General Dementia Knowledge:

Signs, Symptoms, Progression

Panelists:

Ellen Lindsey
Phipps Slaughter, PsyD
Moderator:

E. Ayn Welleford, MSG, PhD

May 9, 2011
 CHANGES WITH AGING
TYPICAL CHANGES
• Making a bad decision once in a
while
• Missing an occasional monthly
payment
• Forgetting which day it is and
remembering later
• Sometimes forgetting which word
to use
• Losing things from time to time
A-TYPICAL CHANGES
• Consistent poor judgment and
decision making
• Loss of an ability to manage
money
• Inability to keep track of the date
or the season
• Difficulty having a conversation
• Misplacing things and loss of the
ability to retrace steps to find
them
• Trouble with visual and spatial
relationships
• Challenges in planning or solving
problems
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 DEMENTIA
Dementia
IS NOT a
specific
disease.

Memory loss generally Dementia is a

GROUP OF SYMPTOMS
occurs in dementia,
affecting intellectual and
but memory loss alone
social abilities severely
does not imply you enough to interfere with
have dementia. daily functioning.
DEMENTI
A

Alzheimer's disease
is the most common There are many
cause of a causes of dementia
progressive symptoms.
dementia.

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 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).
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DEMENTIA CAUSES CHANGES IN

personality
memory/ mood
behavior
language
navigation
thought

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

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 CORTICAL DEMENTIAS

• Alzheimer’s disease
• Vascular dementia
• Frontotemporal dementia
• Creutzfeldt-Jacob disease

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

Average
course of
DAT: 6-
20 years
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AD (cont.) – 10 WARNING SIGNS
WARNIN
Changes in G SIGNS Memory loss
that disrupts
mood and daily
personality functioning

Withdrawal Challenges in
from work or planning or
social solving
activities problems

Difficulty
Decreased completing
or poor familiar tasks at
home, at work or
judgment at leisure

Misplacing Confusion
things and losing
the ability to with time
retrace steps or place
New problems Trouble
understanding
with words in
visual images and
speaking or spatial
writing relationships
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 Plaques Tangles

Acethylcholine Deficiency

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 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.
 

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 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

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 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
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 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 E
 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.

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 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
    
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VASCULAR DEMENTIA
CAUSES:
• Untreated high blood pressure
• Diabetes
The second
most common
dementia
after
Alzheimer's
• High cholesterol
disease
• Heart disease

ASSOCIATED SYMPTOMS:
VaD ••can
Confusion and agitation; depression
Result of a
damage to the
brain caused by be cortical
problems with
the arteries Unsteady gait
serving the brain
or heart. and subcortical
• Problems with memory
• Urinary frequency, urgency,
incontinence
Approx. • Night wandering
25-30% of
all • Decline in ability to organize
dementias
are VaD thoughts/actions, difficulty planning
• Poor attention/concentration

Prevalence of TREATMENT:
VaD ranges
from 1 to 4 Damage caused by infarcts cannot be
percent in
people over
the age of 65. 
reversed. Future cerebrovascular
incidents can be controlled (control of
cardiovascular risk factors) L
FRONTOTEMPORAL DEMENTIA
CAUSES:
• Unknown
(Fronto-temporal•areas
Group of
diseases
characterized by
Possible
generally associated with personality,
genetic mutations.
of the brain are
the degeneration
of nerve cells in
the F-T areas of
ASSOCIATED
behavior and language). In these SYMPTOMS:
dementias, portions of these lobes atrophy.
the brain
• socially inappropriate behaviors
• loss of mental flexibility
• decline in personal hygiene
Begins
earlier and
• language problems, and
progresses
faster than
• movement disorders
AD • difficulty with concentration and
thinking.
TREATMENT:
Occurs at • Irreversible dementing process
ages
younger
• Agitated symptoms respond to
than AD, antipsychotic meds
i.e., 40-70. • Compulsive symptoms respond to
SSRIs (antidepressants)
• Some patients also benefit from
One form ADHD meds to stimulate frontal
Pick's disease affects parts of the
of this
brain that contain lobe
fibrousfunction
tangles
condition
is Pick's • Behavioral
made up of an abnormal protein interventions may be
disease. called tau protein effective to encourage behavioral
control whenever possible
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CREUTZFELDT-JAKOB DISEASE
CAUSES:
CJD is a
degenerative
abnormal versions of a protein called a
brain disorder
that leads to
prion.
dementia and,
ultimately, death.
(rapid TRANSMISSION
progression)
Risk of CJD is low.
Cannot be transmitted through
coughing, sneezing, touching or
The "classic"
Creutzfeldt-
sexual
Variant CJD contact.
is linked primarily to
Jakob disease eating beef infected with
has not been CJD DEVELOPS:
bovine spongiform
linked to
contaminated • Spontaneously
encephalopathy (mad cow
(majority
of cases)
beef. disease.
• Genetic mutation (family history)
• Contamination.  (very low number
of exposures to infected human
1 in 1 million tissue during a medical procedure)
people are
diagnosed
with CJD per ASSOCIATED SYMPTOMS:
year (usually
older adults).
personality changes, anxiety,
depression, memory loss, impaired
thinking, blurred vision, insomnia
difficulty swallowing, motor issues.
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 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

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

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DEMENTIA DUE TO PARKINSON’S DISEASE
GENERAL PD SYMPTOMS:
PD is a
• Movement problems (tremor, stiffness, slowness)
progressiv • Walking problems (freezing, shuffling gait)
e disorder • Speech problems (soft voice, trails off, monotonous)
of the
CNS
• Other oral problems (drooling, difficulty
swallowing)
• Fatigue
• Blank facial expression
Results from
a deficiency DEMENTIA SYMPTOMS IN PD PATIENTS:
in the
neurotransmi • Slowed reaction time
tter
DOPAMINE
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 speech or facial expressions
people in
the US
TREATMENT
There is no known treatment that stops or reverses
dementia due to PD
• Medications that increase dopamine production
50%+ of
people 20-40% have help
morecontrol movement aspects of PD (not cognitive)
with PD • Some surgeries can be helpful (e.g., Deep Brain
severe symptoms/
have
dementia stimulation), but not for dementia symptoms
MCI. • Stem cell research is being conducted, results are
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DEMENTIA WITH LEWY BODIES
CAUSES:
Deposition
- Not known
of
of Lewy
Lewy
bodies in
- LB often found in the brains of people w/PD.
both, cortical
and
SYMPTOMS:
subcortical • Core criteria (must have two):
o Fluctuating attention and concentration
o Recurrent, well-formed visual hallucinations
Has o Newly emerged PD-type motor problems
features • Suggestive features (these may be present):
of both
PD and
o History of REM sleep behavior disorder (violent
AD sleep behavior or sleepwalking)
o Sensitivity to neuroleptic (antipsychotic) meds
• Supportive clinical features (don’t have to be
Affects 1% present):
of those o Repeated falls, Syncope (fainting), Depression
age 65, 5%
over age TREATMENT
85
• Older antipsychotics (e.g., Thorazine, Haldol) are
usually avoided because they can cause deadly
reactions in LBD patients
Usually
progresses
progresses • Anti-dementia medications (e.g., Aricept, Reminyl)
more rapidly
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 L
ALCOHOL-INDUCED PERSISTING DEMENTIA
Sometimes ASSOCIATED SYMPTOMS:
referred to
as o Severe memory impairment
Wernicke-
Korsakoff’s o Inventing false memories (confabulation)
syndrome
o Reduction in speech
o General apathy
A dementia o Gait problems (coordination)
syndrome
syndrome
caused by o Tremors
many years
of heavy o No insight into difficulties
drinking
o Hallucinations (in some patients)

Usually
Usually the
the result
result
TREATMENT
of
of aa combination
•
combination
of
of malnutrition
malnutrition
(thiamine
(thiamine
Can be partially reversed if caught early and
deficiency)
deficiency) and
brain
brain damage
and
damage treated with high doses of thiamine
directly
directly caused
caused by
by
alcohol
alcohol
• Abstinence from alcohol is ESSENTIAL to stop
progression of dementia
o Support programs can help maintain
Accounts
abstinence
for < 5%
of all o Periodic blood tests, breathalyzers can also
dementia be useful
s

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 ANOTHER WAY OF LOOKING AT
DEMENTIAS
REVERSI IRREVER
BLE SIBLE
●
Depression, delirium
Dementia of the
●
●
●Emotional disorders
●

●Metabolic disorders (e.g.,

●

hypothyroidism Alzheimer’s type

●Eye and ear impairments
●

●Nutritional (e.g., B12 deficiency)

●
●
Dementia of the
●Tumors
●

●Infections
● Parkinson’s type
●Alcohol, drugs, medication
●

interactions
●
etc.
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 REVERSIBLE COGNITIVE IMPAIRMENT
COGNITIVE
PSEUDO DELIR IMPAIRMENT
DEMENTI DUE TO

A IUM MEDICAL
CONDITION
●
●Acute period of confusion brought about by
●
●Dementia patients: bad guesses
many potential causes ●
●Malnutrition
●Medical conditions
●
●Pseudodementia patients: “I don’t know.”
●
●Medications (alone or in combination with
●
●
●Vitamin deficiency (e.g., B12)
●Dementia patients: slow onset,
●

one another) ●Electrolyte imbalance

●
●Pseudodementia patients: problems
●
●Altered sleep schedule (most often in
●

appeared rather suddenly ●Cardiac and/or pulmonary

●

●Dementia patients: unaware of deficit

●
dementia patients)
●Pseudodementia patients: keenly aware of
●
●Intoxication by legal or illicit substances
●
conditions
●Always rule out delirium before diagnosing
●

deficits (and often complain of distress) ●Insufficient oxygenation of

●
●TREATMENT
●
dementia
●Psychotherapy (if available and the patient
●
●The cause of the delirium could be deadly,
●
blood to brain
must discover it early
is willing) ●Metabolic conditions
●
●TREATMENT
●
●Antidepressant medications (e.g., Zoloft,
●
●consists of treating the underlying medical ●Organ failure leading to
● ●
Wellbutrin, Celexa)
condition
●Maintaining physically active daily regimen
●

●Regular sleep habits

●
●Rule of thumb: delirium lasts one week for
● insufficient metabolization
each decade of the patient’s life (e.g., 65 y.o. of nutrients, medications
= 7 decades = 7 weeks)

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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. 

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. 

Why?

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PREPARING FOR A DOCTOR’S DIAGNOSIS POST DIAGNOSIS
VISIT

●
Write a list of symptoms, be
specific
●
Include when, how often and
Keep a log where
●
Develop list with input from
other family members

Clinical Devel Develop Grow

Examination a Get Educat
op relation legal a e
List current long- ship and suppo yoursel
and previous Neuropsychological with financia f about
term rt
health Testing your l issues the
care healthca syste
problems in order disease
Blood Tests plan re team m

Brain Imaging Tests

●
prescription, vitamins
Bring all ●
herbal supplements and
medication ●
over the counter
medication

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 Alzheimer’s Association
Educational programs for
families and professionals
• 24-hour Helpline
• Information and referrals

1-800 272-3900     • Care consultation

                          • Support groups
The Alzheimer's Association is the leading voluntary
health organization in Alzheimer’s, care, support and • Online community
research. Its mission is to eliminate Alzheimer’s disease • Safety services
through the advancement of research; to provide and
enhance care and support for all affected; and to reduce the
risk of dementia through the promotion of brain health.

www.alz.org

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VIRGINIA DEPARTMENT FOR THE AGING

www.vda.virginia.gov

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 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
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SENIOR NAVIGATOR

seniornavigator.org
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VCU – Department of Gerontology

www.sahp.vcu.edu/gerontology/
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Ellen Phipps
VP Programs & Services
Alzheimer's Association,
Central & Western VA
1160 Pepsi Place, Suite 306
Charlottesville, VA  22901
434-973-6122
Lindsey K. Slaughter, PsyD
Psychology Director
Licensed Clinical Psychologist
Piedmont Geriatric Hospital
P. O. Box 427
5001 E Patrick Henry Highway
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/
DISCUSSION
and
Q&A
 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!