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Vascular Dementia Dementias in SSA: clinical diagnosis, pathology & therapeutics 9th RTC in Sub-Saharan Africa Ouagadougou, Burkina Faso, 08 – 11 November 2017 Prof Raj N Kalaria Institute of Neuroscience, Newcastle University Campus for Ageing and Vitality, Newcastle upon Tyne NE4 5PL, UK Email: [email protected] Newcastle Centre for Brain Ageing and Vitality Neurodegenerative Dementias (specific molecular pathologies causing dementia) • Alzheimer’s disease and age-related disorders • Dementia with Lewy bodies (DLB); Parkinson disease with dementia (PDD) -The synucleinopathies • Frontotemporal dementia (+tau) / Tauopathies – FTD and Parkinsonism Chr. 17, CBD, PSP, Pick’s disease – Argyrophilic grain disease (AGD) and Tangle only dementia • Frontotemporal dementias (-tau) – FTDs with ubiquitin, progranulin and TDP-43 inclusions • Prion diseases – Creutzfeldt-Jakob disease, Fatal familial insomnia, GSS, Kuru • Trinucleotide Repeat disorders (polyglutamine diseases) – Huntington’s disease (HD), Spinocerebellar ataxias, Friedreich’s Ataxia • HIV-related Neurocognitive Disorders; HAND, HAD, HIVE • Motor Neurone Disorders; ALS, PLS, SMA with dementia GBD 1990-2013: DALYs for all Causes Tree Map of Low and Middle Income Countries: Murray et al, 2012; All ages 70+ years and Both sexes Whiteford et al, 2013 Numbers of People with Dementia 47 million Wimo A et al 2015 What Are the Most Common causes of Degenerative Dementias? Vascular dementia Other 15-25% dementias: eg, Lewy body dementia, Parkinson’s 10-30% dementia 55-70% Frontotemporal lobar dementias Alzheimer's disease Frataglioni L, et al. Neurology. 2000;54:S10-15 Rarer dementias not shown but do not amount to >15 of total. Prevalence of Dementia Worldwide Dementia is a clinical syndrome caused by neurodegeneration . Alzheimer’s disease (AD) is the most common type followed by vascular dementia (VaD), dementia with Lewy bodies (DLB) and frontotemporal dementia (FTD). Prince M et al, 2010 Worldwide costs of dementia forecast? 2500 $) 2 tUS$ 2000 bUS 1500 1000 500 Global Global costs of dementia ( 0 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Year Dementia in Infectious Disease • Factors include viral, bacterial, fungal, and parasitic organisms HIV is the most common cause • Presence of fever, peripheral leukocytosis, or CSF pleocytosis should prompt investigation for an infectious agent • Consequences on behavioural and cognitive function most frequent in immunocompromised patients HIV-related Neurocognitive Impairment in SSA Total reports (2014): 51 hospital-based studies case-control (10), cohort (6), cross-sectional (31) 14 countries: South Africa (14), Uganda (8), Nigeria (6), Zambia (4), Kenya (4), Cameroon (3) DRC (3), Diagnostic tools: Ethiopia (2), Malawi (2), CAR variable. (1), Botswana (1), Guinea International HIV Bissau (1), Tanzania (1), Dementia Scale Zimbabwe (1) (IHDS) 21-80%; Sloan Memorial Absolute participants Kettering scale with HAND 0-396; frequently used prevalence 0%-80% Lekoobou A et al, BMC Public Health, 2014 Frequency of HIV Meningoencephilitis • ~50% HAND- HIV-associated neurocognitive disorders • ~20% HAD- HIV associated dementia • ~2% HAD with ART treatment • >50% HIVE- HIV encephalitis as less severe HAND – Persistent immune activation, inflammation, viral escape / blipping in treated subjects, – comorbid conditions show HIV disease progression and ↑ HAND risk Sub-Types of HIV and Cognitive Impairment Pathogenesis and Cellular Mechanisms Mechanisms in HAND with Age Mechanisms leading to HAND are exacerbated in >50 yr olds with years of chronic neuroinflammation. Neurotoxins, inflammation and OS combined with normal aging processes increase HAND burden in ageing HIV patients Fields J et al, 2014 Rapidly Progressing Dementia Cognitive/behavioral symptoms and neuropsychological profile were compatible with diagnosis of AD (DSM IV-TR). MRI scan medial temporal lobe atrophy (MTA) = highest atrophy rating scale Treponema pallidum hemagglutination and VDRL in CSF + Treated w/ 0.15 · 106 IU/kg benzylpenicillin for 2 wks. 6 months later, MMSE 27/30 slight improvement of language-related skills, but little improvement in memory What is Alzheimer’s Disease? A progressive degenerative brain disorder and the most common cause of dementia Alzheimer’s Disease: Main features • Alzheimer type of dementia: 55%-60% of all dementia cases • AD ~doubles after age 65 yrs: – >65 yrs 5% (3%- 11%); >75 yrs: 10% (7%-15%); >85 yrs: 20%... • Majority of AD late-onset: Slow gradual onset and progression; – Predominance of memory impairment (a. over intellectual impairment or b. meet general criteria for dementia) – 5% estimated to be of familial form: autosomal dominant inheritance – Mild cognitive impairment (‘early stage’ of AD) 63%-80% will progress to AD • Diagnosis of exclusion: no evidence of CVD, HIV, PD, HD, NPH • Failure rates to detect dementia: Clinicians fail to detect in 21%-72% of patients • Definitive diagnosis by neuropathological examination – presence of amyloid plaques and neurofibrillary pathology Age and IIliteracy are the strongest risks Alzheimer’s disease (common dementia) • Age • Family history • Down’s syndrome • Head injury • Apolipoprotein E-4 • Vascular factors • Smoking • Female gender Kalaria RN et al, 2008; 2012 Diagnosis of Alzheimer’s Disease: NINCDS-ADRDA Criteria Dementia • Impaired memory • Clinical examination • 1 other cognitive domain impaired • Neuropsychological tests Probable/Possible diagnosis • Progressive worsening • Absence of other disorders that could account for deficits Definitive diagnosis Diagnosis of AD by autopsy McKhann G, et al. Neurology. 1984;34:939-944 McKhann G et al, Alzheimers Dement 2011;7:257-62. Diagnosis of Dementia Criteria (NINCDS-ADRDA, 1984; ICD-10, 1993; APA, 1994; 2011) Development of multiple cognitive deficits manifested by both: • Memory impairment (impaired ability to learn new information or to recall previously learned information) • One (or more) of the following cognitive disturbances: a. Aphasia (language disturbances); b. Apraxia (impaired ability to carry out motor activities despite intact motor function); c. Agnosia (failure to recognize or identify objects despite intact sensory function); d. Disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting) • Cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning AD Versus VaD: “Classical” Clinical Features AD VaD Presence of vascular conditions and risk factors Onset and progression Insidious and Abrupt and gradual stepwise Neuroimaging positive X for CVD Psychiatric comorbidity May be present Frequent Executive dysfunction None or mild Focal neurological signs X and symptoms Memory impairment May not be prominent Gait disturbances X Emotional lability X Increased urinary frequency X Diagnostic criteria DSM-IV, NINCDS-ADRDA DSM-IV, NINDS- AIREN Cross-section Through a Memory Clinic SMCI--subjective memory Parkinson's impairment dis. Missing UNS SMCI MCI-mild cognitive impairment Other dg FTD + PPA AD-Alzheimer’s disease VAD + MIX VaD-vascular dementia MIX-”mixed” dementia AD FTD-frontal lobe dementia MCI Depression PPA-primary progressive aphasia Data from the Geriatric Dept., Huddinge University Hospital UNS-dementiaN =of 402 unspecified Jönhagen & Wahlund, 2001 origin Diagnostic issues in AD (2) Early and Late-onset EOAD (<65 years; usually familial) Relatively rapid onset and progression; memory impairment; aphasia; agraphia; alexia; acalculia or apraxia (presence of temporal, parietal and frontal lobe involvement) LOAD (>65 years) 1. Evidence of very slow gradual onset and progression (may only be obvious retrospectively) 2. Predominance of memory impairment (a. over intellectual impairment or b. meet general criteria for dementia) Genetics of AD: how much of AD is explained by autosomal dominant or recessive patterns? Sporadic AD 90-95%; Familial AD ~5-10% *Current estimates from ~500 families world-wide Genes and Molecular Genetics of AD Manhattan plot of stage 1 for genome-wide association with Alzheimer’s disease (17,008 cases and 37,154 controls). Red line- The threshold for genome-wide significance (P < 5 × 10−8). Newly associated genes (Red) and previousyl identified genes (Black) are shown. Red diamonds represent SNPs with the smallest P values in the overall analysis. CognitiveAgeing related thresholds leading to Alzheimer’s Disease Memory Language Spatial ability Aggressivness Apathy Personality changes Dementia ADL (Activites of Daily Living) Social ability Signs of Dementia vs Age-Related Changes • Memory loss that disrupts daily life: forgetting recently learned information • Challenges in planning or solving problems: changes in their previous abilities and concentrating • Difficulty completing familiar tasks: difficulties in daily tasks in familiar environments • Confusion with time and place: lose track of dates, seasons and passage of time • Trouble undertstanding visual images and spatial relationships: difficulty reading, judging distance, colour, contrast • New problems with words in speaking or writing: difficulty following/joining conversation, vocabulary problems.. • Misplacing things and losing ability to retrace steps: losing things and the way • Decreased or poor judgement: experience changes in decision-making • Withdrawl from work or social activities: cannot keep up with social activities, hobbies, work projects,
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