SLHS 580: 11/13 “Alzheimer’s Disease and Dementias” Part 1

Braak Stages 1 and II

The Transentorhinal Stage

Tangles in the entorhinal cortex

—> Important for memory formation, mood, sense of smell and taste

Braak Stages III and IV

Limbic Stage

Tangles spread to hippocampus

—> Critical to encoding new information

Braak Stages V and VI

Isocortical Stage

Spread to neocortex

—> Executive function, orientation in time, language, spatial reasoning, object/face recognition

What behaviors did the first diagnosed Alzheimer’s case, Auguste D, display?

• Confusion (ex. paranoia)

• Emotional Distress

• Language Abnormalities (semantic, perceptual)

• Short-Term Memory Loss

• Receptive/Expressive Language Difficulties/Loss

What Alzheimer’s biomarkers did they find in the autopsy of Auguste D.?

• Tissue shrinkage

• Plaques in nerve cells

• Atherosclerosis (hardening) of arteries that supplied the brain (resulting in cardiovascular disease) —> pointing to vascular dementia + Alzheimer’s disease

When a person is starting to identify symptoms of Alzheimers, what is the process in getting a diagnosis for Alzheimer’s? (how do they get tested for it?)

• Medical work up by primary care physician

• Neuropsychological Assessment

• Speech and Language Evaluation

In order to be diagnosed with Alzheimer’s Dementia, what three behavior symptoms that must be present?

1. Impairment in short term memory

2. Impairment in another area of cognition

3. Impairment in social/daily living (getting dressed, driving, etc.) ADLS

When Alzheimer’s Diagnosis is given, is it likely the pathology has spread far?

Yes, when we compare to Braak Stages, by the time the individual is showing the three necessary behaviors in order to qualify a diagnosis, the pathology has likely spread far (III>)

Can Alzheimer’s Disease be diagnosed based on brain pathology and biomarkers before symptoms are present?

As of 2011, AD (not dementia!) diagnosis can be made based on brain pathology (bio-markers/blood-based biomarkers) before symptoms are present thorough neuroimaging (PET) imaging and cerebrospinal fluid testing.

Are biomarker’s the main method of evaluation for diagnosing Alzheimer’s Disease? Why?

No, although they can diagnosis, they are mean to be a secondary measure of confirmation to the clinical symptomatic measurements (behaviors associated with a diagnosis).

—> A diagnosis before an individual shows symptoms might cause anxiety or change how the person approaches life (as a result, some individuals might not want to know a early diagnosis)

What other assessment measures can you use in your diagnosis criteria?

• Rating Scales

• Observation of Individual

• Interviews with PT, Family, etc.

• Self-Report not that sensitive for subtle changes

Are early diagnosis of Alzheimer’s relatively common?

No, difficult to diagnose early.

You have the following diagnostic information:

• Patient has poor memory

• Patient reports they forget to take meds

• PET scan demonstrating they have plaques in etorhinal cortex

Which of the following statements is true?

A) You can officially diagnose the patient with AD.

B) You can document the symptoms as AD, but you cannot tell the patient until they show more clinical behaviors.

C) You need to collect more diagnostic information before moving forward.

C)

What does it mean that the clinical stages of Alzheimer’s based on a behavioral profile?

There is a global deterioration scale of 7 stages.

• Stages 1-3 are pre-diagnostic (what is happening before the individual comes into doctor to get diagnosed)

(Alzheimer’s Behavioral) Stage 1

No Impairment: no symptoms; subclinical stage

• No behavioral symptoms

• Can last 10 to 50 years (you can have biological markers without showing symptoms)

• Pathology (plaques and tangles) only in etorhinal cortex

• No memory symptoms because damage may not be pervasive enough (the cognitive reserve allows the brain to work around the damage)

—> Stage 1 overlaps with Braak Stage I-II

(Alzheimer’s Behavioral) Stage 2

Very Mild Cognitive Decline: encoding and storage of new memories affected; short-term memory loss; mood-related changes

• Can last 2 to 4 years

• Pathology in entorhinal cortex (more pervasively) and hippocampus (encoding of storage of new memories is now affected)

• Short-term memory loss

• Mood related changes because limbic system is affected (ex. apathy, fear, anger, anxiety)

—> Stage 2 overlaps with Braak Stages III-IV

(Alzheimer’s Behavioral) Stage 3

Mild Cognitive Decline: onset of mild dementia; difficulty with word retrieval, comprehension, recognizing people/faces; may wander and forget where they were going/get lost

• Can last 2-8 years

• Onset of mild dementia

• Pathology spreads past etorhinal cortex, and now to temporal and parietal lobes (leading to visuospatial deficits, difficulty recognizing new faces/names)

• Problems with word retrieval

• May lose or misplace valuables

—> Stage 3 overlaps with Braak Stages V-VI

Is language or cognition more affected in Alzheimer’s?

Cognition; language is generally less affected than cognition.

How is language and communication affected by Alzheimer’s? How is their speech characterized?

Communication deficits in mild word retrieval, subtle comprehension problems

Characterized by:

• Perseverative utterances: repeating themselves, getting stuck in sentences

• Empty speech: saying alot of stuff but doesn’t mean anything

• Circumlocution: talk around the word retrieval issue

• Jargon (nonwords)

• Unrelated thoughts (going off-topic) and pragmatic difficulties

(Alzheimer’s Behavioral) Stage 4-5

Moderate to Moderately-Severe Cognitive Decline: onset of moderate dementia; misinterpretation of events; paranoia/paranoid delusions

• Can last 2 to 6 years

• Pathology spreads to frontal lobes (how we experience things: personality/perceptual effects like misinterpretation of evens and paranoia/delusions)

• Forgetfulness of recent evens, one’s own personal history

• Becoming moody or withdrawn

(Alzheimer’s Behavioral) Stage 6

Severe Cognitive Decline: onset of severe dementia; visual deficits; major changes in sleep, bladder/bowel control, personality

• Can last 2 to 4 years

• Pathology spread to occipital lobe (visual deficits)

• Lose awareness of recent experiences and their surroundings

• Can distinguish familiar/unfamiliar faces but have troubling labeling them

• Need help with ADLS (ex. dressing)

• Major changes in sleep patterns and have trouble controlling their bladder or bowels

• Major personality and behavioral changes; may wander or become lost

(Alzheimer’s Behavioral) Stage 7

Very severe cognitive decline: impairment of basic functions; aspiration pneumonia more likely; bedridden

• Onset of severe dementia

• Pathology is widespread across the brain

• Complete impairment of basic functions (ex. walking, eating, drinking, dressing)

• Falls become more likely

—> Stage 6-7 overlaps with Braak Stages V-VI

What clinical stage of AD do you think Auguste D. was experiencing at the time of diagnosis?

Stage 5

• Stage 7 is too severe: she is still able to walk, etc.

• But stage 4-5, the perceptual deficits are starting (ex. paranoia), emotional distress and regulation problems