A Revealing Look at the Different Types of Alzheimer's and Dementias

I'd like to welcome everybody to today's presentation of Alzheimer's and dementias. Types, symptoms and consequences. I'm your host, Dr. Donnelly Snipes. Now, next week we are going to be talking about the interventions. Today is sort of part one, if you will, of dementia. We're going to discuss the different types of dementias, their causes, symptoms and course. We'll identify disorders frequently misdiagnosed as dementia and we're also going to talk about conditions that frequently co occur with dementias. And then we'll t touch on screening tools and tasks for dementia care. Most of the stuff for screening tools will come next week. Dementia is an umbrella term describing a syndrome characterized by a decline in cognitive function significant enough to interfere with daily life. Now, a lot of times we think cognitive function. So it only affects their thinking. No, it doesn't. It affects their entire nervous system. And we need to start thinking more broadly about people's abilities to function instead of just the way they think, the way they are able to manage their life. Alzheimer's disease is one specific type of dementia. People with dementia display a broad range of cognitive impairments, behavioral symptoms and mood changes. It's important to recognize that some of these changes that are happening cognitively as we have neuronal decline impact the brain's ability to modulate neurotran transmitters and hormones, and it impacts a lot of stuff going on under the hood, if you will. The development of multiple cognitive deficits is required in dementia, as evidenced by both memory impairment and Whoops. Agitation. And what we're going to talk about is memory impairment and cognitive disturbances. I'm sorry. And you're also going to have agitation. Memory impairment is the impaired ability to learn or remember new information. This may be learning somebody's name. This may be inability to learn their way around their new apartment or their way around the neighborhood. It also may include losing valuables. They put something somewhere and they can't remember where they put it. Now, I know a lot of us have that problem, so we need to look at these symptoms on a spectrum and how significantly these memory lapses, if you will, or difficulties impair the person's quality of life. Inability to recall previously learned information, well, that's an obvious symptom. Now, if it's something like algebra, I have not used algebra since. Well, I did homeschool my kids, but Even that was 15 years ago. I'm not going to recall a lot of that. I'm going to have to go back and look at how to do algebra or multiply multiply fractions. But what we're talking about is previously learned information that the average person would typically be able to recall. Difficulty with spatial tasks such as navigating around the house or in the in the immediate neighborhood. It's important to rule out any vision impairments because when you can't see very well, you may not be able to find your way around as easily. Or things may not look quite the same. I know if I go into a neighborhood dark versus in the middle of the day, it looks very different. I have different landmarks that I look for at night versus during the day. If you're somebody who has impaired vision, you, you may not be able to see some of those landmarks you used to use and have difficulty navigating. So we do want to rule out vision impairments before we automatically jump to cognitive decline. But these spatial tasks typically involve navigating, remembering how to get from one place to the other. So if you have memory impairment as evidenced by one of those things, you know, that's an indication that there may be a need for further evaluation. And cognitive disturbances such as aphasia, which is a language disturbance, sometimes people can't find the words or they speak in word salad. Apraxia Impaired ability to carry out motor activities despite intact motor function. Maybe they can't feed themselves even though there's no neurological reason. They didn't break their arm, they didn't have a stroke that they can use their arms, but for some reason they're not able to feed themselves. Agnosia is failure to recognize or identify objects despite intact sense sensory function. This agnia can also significantly impair nutritional health of the older adult because if they can't smell the food, if they can't see it and identify it as food, then it's going to impact their appetite and they may not be willing to eat. A lot of people with dementia develop food idiosyncrasies, we'll call them, because some things they don't recognize as food anymore, even though it may be something they always ate, and, and, or a disturbance in executive functioning. Now we also want to see or we will see in dementia agitation. Within the context of dementia, this can refer to a range of behavioral disturbances including aggression, combativeness or just hyperactivity or disinhibition. And hyperactivity is pretty self explanatory. Disinhibition is kind of inability to control oneself. Individuals with cognitive impairment have borderline functioning in several areas, but definite impairment in none and should be evaluated over time. So this is on a Spectrum cognitive impairment dementias, often depending on the type of dementia, but most develop gradually over a period of time, and it'll start out with mild cognitive impairment and then progress to significantly more severe forms of dementia. When we talk about executive functioning deficits, what we're looking at can be any of the following. Attention to. To what's going on, difficulty for them to maintain attention to a TV show or a conversation, perception, insight and judgment if they're going outside. Yesterday we had a parade for some of the residents at one of the assisted living facilities, and it was really cold outside. And if the ones who would go outside without a jacket, you know, shows poor judgment because they knew it was cold outside and everybody else was wearing jackets and it was important to get them to wear a jacket. Organization, orientation to person, place, time, processing speed, and we've talked about a lot of these things do decline a certain extent in normal aging. It is important to understand that some of this stuff is common to a certain degree in normal aging. It's a spectrum, and we'll differentiate dementia from normal aging a little bit at the end of the presentation. People with executive functioning impairments also have difficulty with problem solving, reasoning and metacognition, or a person's ability to kind of monitor what they're doing and be aware of themselves in time and space. Alzheimer's is one type of dementia, and a lot of people talk about it separately from the other dementias, but it's. It's really part of the. Under that same umbrella, it potentially involves genetic risk factors, but this is dynamic. Just like you can have the genetic risk factor for developing schizophrenia, you can have genetic risk factors for developing Alzheimer's. Doesn't mean you're going to develop schizophrenia or Alzheimer's. It means you have this more likelihood, you have this vulnerability to developing it. And if all the other conditions are right, then it could trigger that vulnerability and make it, make you develop or start developing Alzheimer's. Tau protein accumulation and neurofibrillary tangles can cause neuronal death. Now, the plaque hypothesis that had been postulated for many, many years has since been debunked, and they've gone. The researchers have gone back to a belief of, well, there's a lot of stuff that needs to align in order to cause this, but we can't find one particular thing. Chronic neuroinflammation that disregulates the brain's immune system and causes neuronal injury can greatly increase the risk of dementia and Alzheimer's development. Inflammation, systemic inflammation may also interact with vascular risk factors and metabolic disturbances like diabetes, further aggravating the disease process. So the more things that get out of whack, the more inflammation we're going to have, the more more the brain environment is going to become neurotoxic from that inflammation and the more neuronal death we may experience. Hypertension, high cholesterol, diabetes and obesity, compromised blood flow and all have been shown to increase inflammation, causing stress in the body and increasing neurotoxicity and neuronal death. Most of those are at least somewhat modifiable. And it's something that we can look at to educate patients about metabolic dysfunction, including insulin resistance. And impaired glucose metabolism in the brain can also cause inflammation. Notice I said insulin resistance, I didn't say diabetes. We already talked about diabetes. But insulin resistance is something you can have even if you're not pre diabetic or diabetic. Insulin resistance means that your body does not respond appropriately to the blood sugar when it's in your system, which leads to systemic inflammation. Insulin resistance is something that we definitely can definitely can modify, and it's a huge risk factor for a lot of health conditions. Chronic stress, poor sleep and exposure to air pollutants, which cause stress on the body, can also increase systemic inflammation and the risk of Alzheimer's. And finally, socioeconomic factors, including access to quality health care and educational opportunities, can impact Alzheimer's risk. People who have early educational opportunities have more cognitive reserve, they've learned more stuff, they have more active neurons, if you will, so they can afford to to lose a little bit more. But people who didn't have that, don't have that benefit. They don't have that wiggle room of neurons that they don't necessarily need. People who are of low SES or who are under chronic stress often have more systemic and chronic systemic inflammation. And people who are of lower sesame tend to not get early treatment for contributing conditions like diabetes and hypertension because they can't afford to go to the doctor or they can't afford to take the day off to get a doctor's appointment or the medication or whatever. There's a lot of I can't afford it that goes into it. And so they may not seek treatment that could potentially prevent the development. Alzheimer's symptoms, early symptoms, mild memory loss, especially for recent events, not remembering what you just did, not remembering what you had for breakfast. You know, we're looking at really recent events, difficulty finding common words and subtle changes in judgment. Like I mentioned earlier, going outside when it's 40 degrees without a jacket on. For most of us, that would be considered poor judgment. Some people really like the cold. But, and, and we need to differentiate between is this person actually cold or is this actually poor judgment for this person, or do they have a different sensory preference? But that's a whole different issue. So this mild memory loss, the person that we're working with or our loved one is going to start showing symptoms. And difficulty finding common words is one of the big ones. It's not like they're trying to remember the name of a song when it comes on the radio. That's not what we're talking about. It's talking about forgetting common words like refrigerator or stove. Middle stages of Alzheimer's, more severe memory impairment. Language starts becoming more difficult. We often start seeing more aphasia, disorientation, and changes in personality. Remember, as people age, they have more difficulty adapting because their cognition is slowing. And these changes in personality, typically they become more irritable, but can sometimes just be attributed to them having difficulty understanding what's going on. And they're feeling vulnerable, they're feeling afraid. When we're addressing somebody who is showing changes in personality, we really want to evaluate it from a trauma informed perspective to figure out what is causing this. Is it the neurons have rewired in a different way, so to speak? You know, that's overly simplified? Or is this a symptom of their anxiety because they know something's not right but they can't figure it out or they feel vulnerable? In late Alzheimer's, there's profound cognitive and functional decline. Loss of speech, psychotic symptoms like hallucinations and delusions, inability to perform basic activities of daily living, incontinence, gate and motor disturbances, so difficulty functioning, moving their body, and eventually becoming mute and bedridden. When people get into late stages of Alzheimer's, often hospice is called in. This is a terminal illness and we need to prepare families for that. The average age of onset is typically after age 65, with a gradual progression over 8 to 10 or more years, often beginning with mild cognitive changes and advancing to severe dementia. Now it says 10 plus years. I want you to focus on that. We don't want to tell somebody. Okay. Well, the Average time is eight to 10 years. So, you know, start counting down your Christmases. No. Oh my gosh, no. There are a lot of things that we can do looking at the person's life, lifestyle, thinking back to last week's class, to help them reduce inflammation and slow the progression of this cognitive decline. Vascular dementia is another type of dementia, and it is caused when there's a long lasting blockage or lack of blood to the brain. A that's a major stroke. In a transient ischemic attack or a tia, the symptoms typically resolve within minutes to a few hours and usually within less than 24 hours. But they're a risk factor for a full stroke. In a tia, something kind of gets stuck in a blood vessel and impairs the blood flow to the brain. But then all of a sudden it clears itself. In a stroke, it's permanently stuck. They just, it's there. Multiple TIAs. So if you have this happen often and there are a few politicians that I think may have it going on, one I can think of in particular won't name them because I haven't done an assessment on them. But when you start having multiple TIAs, you're having additive damage. So if blood flow was blocked for an hour this time and two hours the next time, then an hour the next time, now we've got four hours of blockage and so it is additive over time and we are having losing brain cells, but not nearly as dramatically as we see in a full stroke stroke screening. I mentioned this last time and we didn't go through the screening. It's important for everybody to know it's the mnemonic is fast face drooping or numbness on one side of the face. Ask the person to smile. If one side of their face doesn't move, it's a warning sign. Arm weakness. Ask them to raise their arms. If one arm can't stay raised or if they can't raise it at all, that's a warning sign. And the same thing can be done for legs. So you may want to check both the arms and the legs. Speech difficulties, sudden slurred speech confusion or difficulty understanding or forming words. Ask them to repeat a simple phrase like the sky is blue. And if they can repeat that back to you, great. If their speech is un not understandable, they're slurring it too bad. Or if they use different words and it just doesn't make any sense, that's a huge, huge warning sign. And T just stands for time to call 91 1. If somebody shows any one of these symptoms, call 91 1. It is definitely better safe than sorry because the faster that blockage is cleared, the faster the blood flows restored, the less damage is going to be incurred and the better the prognosis for the person. Vascular dementia's average age of onset is often again later in life and more commonly after age 65. Think about the people that, you know, you've worked with who've had strokes, typically they're older. You can have people who have strokes that are much younger because they were abusing cocaine, for example, which is a stimulant, or because they were drinking really heavily and then they decided to detox without medical supervision. That's, you know, you can very easily stroke, have a stroke in alcohol detox. So it can happen to younger people, which is another reason we see younger people in long term care who've had devastating strokes. Typically, the development of vascular dementia is more stepwise. They'll have a stroke which will impair their cognition, they lose a certain amount of brain cells and they, they're steady with that. And then if they have another stroke, if there's another vascular incident, then they're often going to have another decline. And it's stepwise like that. Once you've had a stroke, you're at at greater risk for stroke. And even TIAs, again are additive and we need to pay attention to that. Other vascular insults could include getting a concussion, for example, or significant bleeding from anywhere in the body that disrupts blood flow to the brain. Those can also be potential factors that impact the person's cognitive stability. Vascular dementia risk factors Clogged arteries and systemic inflammation. If the brain can't get blood, it can't get oxygen, it can't get nutrients, it's going to die. Simple enough. Chronic stress can lead to hypertension. And chronic stress, we know, increases blood sugar, increases blood pressure and increases systemic inflammation. High, excuse me, high cholesterol is also another factor. So you have chronic stress, hypertension, high cholesterol, diabetes or, and, or insulin resistance. Even if you don't have diabetes or prediabetes, if you've got insulin resistance, it's a risk factor for vascular dementia. Be aware, smoking and tobacco use impacts the vascular system of every person who uses it and increases the risk of stroke. Kidney disease impairs the body's ability to get rid of toxins, which include increases systemic inflammation. Kidneys are also responsible for maintaining the fluid balance in the body. And if there's not enough fluid, then you're going to start to see sluggishness, if you will. Heart conditions. The heart's not pumping blood, it's not getting to the brain. Excess alcohol use, Alcohol in and of itself is inflammatory and as I just mentioned, detoxing from excess alcohol use. During the detoxification process, people's blood pressure goes up. And if you've been really drunk or if you've been, if you're tolerant and reliant on alcohol, then when you start to detox, your body just can't adapt and your blood pressure can spike like nobody's business. Alcohol detoxification should always be undertaken with medical supervision. If you're working with somebody who meets the criteria for alcohol dependence and inflammatory diets. Stuff we eat increases our blood sugar dramatically and contributes to that systemic inflammation. Lewy Body dementia. And somebody in the audience had specifically asked about Lewy Body Dementia, so I spent a little more time on that one. Accumulation of Lewy bodies, which are a type of protein aggregate in the brain, is what causes this type of dementia. It's possibly. Don't you love this? Possibly related to both Parkinson's and Alzheimer's pathologies, which means the same things that cause Parkinson's and Alzheimer's may cause Lewy Body dementias. A lot of it comes down to. We don't really know. We can see some correlations, but we just can't get a good model. People with Lewy Body dementia. And I want you to think about this as we go through as a clinician or as a caregiver. What is it that I need to be aware of? What is it that I can do to help my person on a daily basis? There's fluctuating cognition with pronounced variations in attention and alertness. So at breakfast, dad may be alert and happy and functioning, and, you know, everything's great. And then three hours later, he's not alert anymore. And his attention, he. He's almost catatonic, not. Not quite catatonic, but his attention's not there. He's not very alert. He's sort of stuporous. And that's not uncommon. If you're worried, obviously, ask the physician, ask the neurologist about, you know, is. Is my dad okay? That's a perfectly legitimate question. But recognizing and as a caregiver, developing an understanding. You don't like it, but not freaking out every time they start to. They suddenly become inattentive and not alert. It's like, okay, that's part of that normal fluctuation. You can look for precipitating factors. Is it time of day, something they eat? Especially if it's something they eat. We want to look at blood sugar. Is there a possibility that it has to do with. Maybe they have a urinary tract infection, so they just ate, and then a couple hours later they have to urinate. But it's so painful because of that UTI that they sort of check out. There can be a lot of things that May contribute to it. But again, as a caregiver, just developing an awareness that this is going to happen and it is expected and then figuring out how you're going to deal with it. They may have visual hallucinations. And as I've mentioned in the presentations before on schizophrenia, when people have hallucinations and delusions when they're in a florid psychotic episode, arguing with them about what's real is pointless because it's real to them. If they're having visual hallucinations, helping them figure out what they need to do to feel safe, helping them, validating that they feel scared that they see something, you can acknowledge that you don't see it. You know, you don't have to say, oh my gosh, yeah, I see him and blah, blah, blah. But acknowledging I, I know that you see this thing right now or you see this person right now and you're feeling very scared about it. What can we do to help you feel safer? That goes so much further than trying to disempower them and contradict them and take away their power. Auditory or tactile hallucinations can also occur, but they're less frequent. May hear things that really aren't there or feel like somebody poking at them or something. Much less common, but it can occur. Delusions, particularly paranoid delusions, are common, especially in later stages of Lewy Body Dementia. Sleep disturbances very common. And REM behavior disorder. And this kind of goes with sleep disturbances. In early stages of Lewy Body Dementia, individuals may act out dreams physically or verbally due to loss of normal muscle tone during REM sleep. REM behavior disorder. Now remember, when we don't get enough good sleep, what does, what happens? Systemic inflammation. It's a stressor. And it increases oxidative stress. It increases inflammation, which increases the progression of neuronal death. Okay, so we, we know the lack of sleep, the REM behavior, just behavior disorder is impairing the person's ability to get good quality sleep. REM behavior disorder can occur years or decades before cognitive decline in and is a significant early sign of Lewy Body dementia. Or DLB is dementia with Lewy Bodies. But either way, really important to recognize in our younger clients. If they're having REM behavior disorder, they're at high risk. We need to figure out, help them work with a neurologist, a sleep specialist to figure out how to get better sleep in order to try to mitigate any impacts that it's going to have. People with Lewy Body dementia also have Parkinsonian motor symptoms. Rigidity and tremors. In particular, they have problems with planning, decision making, and sometimes memory. Now, notice a lot of the other dementias, memory problems come first. With Lewy Body Dementia, memory is not necessarily the first thing. They may have a shuffling gait and balance problems and an increasing risk of falls, which is especially problematic if you've got an older adult who is more prone to hip fractures, etc. Another interesting unique factor for Lewy Body Dementia is autonomic dysfunction. And people who've had pots, Postural orthostatic tachycardia syndrome are very familiar with autonomic dysfunction. But our autonomic nervous system is our automatic nervous system. If you want to think about it that way. It's the part of our bodies that responds without us having to think about it. We don't have to remind ourselves to blink our eyes or to breathe in somebody. With Lewy Body Dementia, we see orthostatic hypotension. They. Their body doesn't respond when they stand up, and they often have a rapid drop in blood pressure because their body doesn't respond and keep their blood flowing as. As they change their altitude, if you will. They may have constipation because those auto autonomic nervous system stuff in the gut is not moving. The food along the peristalsis may not be happening. They may have urinary incontinence or urgency and temperature disregulation. This is a huge one. Why is that? Well, all of these are huge. Urinary problems can cause urinary tract infections. Constipation can cause pain. Orthostatic hypertension can cause falls. Temperature disregulation is one of the most common things contributing to agitation in people with dementia. Other than pain, if they suddenly get hot or they suddenly get cold, their. Their body's not able to regulate itself, and that can cause them to be very uncomfortable. So they may suddenly start getting agitated or taking off their clothes. It's not that they're in a psychotic episode, it's that they're hot and they're trying to make themselves feel better. Increased sensitivity to antipsychotic medications, which can cause severe adverse reactions. This is another huge one, because in a lot of nursing homes and assisted living facilities, antipsychotic medications are used to help blunt some of the agitation. And there's argument about whether that's helpful or ethical, but it happens. So let's just acknowledge that it's happening. But people with Lewy Body Dementia become increasingly sensitive to those antipsychotics, which means a normal dose for Them may suddenly be too strong and could potentially even be toxic and cause adverse reactions. If you see your patient is stable on an antipsychotic for a while and then all of a sudden they start decompensating, we want to wonder why, we want to wonder what's going on. They could be dehydrated, they could be not taking their meds, or they could be developing a sensitivity to the meds. Lewy Body Dementia typically has an onset between ages 50 and 85. So this is one where you may see a lot of younger people in long term care, gradual progression, but with pronounced fluctuations in alertness and cognitive ability. And the decline is much more stepwise or in, In. I'm sorry, in vascular dementia, the decline is much more stepwise. In Lewy Body dementia, it is much more progressive. Lewy Body Dementia often starts with visuospatial and attention deficits. Okay. Alzheimer's typically starts with memory loss. So if we're trying to differentiate which one we're dealing with, these are things you may want to look for. In Lewy Body Dementia, cognitive Decline occurs within 1 year of motor symptoms. In Parkinson's related dementia, motor symptoms appear at least one year before. For cognitive decline. In frontotemporal dementia, we have two variants. The behavioral variant, where there's marked changes in personality, social conduct and empathy and disinhibition. They also may express sort of apathy. And then you have the language variant where there's difficulty in speech, word finding and understanding language. Frontotemporal dementia, to the best of their understanding, has a really strong genetic component. The average age of onset is commonly between 45 and 65. So this is the earliest onset and typically we don't see it with starting after age 65. With a lot of these other dementias we've talked about, they start gaining steam and start being diagnosed at age 65. So this is one of your early onset dementias. Degeneration is primarily in the frontal and, and or temporal lobes, where we do all of our executive functioning, our attention, our planning, our problem solving, our wise mind stuff is where this decompensation occurs. Frontotemporal dementia is progressive, often starting with personality or language changes rather than memory loss. In Parkinson's, pseudo dementia. Okay, fine, we'll call it pseudo dementia. Dementia symptoms that occur within the auspices of someone with Parkinson's disease. The initial symptoms are often related to Parkinson's motor changes. So your initial symptoms are often rigidity, tremors, difficulty with movement. There's progressive cognitive decline, including reduced attention, impaired Executive functions and slow thought processing, visual hallucinations, fluctuations in alertness, and sometimes mood disturbances such as depression and anxiety, which you would expect in somebody who is going through what they're going through. If they're experiencing Parkinson's and experiencing dementia symptoms. Onset of dementia, dementia symptoms. It's important to recognize that only about 50% of people with Parkinson's disease will develop Parkinson's pseudo dementia, and they believe that it's multifactorial again, which means, of course, if it's going to be Parkinson's pseudo dementia, they've got to have Parkinson's. But then why do some people develop it and why do other people with Parkinson's not develop it? They're not really sure. They think it's a lot of things, including systemic inflammation and all those other risk factors. We talked about. Consequences of dementia. Now we're getting into the meat and potatoes. Mobility and balance issues with movement becoming more rigid and uncoordinated, which means people are at greater risk of falls. They're going to have more difficulty getting in and out of the bathtub, more difficulty potentially toileting or feeding themselves or holding a cup of coffee if they're, if they have got severe tremors, we've got to be aware of hot and cold beverages and foods. There's an increased risk for pressure ulcers in people with dementia because they may not be aware that it hurts. They may not be aware of their body signals as that autonomic nervous system starts to go on the fritz. There's poor nutrition and hydration due to reduced appetite, difficulty recognizing food as food, changes in taste and smell, and sensory sensitivities. As I mentioned earlier, some people may not recognize food that they've always eaten. They may not recognize it as food anymore, so they don't want to eat it. They think it's poison. They think it's a trick. They may not have as much of an appetite for a variety of reasons, but especially if they can't smell as well, which is a common problem for older adults with and without dementia. And they may develop sensory sensitivities. And, and by that I mean certain textures may be offensive to them. And we need to be aware of what it is that's going on. An occupational therapist can help sort some of this out. They may develop dysphasia. And if they're not eating well, we do need to consider dysphasia because it's a progressive disorder that impacts the swallowing reflex. And so people may not feel like they can actually figure out how to get the food from where they put it in their mouth back to swallow it and swallow it down without choking. As dementia advances, the swallowing reflex may become impaired, resulting in challenges with managing saliva and safely swallowing. Even when they're not eating, just drinking or swallowing their own saliva can become problematic for some people. And generally by the time we get to advanced dysphasia, the person is in later stages of dementia. But it's not necessarily the only time you see that. You can see it after stroke, you can see it after certain other things in some people. We know that nutrition is essential. We know that poor hydration will impact cognitive functioning. We know that poor hydration will impact the effectiveness of their medication. Medications. We know that poor hydration can contribute to the development of certain infections, especially UTIs and things. So paying attention to your patients weight, if you're not their nutritionist, if you're not there when they're eating, paying, paying attention to their weight and whether they look like they're hydrated, if their eyes, eye sockets are sunk in, if their pallor is, is, is not good, if they don't look kind of rosy, if you can tent their skin on their hand or they content their skin on their hand, I would encourage you to have them do it and it doesn't snap right back. It's something to consider to ask them about whether they're drinking enough. Urinary and fecal incontinence is another consequence of dementia. They may not recognize their bodily cues. They may not even tune into the fact that hey, I've got to pee or I've got to po. So they may soil themselves. They may have lost the inability to control those sphincters. It's another issue. They may forget where the toilet is. And even in a small like one bedroom assisted living facility, some somebody may forget where their toilet is or forget how to use it, or they may not use the bathroom due to urinary tract infections or rashes or even constipation. We need to do a thorough assessment. If somebody suddenly starts showing incontinence, let's have them talk with the doctor to figure out why that might be going on and we can ask them about some of this. Did you realize that you needed to go to the bathroom? Are you having pain when you go to the bathroom? And that can help inform the physician. There's an increased risk of infections due to poor hygiene, not wiping well when they go to the bathroom, not washing their hands, not remembering to wash their hands, sleep disturbances which exacerbate confusion and contribute to falls and accidents due to impaired alertness. As people develop dementia, we've all heard about sundowning, their circadian clock starts to misfire, if you will. Maintaining routine, maintaining light levels during the day, maintaining temperature levels, you know, warmer in the day and cooler at night, Doing as many things as you can to help them trigger that circadian clock or maintain that circadian clock will be helpful. Helping them do things during the day besides sit around all day and watch tv. That can help them get out. Some of their energy can also be helpful. Now, not everybody can move around very well, so it may be chair yoga or even just singing and clapping may be a lot for some people, whatever they can do, but any sort of cognitive or physical engagement is going to help tire them out. And depression, grief and anxiety, these are your emotional consequences of dementia. Most people are well aware of what's happening in the early and middle stages. And it's terrifying, it is maddening. It is can make them feel hopeless and helpless. It can cause a lot of grief and among them as well as their caregivers. And we need to help them process this stuff because holding on to it increases stress, increases neuroinflammation, increases blood sugar, increases blood pressure, increases all the bad stuff. We need to help them figure out what things can we get rid of to help you slow the progression of this disease. Worsening diabetes. Forgetting to take their insulin, forgetting about managing their blood sugar. They forget they're not supposed to eat cake. My husband's grandfather, he doesn't forget. He knows good and well he's not supposed to eat cake, but he says he doesn't care. So is that bad judgment or just being 96? I don't know. But people who have diabetes and dementia may forget that there are certain foods that they're supposed to eat in moderation or not at all. They may forget how to manage. They may not may forget what this thing is on their side or on their arm, which is their continuous glucose monitor. Or they may forget how to give themsel a insulin bolus if they need it, or how to clean the clean their pumpkin. Diabetes. 85 million US adults do not know they have diabetes or pre diabetes. This includes older adults. Nearly 1 in 4 individuals with diabetes don't know they have it. Approximately 96 million American adults, more than 1 and 3 have prediabetes and 80% of those with prediabetes are unaware of it. And remember, this doesn't even begin to tap into insulin resistance. So we've got the majority of the population out there who has some insulin resistance that is contributing to unnecessary systemic inflammation? Diabetes screening questions. Have you noticed increased thirst or frequent urination more than usual? Do you experience unexplained weight gain or difficulty losing weight, particularly around your belly? Have you had unusual fatigue, low energy levels or daytime sleepiness? Now, obviously, for each one of these questions, There are probably 10 different explanations, but this is just a screening. And if they answer yes to a lot of these questions, we refer them out to their physician for a testing. Have you noticed changes in your vision, such as blurriness? Do you experience tingling, numbness or burning sensations in your hands or feet? Have you had frequent infections, urinary tract infections, skin infections, or slow healing wounds? Do you experience frequent hunger even after eating? Do you have darkened patches of skin around your neck, armpits or other folds? Do you notice worsening mental clarity or feeling like you've got brain fog when you're stressed or after meals, especially heavy carbohydrate meals. Why stressed? Because stress increases blood sugar and high carbohydrate meals increase blood sugar. So if their mental functioning goes down precipitously during either one of those situations, it's an indicator. If they answer yes to multiple of those questions, really encourage them to go see their doctor and get tested. That can't hurt to get tested. Best case scenario, the doctor says no, you know, there's nothing going on. Hypothyroid causes slow metabolism, fatigue, cognitive dysfunction, poor concentration, memory impairment and depression. Hypothyroid can be misdiagnosed as dementia. One of those things that we talk about in a lot of my classes is misdiagnosis because it's so stinking prevalent. Um, we want to ask ourselves if we start seeing signs of cognitive decline and, or muscle rigidity and difficulty with balance and coordination. All right, those are certainly symptoms to be concerned about, but we want to ask ourselves why? What's going on with this person right now? What can we rule out? Hypothyroid is one we me, I mentioned that nearly 14% of older adults have hypothyroid. If it's gone undiagnosed, then they may be getting told they've got dementia, when in actuality it's hypothyroid. I know you'd think that this wouldn't be missed, but it gets missed, especially if they're not going to a geriatric specialist. B12 deficiency can also be misdiagnosed. Now, B12 comes from fortified foods or animal products, especially if you're working with somebody who Is a vegan, especially a vegan, to a certain extent a vegetarian. They may not be getting enough B12, especially if they're not taking supplements or eating other fortified foods high in B12. Additionally, older adults have more difficulty absorbing B12, which can cause neurological changes such as confusion, memory loss, irritability, fatigue, and eventually anemia and related nerve damage. So B12 is a big thing. We need to make sure that they're getting it. Blood test can tell you, Very simple blood test can tell you whether they've got, they're getting enough B12. Not only are they ingesting enough, but enough is getting absorbed in their system. Dehydration, another common misdiagnosis. If somebody is perpetually dehydrated. Again, my husband's grandfather probably drinks 12 ounces of fluid a day, and we are really obviously trying to get him to up that. But he's not thirsty. Remember, older adults with and without dementia have a decreased thirst reflex, so they're not as thirsty anyway. If they have dementia, then they may, even when they do get thirsty, they may not recognize that, that they're thirsty, so they may not drink. Dehydration leads to a decrease in blood volume and blood pressure, which can lead to dizziness, increased falls. It also disrupts electrolytes and impacts the effects of their medications. Poorly controlled diabetes is another common misdiagnosis. There's a lot of people who haven't gotten diagnosed with diabetes or even if they have their blood sugar all over the place, and if they're not monitoring it, well, if they don't have a continuous glucose monitor, people may think that their confusion when their blood sugar is all over the place is dementia, when in actuality it's. It's the blood sugar. Undiagnosed insulin resistance. Along the same lines. Insulin, that's what we keep talking about with diabetes. Insulin is a critic, is critical in brain function, glucose metabolism, neurotransmitter regulation, and neuronal signaling, insulin resistance. So when your body secretes insulin and the cells just don't even know what to do with it, or don't pay attention, if you will, it disrupts these processes, which can cause cognitive impairments. Delirium is another issue that's often kind of lumped in with dementia, but it's very different. It's an acute condition, which means it's suddenly happens and it's triggered by infections, including UTIs or pneumonia. So if somebody has a UTI or a kidney infection or sinus infection, even if it's bad enough, they may get To a point where they've got delirium. And it's not dementia. It's something that once you clear up that infection, the cognitive impairment is likely going to go away. When people have delirium, especially those that are triggered by infections, medications or dehydration, it causes rapid cognitive decline, hallucinations and confusion. And a lot of times when we're sick, we just, we're too tired to get up to get anything to drink, so we may get dehydrated. Hearing loss. I know, again with the hearing loss, but that's how important it is. Hearing loss, especially age related hearing loss, causes communication problems, apparent memory issues. So I told you this this morning and granddad's sitting there going, I didn't hear you tell me that. Social withdrawal reduced cognitive stimulation, which can worsen cognitive decline and slowed response or disorientation in conversations when the person takes longer to respond or responds inappropriately to questions, not rudely, but somebody asks, what do you want for dinner? And they say, no, I'm not too hot right now. That's not what I asked, but that's what the person heard. It's not because they have dementia, it's because they have hearing impairment. But it creates the appearance of confusion and disorientation. So let's rule out that hearing loss. And of course, got to put in there brain tumors. If you've got something growing in that brain, pressing on certain parts of it, it's going to impact your cognition. Depression and grief in older adults often presents as pseudo dementia, which include cognitive impairments, poor memory, attention and executive functioning that result from severe mood symptoms. This is reversible as they process their grief as they come out of their depression. But we need to help them, empower them to have the tools to do that. Bipolar disorder, and believe it or not, there are a lot of older adults who have bipolar who were never diagnosed. So bipolar disorder in older adults can lead to periods of cognitive dysfunction during manic or depressive episodes. Symptoms like distractibility, poor decision making, and memory issues are often mistaken for dementia. Remember, in bipolar disorder, you have to have a hypomanic or a manic episode at least once in your lifetime and a major depressive episode at least once in your lifetime. But other than that, it. Bipolar disorder presents very differently. There are some people who have one hypomanic episode early on, and then every episode after that is a depressive episode. And so they're diagnosed with depression, not bipolar disorder. And then they suddenly have another hypomanic episode at some point. And people start thinking that that's personality changes and poor judgment caused by dementia. No, no, it's personality changes and poor judgment caused by bipolar disorder and medication side effects. I know we're running out of time here, so I'm not going to belabor this list, but there are a lot of medications that older adults cannot handle either at all or at the same levels as the average adult because of their reduced liver and kidney functioning and other medications that they're on. We've Talked about Cytochrome P450 in other videos and how if you take multiple medications that require the same enzyme to break them down, that there's competition and it takes longer for the body to clear those medications anyhow, over the counter antihistamines like Benadryl can cause cognitive symptoms, bladder control medications, muscle relaxants, anti anxiety medications, opioids, long term use of corticosteroids. And this can be for somebody, for example, with rheumatoid arthritis, blood pressure medications like beta blockers and clonidine can cause cognitive symptoms in adults. And statins, your cholesterol medications. And as we talked about before class, chemotherapy and radiation can also be misdiagnosed as dementia, especially if the person is taking the medication for a long time. Then it seems like you don't even look at could this be a medication causing. Seems like something's going on systemically with them. So we do need to evaluate what medications they're on. Even as a counselor, we're not prescribers, we're not going to tell them what to stop taking. But if they're starting to evidence cognitive symptoms and they're on any of these medications, then we probably need to empower them to talk with their physician or if you have a release, then do some coordination of care with the physician. Because it's possible that the dose that they were on prescribed five years ago, that they've been on ever since is now too strong because their liver function has declined that much. The 88 and Mini Cog are among the many possible tools and we're going to talk about those a lot tomorrow or next week to use to screen for dementia. Patients should be screened for cognitive impairment if they or others express concerns about changes in memory or thinking. If you observe problems in the person's memory or thinking, if the person's 80 or older, if they have low educational attainment, history of diabetes, stroke, depression, trouble managing money or medications, especially, you know, recent, it's not like they've always had this problem. And episodes of delirium, episodes of confusion or disorientation. We want to screen. That's not a diagnosis, that's. Let me ask you a few questions that to see if I need to refer you to a neurologist or to your physician. When we're screening, we want to have them describe the symptoms, the frequency, the severity and the onset. When did this start happening? Did something change in their life like their spouse died? Well, that's probably going to precipitate some significant cognitive changes during the grieving period. And that's not dementia, that's grief. So did something change? Did they have to move? Did they start a new medication, change medications? Is their sleeping impacted? Is their living situation changed? And has the change been gradual or sudden? If it's sudden, we really want to think delirium, we want to think infections or we want to think this person started taking a new medication. And try to evaluate for those things and obviously refer to, to the physician for any sort of testing. Refer to the physician to rule out nutritional deficiencies, dehydration, hypothyroid, diabetes, transient ischemic attacks, hearing loss, infections, medication, side effects and brain tumors. And they can do this with an evaluation, you know, in their office and blood work. If they think there's a need for it, they can request a PET scan, a CT scan or an mri. So there are a lot of things doctors can do to differentially diagnose Differentiating Alzheimer's from aging. Memory loss that disrupts daily life, such as forgetting recent events, repeating the same questions, or difficulty remembering appointments is more common in Alzheimer's. And remember, it's a continuum. All of us have some level of difficulty with this sometimes, but this is when it starts impairing their ability to live independently. Noticeable difficulty with complex tasks, problem solving and decision making, and marked changes in language abilities, including finding common words like refrigerator, cat, dog, following conversations or understanding instructions. Always rule out hearing loss. There's also problems with visuospatial skills. They start getting lost in familiar places and difficulty judging distances. Problems with executive functioning, personality and mood changes, sometimes with hallucin, hallucinations or delusions and a progressive decline over time that goes beyond normal age related changes and negatively severely impacts activities of daily living. So again, this we're going to see a lot of the same changes we see in typical aging, but to a greater extent and in a progressive fashion and usually progressing much more quickly than in what we would consider typical aging. There are a variety of different types of dementia. Hypertension, insulin resistance, cardiovascular disease and genetics all play a contributing role the cognitive impairments that come with dementia can have significant negative consequences on the person's health and well being and must be mitigated. We want to empower them as much as possible for as long as possible to do for themselves. That will keep them engaged and will help maintain some of that cognitive activity. Further, there are many conditions that cause dementia like symptoms and contribute to the development of dementia and that can be addressed to significantly reduce the risk of dementia. If somebody's got cognitive impairment from depression, for example, if we intervene with that depression so they are not withdrawn, so they are not isolated, so they are not sedentary and cognitively kind of flat, then we're going to reduce the risk of dementia. So there are a lot of things and hearing loss, it's another thing. Hearing loss, we know untreated actually exacerbates cognitive decline. If we identify hearing loss as hearing loss early and intervene, then we can eliminate that contributing factor to dementia. Everybody have an absolutely amazing rest of your week. Now remember next week, since it's a holiday week, we're meeting on Monday and the week after that because it's a holiday week, we're meeting on Monday again and then we will go back to our normal, regular, regularly scheduled programming at the beginning of the year. Thank you again for everybody for being here. Thank you for being attentive. I know this was a very clinical, boring presentation, but there is a lot of information out there and if you're a starting out clinician, ultimately what type of dementia the person has is less important from a therapeutic counseling perspective as what are their symptoms and how can we help them feel empowered and safe and help them move to have toward their rich and meaningful life as they define it. And you know, from there we can figure out what the treatment plan needs to look like. Crystal, I am glad it is helpful. Stephanie, I am so sorry to hear that your aunt has dementia. I'm glad she's stable at the moment and you know, every day, well, maybe not every day, but very frequently they're coming up with new treatments, not necessarily drugs, treatments to help slow the progression of cognitive decline and dementia. So I would encourage you to, you know, kind of poke around in PubMed if you feel like it and periodically to see what is out there. It's also important. Well, not important, but you're also able to look online to find any clinical trials for things that they're using to address dementia. We did a video, oh gosh. A couple months ago about a transcutaneous vagus nerve stimulating device that actually was first trialed with people who had had a stroke and they found that by controlling the vagus nerve at the right time and you know, stimulating at the right time and down regulating it at the right time, they were actually able to help people regain physical function and regain movement of their, in this particular study, it was their arm. So that's really exciting as well. And I think there's a lot of generalizability to what's going on there. So there's stuff out there. If we haven't, if we haven't found it yet, or if I haven't talked about it yet, it's out there and hopefully I will be able to provide it to you as it comes out. If somebody has dementia, it is never too late to improve your quality of life, reduce inflammation, manage your blood sugar and, and hypertension and take those steps that we talked about last week to slow the progression of the disease. Oh my gosh, I am so sorry, Crystal. That is infuriating. I would encourage you to work with her maybe to write down the symptoms she's experiencing. So maybe she's experiencing problems in her visuospatial abilities and she gets lost easily. So problems with visual spatial abilities as evidenced by, and then, then give two or three examples of what's going on with her that makes her think that she has that symptom and do that for every symptom she has and then take it into the doctor and give it to them and, and have a frank discussion about. Okay, if you don't think it's dementia, then what is it? I would encourage you to go through that list of things that we talked about that's, that are frequently misdiagnosed as dementia and make sure she doesn't have any of those. Hypothyroid hearing loss, those are two of the big ones that I would definitely look at. This frustration, feeling gaslit, feeling powerless, especially if she believes she's got dementia is probably increasing her anxiety, increasing her stress and increasing her systemic inflammation. She needs to feel heard. A Jarius, a doctor that specializes in geriatric medicine is going to be one of the best people to go to. A neurologist would be another type of doctor that specializes in dementias that would be good to go to. I wouldn't go to just a GP or a, just any old run of the mill psychiatrist if she's already having difficulty getting feeling like she's being heard. But definitely I have had 100% success so far when, when I write things down, you know, here's the symptom as evidenced by. And here are three examples. And I give it to the doctor. It's harder for them to ignore me and it's harder for them to ignore her. I'm also wondering whether maybe when she gets into the room with the doctor, she may get bullied and maybe they don't intend to bully her, but she doesn't really assert herself and advocate for herself very well because they start to shut her down and she just clams up. My grandmother used to do that. Um, and ultimately my mother had to go in and my mother was very assertive. So the point got through. But it could be that she may need some advocacy. And if she is in. I'm, I'm assuming you haven't said anything about her being in long term care, so I'm assuming she's living independently. If you can go with her or if somebody else can accompany her to make sure that she feels like she's being heard, that can be helpful. I'm not sure if there's such a thing as an ombudsman for outpatient, but I know in long term care and nursing care facilities the ombudsman is a advocate for the patient. And if there's a problem, you call the ombudsman and you go, I'm not being heard, I'm being gaslit. I need your advocacy here. And they will step in and help you rectify the situation. Like I said, I don't think there are any for standard outpatient. So I would encourage you write it down. Find a geriatric specialist or a neurologist to go see. And if they don't think she's got dementia, then what does she have? What's contributing to this? And what suggestions do they have for helping her manage the symptoms that she is having? Because that's their job, to help her live her rich and meaningful life. And I'll leave it at that. That's their job. And Crystal, I've seen studies that have said that doctors kind of make up their mind about what your diagnosis is pretty much within. I can't remember if it's 30 seconds or three minutes of talking to you, but it's some really short period of time. They learned a lot from books. Therefore, if they read something, I believe if they read something, it actually clicks better and they pay more attention to it and than if you're talking about it. Because I, I believe for a lot of doctors, and I've had, I've had this experience multiple times, you're talking to them, you know, they're not even listening to you. Sometimes they're even writing notes in your chart and just kind of, huh, huh. Giving you these minimal encouragers. But you could tell them that the sky's purple and the Pope just walked in and they wouldn't even, like, flinch. So writing it down, I think is good because then they also can't argue that you didn't say something. And you can say, all right, we're going to go through this point by point having this symptom. What could be causing it? You know, have we ruled these things out? And you can get a much more academic, I don't know what word I'm looking for here response where she. She will feel that at least she's been heard. She may not have the answer she wants, but she will know that at least she's been heard, Oh my gosh, I'm sorry. That her husband just passed away. So the grief is probably contributing to it. But telling her it's just the grief or quote, normal aging, if she doesn't feel like it is, is. Is gaslighting. So a good doctor would say, okay, this is what I think it is, but I'm hearing you think it's more. So let's tell me why you think it's not just the grief. And they can do a better, better assessment. I wish there was some job out there I could get where I could just advocate, get paid to go advocate for people and go to doctor's appointments and stuff with them and be like, hey, Doc, pay attention. There are some very good doctors. Okay, I have. The doctor I go to now is wonderful. She's amazing. But I went through several before I finally found one that actually listened and didn't think that they knew everything. Okay, everybody, have another again. I know I already said it. Have an absolutely fabulous rest of your week. Next week's video and and live webinar is on Monday because Wednesday is Christmas and I'm not working on Christmas. So I will see you Monday.