Recently, I listened to one of the best live presentations on Alzheimer’s Disease I have ever attended. Less than an hour in length, the WellMed Charitable Foundation sponsored teleconnection provided more information than I have garnered from seminars and workshops lasting ten times as long.
Nestor Praderio, MD was the presenter for this podcast under the topic Behavioral Disturbances in Dementia. Dr. Praderio is a geriatrician and psychiatrist currently practicing in Corpus Christi, Texas. He used his time very efficiently, discussing the behavioral and emotional subcategories of AD including psychosis, apathy, agitation, irritation, patterns of activity, and depression. He spoke briefly about the neurotransmitters involved in dementia, and duration of stages as applicable to AD as well as other dementias. He then proceeded to discuss which behaviors manifest at each of the three stages---initial/mild, intermediate/moderate, and advanced/severe. He gave examples of a range of behaviors to illustrate each stage.
He spoke about the need for integration of interventions and modalities, how one single approach is insufficient. An effective treatment plan should include behavioral interventions, family support, and pharmacological therapy if warranted, and utilize available community resources. Of particular interest was his mention of the benefits of early diagnosis and treatment to allow for planning and what he called ‘maintenance’ treatment despite the lack of a cure at this time. He spoke of targeting cognitive and noncognitive deficits while enhancing (and not interfering with) what is currently working in caregiving.
But what struck me most was something I had not seen or heard previously. Dr. Praderio discussed a slide titled Symptomatic Course and Alzheimer’s Disease Progression, which he referenced as adapted from Feldman and Grundman (2001).
The slide showed the overlap of symptom categories and developing issues in the progression of AD. The duration in years for each of these presenting issues corresponded to scores on the Mini-Mental State Examination (MMSE). The Mini-Mental State Examination (MMSE) measures cognitive impairment and is administered by a trained interviewer in 10 minutes. It can distinguish between those with depression, dementia, or a combination of the two, and is the most widely used measure of cognitive functioning (Folstein et al, 1975). For example, cognitive symptoms are first to appear in AD and last throughout the disease. This corresponds to an MMSE score of above 25. Loss of functional independence is next, starting around a year and a half after diagnosis (corresponding MMSE score around 20). Then behavioral problems tend to appear at 2 years (MMSE of 12 or so). Nursing home placement may occur at 2-1/2 years (MMSE score around 5-7). I was astonished at how this all fit together.
What an insightful, helpful timeline to average symptom progression and what to expect with the disease. Knowledge helps us plan and prepare for what might be next and reinforce existing strengths. One more tidbit Dr. Praderio had for his listeners: He is experiencing patients living longer with the disease. Perhaps awareness—and preparedness-- is OUR strength.
Sources:
Feldman H, Grundman M. In: Gauthier S, ed. Clinical Diagnosis and Management of Alzheimer’s Disease. Rev ed. 2001:249-268.
Folstein M, Fostein S, & McHugh P. (1975) Mini mental state: a practical method for grading the cognitive state of patients for the clinician.
Journal of Psychiatric Research, 12: 189-198. (Cross Reference) (Medline).
Praderio N (2023, March 14). Behavioral Disturbances in Dementia, WellMed Charitable Foundation Caregiver Teleconnection,
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