Screening, evaluation and Introduction treatment of dementia in the - PDF document

10/10/2017 Outline of talk Screening, evaluation and • Introduction treatment of dementia in the • Dementia definition and syndromes elderly Asian population • Case study • Special issues in the Asian community • UCSF Chinese Outreach Clinics Aimee Kao, MD, PhD Associate Professor of Neurology UCSF Asian Health Symposium 2017.10.05 No disclosures Public health impact of deaths Why is dementia important? from Alzheimer’s disease • Rapidly aging population • Alzheimer Disease is the 6 th leading Percentage change in cause of death 2000 to 2013 cause of death in the U.S. • 5.4 million individuals affected • 1 in 8 Americans aged 65 and older is affected by Alzheimer’s Disease • In 2013, Americans provided provided 17.7 billion hours of unpaid care to people with AD and other dementias • In 2014, AD cost Medicare and Medicaid ~$150 billion Alzheimer's & Dementia: 2015 11:332-384 1

10/10/2017 Rates of dementia in Asian Americans What is dementia? • Recent studies suggest rates of dementia in • An acquired, progressive, persistent Frontal and subcortical: Chinese are comparable to those in U.S. Motor impairment in cognition or behavior • 8% in Hong Kong • Involves 1 or more • 10% in China • ~11% in US cognitive domains • Asians in US, average annual rate: • Sufficient to cause a • 15.2 per 1,000 for Asian ‐ Americans (included Japanese) decline from a • 19.3 per 1,000 for Caucasians previous level of Pre‐frontal : functioning • Little data comparing dementia in Asians vs. other Executive function and Parietal/temporal : behavior Americans • Dementia is no Language and Temporal : visuospatial Memory longer a diagnosis of exclusion Sources: Fei et al., Alz Dis Assoc Disord, 2009; Lam et al., Int Psychogeriatr, 2008; Mayeda et al. Alzheimers Dement, 2016; 2000 U.S. Census Data; 2009 American Community Survey Data Careful phenotyping of dementias is Risk and protective factors critical for appropriate treatment Risk Factors Protective Factors • Lewy Body Disease • Increased age • Physical exercise • Frontotemporal dementia • Progressive supranuclear palsy • Vascular disease • Social engagement • Corticobasal degeneration • Genetics (ie ApoE4) • Multiple system atrophy • Mental activity • Amyotrophic lateral sclerosis • Head injury • Education • Triplet repeat disease (ie Huntington’s Disease) • Lower education • Paraneoplastic disorders • Chronic inflammation • Hashimoto’s encephalopathy • CNS lymphoma • Rapidly progressive dementias (ie Creutzfeld‐Jakob disease) Adapted from Plassman et al., 2007 Courtesy Howard Rosen 2

10/10/2017 The Mini Mental Status Exam Case Study: A 76 yo Chinese ‐ American (MMSE) for dementia screening woman with forgetfulness • CC: “My memory is not as good as it used to be, but overall it’s fine.” Insight? • Very good screening tool • HPI: (from patient and informant) ‐ Over last 2 years, has forgotten to take her pills and missed appointments • Can be administered rapidly (<5 ‐ Family is concerned about her riding buses in the city by herself as she min) and reproducibly got lost and was missing for several hours. ‐ Has had several falls in the last 1 ‐ 2 years • Covers basic cognitive domains ‐ Family worries that she is depressed Depression as a sx? (memory, language, • PMH: Hypertension, hyperlipidemia visuospatial, executive, motor) • Neurological exam: • Normal is ≥29/30 (as long as ‐1 ‐ Socially intact but with a paucity of spontaneous speech is from word memory) ‐ Cogwheel rigidity in arms L>R (parkinsonism) Fall risk ‐ Gait instability • MMSE: 21/30 missing points for orientation, memory, copy of pentagons Executive, memory and visuospatial What is the diagnosis? Answer: It depends on the MRI For vascular dementia, look on T2 or FLAIR sequences for… Periventricular white matter (PVWM) changes (FLAIR image) A. Normal aging B. Alzheimer Disease (AD) C. Vascular dementia (VaD) Lacunar infarcts D. Alzheimer Disease + Vascular dementia 3

10/10/2017 In AD, look for hippocampal atrophy Alzheimer Disease (AD) Normal hippocampus Atrophy of hippocampus • 1 st symptom: Difficulty encoding new memories (due to hippocampal atrophy) • Will spread to include other cognitive domains • Usually social graces and motor functions are spared until late in disease AD symptoms mirror its spreads through Vascular Dementia (VaD) connected neuronal circuits Example of sub‐cortical fibers • 1 st symptom: Difficulty retrieving Early Middle Late memories (sub-cortical pattern of memory impairment) • Stepwise progression • Oftentimes accompanied by executive dysfunction, parkinsonism, psychiatric disturbance (paranoia, hallucinations) • Vascular dementia is distinct from stroke 4

10/10/2017 Amyloid imaging is an early biomarker for AD Diagnosis of vascular dementia PET Imaging + Pittsburgh Compound B (PIB) HO S • Can be difficult NH 11 CH 3 • Symptoms and impairments similar to AD N • Research shows that physicians don’t always agree • Presence of PVWM changes on MRI does not rule Amyloid Plaques • PIB binds fibrillar amyloid in a reversible fashion out AD • Helpful in distinguishing AD from other dementias • Absence of PVWM changes makes AD more likely • Can help to predict who will convert from MCI to AD • Problems with balance and walking are more • Is not a screening tool for asymptomatic individuals common in early vascular dementia • Differs from stroke in non ‐ acute onset and progressive impairment without recovery over time Courtesy of William Klunk, UCB Amyloid is Also Detectable in Normal Treatment of AD and VaD are Older Adults similar 15%-30% of • Acetylcholinesterase inhibitor (ie donepezil) cognitively • SSRI for depression and/or irritability normal older adults are Aβ- • Exercise regimen +/ ‐ physical therapy PET+ • Home safety evaluation to prevent falls, accidents More common in • Planning for the future ApoE4+ and older age • Caregiver support Rabinovici and Jagust 5

10/10/2017 Special considerations in an AD and VaD: Take home points Asian population • By age 90, >50% of individuals have AD plaques • Because of family support, presentation to and tangles, so overlap syndromes are common healthcare tends to be later in disease • Loss of insight is common in dementia affecting • Family interviews may need to be conducted frontal lobes separately out of respect to affected individual • Depression can be a presenting symptom of a • Potential stigma against psychiatric disorders can neurodegenerative disorder make the diagnosis of co ‐ existent depression challenging • Compliance with medications, especially anti ‐ depressants, may be an issue Chinese Outreach Clinics Goals of Chinese Outreach Program 華人外展計劃診所 Chinatown Public Health Center Chinese Hospital • Address the under ‐ 華城公共衛生局 東華醫院 representation of Asian Americans in dementia research • Establish outreach to overcome Thursdays geographical, resource and transportation barriers AM PM • Conduct community lectures to provide dementia education in appropriate cultural context 6

10/10/2017 UCSF Chinese Outreach Team UCSF Sandler Neurosciences Center 外展團隊 Thank you Multilingual and multicultural staff • Dr. Howard Rosen (Neurologist) 羅森醫師，神經 內科 • English • 英文 • Dr. Richard Tsai (Neurologist) 蔡孟鈞醫師，神經 內科 • Mandarin, English • 國語，英文 • Marian Tse (Clinical Outreach Coordinator) 謝譚敏兒， 研 究助理 • Cantonese, Toishanese, Mandarin, English • 廣東話，台山話，國語，英文 • Contact info: Phone 415/476‐1692 Fax 415/476‐0213 Email Marian.Tse@ucsf.edu Purpose of Chinese Outreach Program 華人外展計劃宗旨 • UCSF Chinese Outreach Program ： • UCSF 創立華人外展計劃： • Address the underrepresentation of Chinese Americans in dementia research • 針對華人在失智症 / 老人癡呆症研究領域代表性不足 • Establish outreach clinics to overcome geographical, resource and transportation barriers. • 創立華人社區診所，客服地理，資源，交通困難 • Conduct community lectures to provide dementia education in appropriate cultural context. • 為華裔美國人提供語言，文化適當的失智症 / 老人癡呆症教育 與支持 7