – connects the spinal cord with the brain relays and receives messages to and from muscles, skin, and other organs controls automatic functions such as heart rate, blood pressure, and breathing The Three Main Players Inside the Human Brain Slide 11

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Hippocampus: where short-term memories are converted to long-term memories Thalamus: receives sensory and limbic information and sends to cerebral cortex Hypothalamus: monitors certain activities and controls body’s internal clock Limbic system: controls emotions and instinctive behavior (includes the hippocampus and parts of the cortex) Inside the Human Brain Other Crucial Parts Slide 12

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The Brain in Action Hearing Words Speaking Words Seeing Words Thinking about Words Different mental activities take place in different parts of the brain. Positron emission tomography (PET) scans can measure this activity. Chemicals tagged with a tracer “light up” activated regions shown in red and yellow. Inside the Human Brain Slide 13

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Neurons The brain has billions of neurons, each with an axon and many dendrites. To stay healthy, neurons must communicate with each other, carry out metabolism, and repair themselves. AD disrupts all three of these essential jobs. Inside the Human Brain Slide 14

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Plaques and Tangles: The Hallmarks of AD The brains of people with AD have an abundance of two abnormal structures: An actual AD plaque An actual AD tangle beta-amyloid plaques, which are dense deposits of protein and cellular material that accumulate outside and around nerve cells neurofibrillary tangles, which are twisted fibers that build up inside the nerve cell AD and the Brain Slide 16

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Beta-amyloid Plaques Amyloid precursor protein (APP) is the precursor to amyloid plaque. 1. APP sticks through the neuron membrane. 2. Enzymes cut the APP into fragments of protein, including beta-amyloid. 3. Beta-amyloid fragments come together in clumps to form plaques. 1. 2. 3. AD and the Brain In AD, many of these clumps form, disrupting the work of neurons. This affects the hippocampus and other areas of the cerebral cortex. Slide 17

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Neurofibrillary Tangles Neurons have an internal support structure partly made up of microtubules. A protein called tau helps stabilize microtubules. In AD, tau changes, causing microtubules to collapse, and tau proteins clump together to form neurofibrillary tangles. AD and the Brain Slide 18

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The Changing Brain in Alzheimer’s Disease No one knows what causes AD to begin, but we do know a lot about what happens in the brain once AD takes hold. Pet Scan of Normal Brain Pet Scan of Alzheimer’s Disease Brain AD and the Brain Slide 19

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Preclinical AD Signs of AD are first noticed in the entorhinal cortex, then proceed to the hippocampus. Affected regions begin to shrink as nerve cells die. Changes can begin 10-20 years before symptoms appear. Memory loss is the first sign of AD. AD and the Brain Slide 20

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Mild to Moderate AD AD spreads through the brain. The cerebral cortex begins to shrink as more and more neurons stop working and die. Mild AD signs can include memory loss, confusion, trouble handling money, poor judgment, mood changes, and increased anxiety. Moderate AD signs can include increased memory loss and confusion, problems recognizing people, difficulty with language and thoughts, restlessness, agitation, wandering, and repetitive statements. AD and the Brain Slide 21

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Severe AD In severe AD, extreme shrinkage occurs in the brain. Patients are completely dependent on others for care. Symptoms can include weight loss, seizures, skin infections, groaning, moaning, or grunting, increased sleeping, loss of bladder and bowel control. Death usually occurs from aspiration pneumonia or other infections. Caregivers can turn to a hospice for help and palliative care. AD and the Brain Slide 22

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Clinical Manifestations beginning with memory impairment and spreading to language and visuospatial deficits. Yet, approximately 20% of patients with AD present with nonmemory complaints such as word-finding, organizational, or navigational difficulty. In the early stages of the disease, the memory loss may go unrecognized or be ascribed to benign forgetfulness. Once the memory loss becomes noticeable to the patient and spouse and falls 1.5 standard deviations below normal on standardized memory tests, the term MCI is applied. This construct provides useful prognostic information, because approximately 50% of patients with MCI (roughly 12% per year) will progress to AD over 4 years.

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In the late stages of the disease, some persons remain ambulatory but wander aimlessly. Loss of judgment and reasoning is inevitable. Delusions are common and usually simple, with common themes of theft, infidelity, or misidentification. Approximately 10% of AD patients develop Capgras ' syndrome , believing that a caregiver has been replaced by an impostor. In contrast to DLB, where Capgras ' syndrome is an early feature, in AD this syndrome emerges later. Loss of inhibitions and aggression may occur and alternate with passivity and withdrawal. Sleep-wake patterns are disrupted, and nighttime wandering becomes disturbing to the household.

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AD Research: the Search for Causes AD develops AD develops when genetic, lifestyle, and environmental factors work together to cause the disease process to start. In recent years, scientists have discovered genetic links to AD. They are also investigating other factors that may play a role in causing AD. NIA-funded Alzheimer’s Disease Centers (ADCs) across the country are leading the research efforts looking into causes, diagnosis, and treatment of AD. Slide 24

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Genetic Studies The two main types of AD are early-onset and late-onset: AD Research: the Search for Causes Early-onset AD is rare, usually affecting people aged 30 to 60 and usually running in families. Researchers have identified mutations in three genes that cause early-onset AD. Late-onset AD is more common. It usually affects people over age 65. Researchers have identified a gene that produces a protein called apolipoprotein E (ApoE). Scientists believe this protein is involved in the formation of beta-amyloid plaques. Slide 25

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Partnership between the NIA and the Alzheimer’s Association Need to recruit a total of 1,000 families to find the remaining late-onset risk factor genes 2 or more living siblings with AD One other living family member with or without AD Contact: e-mail: alzstudy@iupui.edu or Website: www.ncrad.org Late-onset AD Genetics Study AD Research: the Search for Causes Slide 26

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Studies at the Cellular and Molecular Level Homocysteine, an amino acid, is a risk factor for heart disease. A study shows that an elevated level of homocysteine is associated with increased risk of AD. Scientists are also looking at inflammation in certain regions of the brain and strokes as risk factors for AD. AD Research: the Search for Causes Oxidative damage from free radical molecules can injure neurons. Slide 27

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Scientists examine characteristics, lifestyles, and disease rates of groups of people to gather clues about possible causes of AD. The NIA is currently funding epidemiologic studies in a variety of different groups. Two of the studies focus on religious communities. Researchers conduct yearly exams of physical and mental status, and studies of donated brains at autopsy. Some early results indicate: Mentally stimulating activity protects the brain in some ways. In early life, higher skills in grammar and density of ideas are associated with protection against AD in late life. Epidemiologic Studies AD Research: the Search for Causes Slide 28

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AD Research: Diagnosing AD Experienced physicians in specialized AD centers can now diagnose AD with up to 90 percent accuracy. Early diagnosis has advantages: Doctors can rule out other conditions that may cause dementia. If it is AD, families have more time to plan for the future. Treatments can start earlier, when they may be more effective. It helps scientists learn more about the causes and development of AD. Slide 29

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Physicians today use a number of tools to diagnose AD: a detailed patient history information from family and friends physical and neurological exams and lab tests neuropsychological tests imaging tools such as CT scan, or magnetic resonance imaging (MRI). PET scans are used primarily for research purposes AD Research: Diagnosing AD Slide 30

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Donepezil (target dose, 10 mg daily), rivastigmine (target dose, 6 mg twice daily or 9.5-mg patch daily), galantamine (target dose 24 mg daily, extended-release), memantine (target dose, 10 mg twice daily), and tacrine are the drugs presently approved by the Food and Drug Administration (FDA) for treatment of AD.

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Clinical trials are the primary way that researchers find out if a promising treatment is safe and effective. Trials examine approved drugs to see if they can be used for other purposes, or look at experimental drugs. Participating in a trial means regular contact with the study team, who can provide state-of-the-art AD care. AD Research: Clinical Trials Slide 31

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Drugs used to treat mild to moderate AD symptoms include: Aricept Exelon Reminyl An additional drug, Namenda, has been approved to treat symptoms of moderate to severe AD. These drugs can help improve some patients’ abilities to carry out activities up to a year or so, but they do not stop or reverse AD. Scientists are also studying agents that someday may be useful in preventing AD. For example, they have experimented with a vaccine against AD. Although the first clinical trial was stopped due to side effects in some participants, valuable information was gathered. AD Research: the Search for Treatments Slide 32

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Researchers also are looking at other treatments, including: cholesterol-lowering drugs called statins anti-oxidants (vitamins) and folic acid anti-inflammatory drugs substances that prevent formation of beta-amyloid plaques nerve growth factor to keep neurons healthy AD Research: the Search for New Treatments Slide 33

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The NIA is launching a new research partnership, called the Neuroimaging and Biomarkers of AD Initiative, to study how the brain changes in Mild Cognitive Impairment (MCI) and AD. AD Research: New NIA Study Using MRIs and PET scans conducted at regular intervals, researchers hope to learn precisely when and where in the brain problems occur. Researchers will also examine blood samples to check for higher levels of abnormal substances that could be considered “biomarkers” of AD. Slide 34

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Between 70 to 90% of people with AD eventually develop behavioral symptoms, including sleeplessness, wandering and pacing, aggression, agitation, anger, depression, and hallucinations and delusions. Experts suggest these general coping strategies for managing difficult behaviors: AD Research: Managing Symptoms Slide 35 Stay calm and be understanding. Be patient and flexible. Don’t argue or try to convince. Acknowledge requests and respond to them. Try not to take behaviors personally. Remember: it’s the disease talking, not your loved one. Experts encourage caregivers to try non-medical coping strategies first. However, medical treatment is often available if the behavior has become too difficult to handle. Researchers continue to look at both non-medical and medical ways to help caregivers.

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Who are the AD Caregivers? Spouses – the largest group. Most are older with their own health problems. Daughters – the second largest group. Called the “sandwich generation,” many are married and raising children of their own. Children may need extra support if a parent’s attention is focused on caregiving. Grandchildren – may become major helpers. Daughters-in-law – the third largest group. Sons – often focus on the financial, legal, and business aspects of caregiving. Brothers and Sisters – many are older with their own health problems. Other – friends, neighbors, members of the faith community. Support for Caregivers Slide 37

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Demands of Caregiving AD takes a huge physical and emotional toll. Caregivers must deal with changes in a loved one’s personality and provide constant attention for years. Thus, caregivers are especially vulnerable to physical and emotional stress. Peer support programs can help link caregivers with trained volunteers. Other support programs can offer services geared to caregivers dealing with different stages of AD. Support for Caregivers Slide 38

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Technology and Caregiving The NIA is studying how computers can provide information and support to family caregivers through: These features have become very popular among users because they reach many people at once, are private and convenient, and are available around the clock. computer-based bulletin boards chat rooms Q & A modules medical advice forums Support for Caregivers Slide 39