Practical Dementia Care
February 5, 2002 12 PM EST

This chat has been produced by ElderCare Online and the Alzheimer Research Forum. Alzheimer's Answers is an educational forum where caregivers can connect with professionals and clinicians to understand Alzheimer's Disease. This Chat Room provides general information that is for educational purposes only and should not be considered as offering medical advice. The information that is made available by this Chat Room should not be used for diagnosing or treating a medical or other health condition. Viewers and participants should always consult a physician or other qualified healthcare provider for the diagnosis or treatment of any medical or health condition. ElderCare Online, the Alzheimer Research Forum and Dr. Lyketsos MAKE NO WARRANTIES, EXPRESS OR IMPLIED, AS TO THE VALUE, USEFULNESS, COMPLETENESS OR ACCURACY OF ANY OF THE INFORMATION THAT IS MADE AVAILABLE BY THIS CHAT ROOM.

Constantine G. Lyketsos, MD, MHS is a Professor in the Department of Psychiatry, School of Medicine The Johns Hopkins University in Baltimore, Maryland. He is a board certified geriatric psychiatrist who directs the Johns Hopkins Neuropsychiatry Service and the Comprehensive Alzheimer Program (CAP). Dr. Lyketsos is an active clinician with an expertise in dementia and Alzheimer disease. With Peter Rabins and Cindy Steele he is an author of Practical Dementia Care (Oxford University Press, 1999).

He has contributed over 120 publications to the international scientific literature on dementia, geriatrics, depression, neuropsychiatry, Alzheimer's disease, and HIV/AIDS. His ongoing research focuses on the impact and treatment of psychiatric disturbances in Alzheimer's disease, on the prevention of Alzheimer's disease, on the epidemiology of cognitive decline and dementia, on the diagnosis of Alzheimer's disease, and on the care of persons with dementia. He was recently cited in Best Doctors in America.

He has special expertise in the design and conduct of clinical epidemiological and intervention studies. Dr. Lyketsos is Principal Investigator of the Depression in Alzheimer's Disease Study (1R01-MH56511), the Maryland Study of Assisted Living (1R01-MH60626), the Clinical Assessment and Validation of the Experimental Alkon Test (CAVEAT), and Baltimore site director for the Alzheimer's disease Anti-inflammatory Prevention Trial (ADAPT; 1R01-AG15477). He is also an investigator in the follow-up study of the Baltimore Epidemiologic Catchment Area study (1R01-MH47447), and the Cache County Study of Memory in Aging (1R01-MH11380). Dr. Lyketsos lectures internationally on most of the above topics. After receiving a BA degree from Northwestern University, he completed an MD degree at Washington University in St. Louis, followed by psychiatric residency and fellowship at Johns Hopkins School of Medicine. He concurrently obtained an MHS degree from Johns Hopkins School of Public Health with a focus on clinical epidemiology.

Dr. Lyketsos (This user has entered ElderCare Chatroom)

RichOBoyle (This user has entered ElderCare Chatroom)

RichOBoyle
Is there any link between alcoholism and Alzheimer's Disease?

Dr. Lyketsos
This is hotly debated. There are studies to suggest that alcoholics are more likely to get dementia. But this may be a result of poor nutrition and propensity to head injury, rather than to alcohol itself. Some population studies actually suggest that alcohol, in particular red wine, may protect against cognitive decline. So, not strong link so far.

RichOBoyle
Is there a demonstrated linkage cause/effect of intake of various metals such as aluminum and copper?

Dr. Lyketsos
No such linkage has been demonstrated to my knowledge. Aluminum miners do not seem to have a higher rate of Alzheimer's.

RichOBoyle
What are some techniques for preventing and dealing with emotional outbursts by individuals with dementia? Is medication advisable under certain circumstances?

Dr. Lyketsos
Emotional outbursts in dementia must first be evaluated and then treated. There are several causes that must be ferreted out and managed individually. Many times the cause is depression, anxiety, or delusions. At other times it is fatigue, pain, or hunger. Often a bladder infection is the cause. The key is to get a good evaluation to figure out the cause. Medication treatment has been proven to work in some cases, depending on the cause.

RichOBoyle
While it is notoriously difficult to estimate the duration of each stage of Alzheimer's Disease, is there any general rule of thumb for predicting the length of each stage? Does the disease progress more quickly as it goes on, or is the progression relatively steady?

RichOBoyle
For example, which causes respond best to medication? Which respond worse?

Dr. Lyketsos
The difficulty comes about from the great variability in the disease. Too many factors are involved. My rule of thumb is to use the MMSE. MMSE>18 is mild, 10-17 is moderate.

Dr. Lyketsos
Causes that respond best to medications:

Dr. Lyketsos
Bladder infections to antibiotics, pain to pain medications, depression to antidepressants, agitation to various treatments, delusions and hallucinations to antipsychotics.

RichOBoyle
Has any research been conducted on the prevalence of suicide among elderly with dementia? How does the incidence of suicide correlate with elderly depression and notification of the diagnosis?

Dr. Lyketsos
One study I know of has suggested a slightly higher rate of suicide in persons with dementia who are depressed. The correlation with depression is very strong. I have never seen a suicidal Alzheimer patient myself (out of thousands) so overall it is rare. I have never seen someone become suicidal on notification of diagnosis. I know of no studies on the latter.

RichOBoyle
At what point does "reality orientation" lose its effectiveness? For example, a very early stage individual should be kept aware of surroundings and "reality"; but at what point does the orientation need to be shifted to keeping them calm and comfortable?

Dr. Lyketsos
Most dementia patients do best if they are provided with structure and activities so that "reality orientation" is not needed. In my experience, this practice is more harmful than good in all stages and I do not tend to recommend it. My emphasis would be on structure and playing o strengths rather than on teaching patients the "reality" they can't remember well which might be upsetting to them.

June
What's the current thinking on depression earlier in life as a risk factor for AD? I've seen mixed data on this. Also, do antidepressants ameliorate any increased risk?

Dr. Lyketsos
I have seen no good study actually ask the question of whether depression early in life is a risk for Alzheimer's. Most studies are retrospective and do not distinguish depression by its age of onset. It is well established that late life depression precedes dementia. This is most likely because in many cases depression is the first symptom of Alzheimer's and precedes the memory symptoms.

RichOBoyle
What are some symptoms or signs that caregivers can see to help them differentiate depression from dementia?

Dr. Lyketsos
Depression: slower thinking, less effort, sad mood, self blame, almost never MMSE below 18 or so

Dr. Lyketsos
Dementia: good effort, prominent memory symptoms, not sad, cheerful

RichOBoyle
What are some common side effects of the drugs used to treat Alzheimer's Disease and depression? What proportion of people can not take one of the drugs for AD due to severe side effects?

Dr. Lyketsos
Side effects for the cholinesterase inhibitors that are FDA approved (in alpha order Aricept, Exelon, Reminyl):

Dr. Lyketsos
stomach upset, indigestion, nausea, vomiting, diarrhea, loose stools, muscle cramps, fainting spells in about 1-2%. These are the most common. In my experience in the absence of pre-existing heart or GI disease 90% of patients tolerate these medications well. If there is heart disease or GI disease 70-80% tolerate well.

RichOBoyle
Can dementia be exacerbated by an injury, fall, or surgery? If so, is the increased dementia permanent? Can it be minimized?

Dr. Lyketsos
Yes, it can be exacerbated by all of the above. The worsening can be permanent. No good studies on how to minimize other than recovering as fast as possible and pursuing aggressive rehabilitation to avoid de-conditioning.

RichOBoyle
What is the normal lifespan of an individual diagnosed with Alzheimer's Disease? What are the most common causes of death?

Dr. Lyketsos
"Normal" is a big word. Most studies from clinical populations (from doctor's offices, hospitals etc) suggest 7-10 years from diagnosis to death with much variability (as little as a few months to over 20 years). Studies from populations suggest life span may be shorter 3-5 years with many not making it to health care. Common causes of death: aspiration pneumonia, inability to eat, death from co-morbid illness, urinary infection.

RichOBoyle
What is vascular dementia and how does treatment differ from treatment for Alzheimer's Disease?

Dr. Lyketsos
Vascular dementia is putatively caused by repeated strokes to the brain, small and large. There is much debate about it being a "real entity." Most people who are clinically diagnosed with it have Alzheimer's pathology seen in their brain. More likely Vascular is conceived as heterogeneous with many different brain condition included.

June
To go back to medications side effect issues: I've had a patient report that when her doctor increased her Aricept dosage, she developed tremors and shakiness. She's on 20mg. What should she do?

RichOBoyle
Can you provide any suggestions on how caregivers can ensure that the medications their loved one is taking are effective? For example, that they are not over- or under-medicated?

Dr. Lyketsos
I cannot advise on individual cases. I should mention that 10mg per day is the high dose that FDA has approved for Aricept.

June
That's helpful to know. Thanks.

Dr. Lyketsos
Be sure and always ask the doctor at every visit what a medication is for and if it can be stopped. Then ask for side effects of the medication and if they show up, ask if it should be stopped. Keep an eye on accelerated decline or new symptoms of any kind after a medication is added or its dose increased.

RichOBoyle
What are some common drugs used to treat agitation and psychosis? Which are to be avoided or preferred?

RichOBoyle
How can the stress of an individual's move from one residence to another be minimized? Can a physical move exacerbate dementia or depression?

Dr. Lyketsos
We dealt with this a bit already. Antidepressants might be sertraline, citalopram; antipsychotics might be risperidone, olanzapine; others might be valproic acid or carbamazepine. There are many more. Our book, "Practical Dementia Care" with Peter Rabins, Cynthia Steele, and myself gives great detail. It is available at Amazon.com.

Dr. Lyketsos
A physical move is unlikely to worsen dementia or its progression. It might worsen depression or agitation. Too minimize effects best to prepare carefully. It should be decided case by case how much to involve the patient in anticipating the move. Some times preparation with visits to the new place are the way to go. Other times best not to involve the patient and simply to move them on the day of the move. If there is doubt this should be discussed with a doctor who is experienced in this.

RichOBoyle
Dr., thank you for responding to these questions. I'm sure that our members will find the transcript useful.

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