When a person with dementia says “I want to go home,” there is a message behind the words. Learn more at www.WiserNowAlz.com.
5 Tips To Cope With Answering The Same Questions Over and Over – Dealing With Dementia Symptoms… One of the most annoying Alzheimer and dementia symptoms is your loved one asking repetitive questions. Here are 5 helpful ways we have found to keep our sanity as a family and make Mom feel less anxious!
Tonight on sixteen by nine nobody can,help me,the human toll of dementia Arni night,yeah yeah heart-wrenching decisions for,families yeah okay dad there is still a,stigma about it people still don’t want,to really talk about what it does to,your mom or your dad the desperate,search for care for those who can no,longer care for themselves we’re all,aging and we still don’t have any cure,for dementia seeking help in a place of,no return in a country far from home we,started some revolution a new way of,thinking about quality of life one,German newspaper likened it to shipping,out your trash I see myself as a pioneer,if we can provide something like family,care and I think it works,here’s Carolyn Jarvis if there were a,country called dementia its population,would be larger than Canada’s the,condition affects 44 million people and,strikes so often and so arbitrarily that,it’s being called an epidemic it,unspools the mind without any cure in,sight it’s why tonight we present a,special one-hour edition of sixteen by,nine taking you inside the world of,dementia on three continents and we,begin in the Netherlands in a village,inhabited entirely by dementia patients,a place that could revolutionize care,my Hut whoo you know fingers crossed she,never gets to the point where she ever,needs a nursing home the world realizes,that dementia is coming for everybody,and it’s it’s coming for us too,yes since the beginning I didn’t I even,did not believe it,that day when we drove her in there um,my sister and I were just dreading it,cuz we thought she’s gonna you know,she’s gonna recognize it and she’s gonna,say don’t put me in here what should it,be,what should life be for people living in,a nursing home on the outskirts of,Amsterdam interwoven in the fabric of,the medieval village of wisp there was a,place with no yesterday no tomorrow,there is only now,all the people living here have severe,dementia it still can enjoy normal life,social contacts being a person,welcome to dementia village population,152 there’s only one way in and one way,out they all died here this is really,the last year’s and life should be good,they feel we are here together I’m not,alone on this world and I can have a,good life five years ago Yvonne van imma,wrong in and her Dutch colleagues opened,the doors to dementia village and,started a revolution it’s like a finish,the neighborhood connect a coffee can,have a stroll so like in normal life all,the doors open automatically except the,exit onto a surrounding outside world,street signs in dementia village,reassure everyone that things are just,as they should be,we have a lot of visitors from all over,the world coming in and some people say,this is a make-believe world and I say,what’s make-believe over here we don’t,act as if this is a normal life it’s,normal life so year Lisa misses the,brand we ring because I mean it’s their,home good morning good morning good,morning we write CUDA bran shares a,common living space with five others who,also have dementia you see this is my my,place there are all my children that’s,yeah what one girl then second girl said,girl and then a boy he said mum here is,a place for you and so I’m here this is,nice place here for me it still works a,bit,the cost of care is almost $8,000 a,month but the Dutch government,subsidizes mrs. Gibran and all her,neighbors how much they pay is based on,income but never exceeds $3,600 I do,everything from,to be busy the most important thing is,that you’re living that you’re having a,normal life that you have fun in life,and that you need care,well that’s not nice but you shouldn’t,feel it all day there that I’m living,but being accepted to live here isn’t,easy,right now there’s a waiting list of 82,people this is me from poha,yeah like former pro bowler who hates us,you know wish I knew you’ve aged,Oh doggies y’all don’t let alone,haha I come from Sumatra weird clothes,yeah oh yeah she needs to make more to,her feature Sonam defeats Omaha – Hey,Dude – ah – Varrick okay that’s all,she’ll know not too hard you see it’s I,have to go also thank you thank you very,much yeah I’m on the road yeah the Han,dicho,five time zones away there is a place,with no locks at all no Gates or fences,in the Land of Smiles the demented are,deposited by their European families,free to live in the moment until they,take their last breath,the cost of caring for dementia patients,has skyrocketed in recent years now,pegged at 600 billion dollars globally,it’s also created an industry of medical,tourism but as you’ll see coming up in,Thailand this is meant as a last stop,honey you beyond the bustle of,Thailand’s northern city of Chiang Mai,there is a quiet street and eight houses,were the inhabitants occupy a private,and mysterious world they pretend like,they are normal normal people living in,a village,Arni night,the whole atmosphere I can really feel,that they they are happy in general,they’re happy 4 p.m. at the care center,called ban hemline chai in English it,means care from the heart they are an,intimate Club of Europeans only 12,people live here entrusted by their,families to spend their last days in the,care of a Swiss expat Martin Woodley a,psychologist who used to work for,Doctors Without Borders,I see myself as a pioneer in Thailand,the family is the most important Singh,and if you if we can provide something,like family cared and I think it works,honeycomb become the tomorrow,Gary is creating his own language the,cake given I do not understand and,somehow somehow it works,downs and yo,he was in an institution with many many,people together and then he came here,and we don’t have to do to give them,medicine to keep them calm to keep them,in a closed area he has a kind of,freedom,I have to take life as it is and as it,comes you get used to it Elizabet came,here because she couldn’t stay alone,anymore and for her and others it was,too much to take care either she goes to,the to the care center in in in,Switzerland or she she try to come to,our place how long am I already here you,stay here for a year and half when did I,come yes for year four years ago years,ago I came,uh-huh okay I’m already four years here,each person has one caregiver on their,side all the time we don’t have to keep,it in a keep out project in offense,yes it is secret and Aaron there from,Germany,his wife is suffering from Alzheimer,disease and also parking zone which is,quite a difficult combination ulrich,currently is facing a unique struggle of,his own his wife Susanna only 65 years,old is slipping away yeah we are sailing,we are a hiking reading listening music,going to concert yeah,since the beginning I didn’t I even did,not believe it,now for Suzanne its I think it’s very,difficult because she fears and she,doesn’t know exactly what’s going on and,but something is going on,Ulrich and Susanna came here from,Switzerland 16 weeks ago now they’re in,the last hours of a four-month trial run,before,Ulrich we’ll have to decide if he leaves,his wife behind lynching come on Amos,acted up life Caston new instructor beta,in the human psyche normally I can read,about half an hour the image paper were,the aapke shop in Berlin it’s calming,her down and sometimes she understands,the jokes and sometimes not that doesn’t,matter it’s the most important thing yes,I do something for her she understands,quite good so English and French – in,German – of course but she can’t speak,it more anymore I’m very hard,she knows that we are here in Thailand,yes I believe sometimes she knows it’s,where we are,sometimes she recognizes and children,yes,in Switzerland celebre is extremely,expensive and to give somebody in this,institution this means it costs you,about 12,000 Canadian dollars only two,or three take care of for 10 to 20,people I thought there must be something,else hmm,for around-the-clock one-on-one care in,Thailand auric will pay thirty eight,hundred dollars a month one-third of,what he would face back in Switzerland,in Cecil Susi is sleeping here and on,sees things take care,is also sleeping in the same room,because Suzy she is standing up three to,eight times a night if she’s caretaker,Kamsa morning she gets a kiss never we,would happen something in the in Europe,if you kiss a patient in in Europe also,you will lose your job if somebody is,dying,you know exactly now it’s finished but,this kind of illness it’s one step until,next step until next step finally,mentally you have no more sin the same,person in front of you as when you,started with this person,I’m afraid maybe,she realized maybe more sand I am,thinking and I will hurt her if I’m,telling her you have to stay here,in 24 hours Ulric were board a plane to,leave Thailand still unsure if he should,leave his wife of 41 years behind nobody,can help me,even some professionals they are talking,talking talking but it doesn’t help me,to take his his kind of decision that,you are alone and we will have that,heart-wrenching decision coming up in,the broadcast but first our story takes,a personal turn for us at Global as our,national news anchor Donna Friesen opens,up about her family and its battle with,dementia that’s next,I’ve never seen,xiety first she forgot what I did for a,living,and I’d you know be sitting on the set,and saying oh mom I’m just about to do,the news you know well can I call you,back she’d say oh you do the news dear,what’s the sauce,I missed that now because then at some,point she forgot how to dial a phone,good evening and thanks for joining us,it seems impossible but four days after,that Boeing triple7,when the wind blew in the winter in a,winter storm the house would actually,shake and I have little snowdrift you,know in my bedroom window because it,would blow through the cracks I look,back on it now and think wow that’s been,difficult for my mother to raise these,three children and you know we were very,poor you know we didn’t call it dementia,then what people would say is oh she’s,going senile and as a kid I didn’t I,didn’t know what’s that man I just,thought oh that’s what happens when you,get old,as I summertime and wedding it’s an,emotional wrench for Donna Friesen to,see her mom these days it means saying,goodbye to her Sam Lucas I was hoping,that at some point she would be able to,move here and live with us but then when,she was here I realized how well she was,masking her memory loss she would every,day forget where the bathroom was in the,house every day she would withdraw money,from the bank and then squirrel it away,I’d find it tucked in drawers in various,places and then she’d say someone’s,stolen my money and then one day she,went out for a walk and she got lost,Donna’s mom leaves 2000 kilometres away,in a place that’s been part of the,freezin family for two generations my,mother put her father there and he died,there and and she said at the time that,she would rather die than ever go in,there and I really took that to heart,you know I thought you know fingers,crossed she never gets to the point,where she ever needs a nursing home but,that day when we drove her in there,my sister and I were just dreading it,because we thought she’s gonna you know,she’s gonna recognize it and she’s gonna,say don’t put me in here,it’s been a tense week unsure if her,mother would survive an ammonia attack,and now wondering if she’ll recognize,the visitor from Vancouver,mom no it’s Donna oh hi it’s a beautiful,color on you too this blue yeah that’s,just your eyes,and mum and dad their mom in the blue,sweater and dad’s next to her we never,talked about whether she had Alzheimer’s,or dementia we never you know verbalized,it never said it we’re just gonna go for,a little ride down the hall okay yeah,okay daytime shift on the second floor,five nurses and a dozen or so health,care aides supervise 102 long-term care,residents half of them are in,wheelchairs and almost all suffered,dementia I brought some photos mom Oh,maybe we could have a look at them yeah,she was taking all the pictures out of,the photo albums first she was just,taking them out and stacking them up and,then she started ripping them up the,dementia or Alzheimer’s or I know was,making her just slowly rip apart her,past her life was all just,and you remember him dad yeah mm-hmm,he’s just down the hall now hmm yeah,Danah was about minus 50 with the wind,show one of those terrible days and he,was went out for what and my mother was,in the house but she didn’t know that,he’d gone out she hadn’t heard the door,he had been out in the snow for we don’t,know how long at that point he had,frostbite on his fingers his knees its,toes he had had a heart attack and he,had hypothermia and since then he has,just slowly descended into dementia,Henry Friesen would never return to the,farm from the hospital he was shipped to,the first available bed for long-term,care in Winnipeg he walked into a room,thought it was his tried to get into bed,and there was someone in there because,it wasn’t his room so the guide punched,his lights out knocked teeth out and,it’s all bruised and yeah pretty,horrible he never should have been,allowed to walk down the hallway by,himself he should have someone should,have been with him so that they’re,directing him because he can’t see now,now the place that they’re in is much,better well my dad was first in this,nursing home he was still walking but he,his dementia was fairly advanced so he,had to be in a locked Ward because the,fear of course is that he would wander,out confinement to a wheelchair brought,a kind of freedom for Henry he was,released from the lockdown ward for the,first time in five years,he’d be under the same roof as his wife,of 57 years sharing the same floor but,perhaps too late for either to realize,hi dad,my dad it’s Donna it’s Donna,nice to see you dad sometimes dad opens,his eyes but well today there is still a,stigma about it people still don’t want,to really talk about it and they don’t,want to talk about what it does to you,and what it does to your mom or your dad,you know my son starts to see changes in,me god forbid he can say hey mom I think,you know something might be happening,you should go to the doctor and the,doctor can say yes it seems like you’re,developing dementia here I can give you,this this is gonna help you you know,there’s something we can do,they’ll come back and see you a little,later okay okay,see in a little bit okay,of the world’s leading developed,countries Canada is the only one that,doesn’t have a national strategy for,dealing with dementia much of the burden,of care falls on family members like,Donna it’s why some are taking their,relatives elsewhere but will a husband,of 41 years be able to part with his,wife and leave her in Thailand for,better care that emotional decision next,I’ve been wanting my mother come here,quite a while she’s 92 and now she’s got,dementia,and she can’t get the level of care she,needs in the UK and rather than sitting,back and being frightened I’d rather do,something about it Peter Brown is a man,with big dreams he’s a British,entrepreneur who owns a four-star,tourist resort in Chiang Mai where he,lives with his Thai wife and two,children okay so every day my children,come to play dumping it in the bed and,something we have to tell them no you,can do that this is Grandma row in 33,hours Peter’s mother Joyce will join the,family becoming the first dementia,guests at the Chiang Mai Kerr resort,we’re in start-up mode so we’re a,four-star hotel resort change into a,care facility I hope we’ve got about 70,people here having the time of their,life getting the care they need,you,a solitary bulldozer prepares the ground,for an expansion to accommodate a new,kind of foreign tourists the kind who,never leaves dementia victims unable to,get the care they need in their own,countries so the builders are coming,first week in March to to do this knock,down the reality war make it Baker,revarnished all these floors we’ve got a,lot of a lot of land we’ve got a,thousand trees they’ve got a lake we’ve,got two swimming pools,we’ve got Gardens the money’s invested,the bank loans assign the tie system,produces thousands of trained nurses a,year and thousands of trained assistant,nurses a year,Thailand is already known for its,medical tourism the industry pegged it,almost four billion dollars a year well,I like about estimator unit there’s only,five people so they can create strong,relationships with the carers this,latest business model that has,entrepreneurs like Peter Brown buying in,is called the granny export business and,it’s touched a raw nerve back in Europe,one German newspaper likened it to,shipping out your trash,you’ve got an elderly parent that you,want to give the best possible care you,can and the other options are abroad,then why not look at them after a long,flight from England Peters mother Joyce,has arrived at her new home,but the man who opened the first,dementia resort for Westerners in,Thailand,Martin Woodley is concerned about what,will happen to care facilities become,too large and impersonal if we start,make large-scale institution here to me,it’s dangerous this kind of trend this,is not a paradise here it’s a very nice,environment but we have to we have to,watch very carefully who for whom is,really the good place here even the,intimacy of the family environment at,ban Camlann chai is no comfort to all,recurrently a husband who confronts his,loneliest hour the last night in a,foreign land before a long pilgrimage,home,last night is it’s a record of my wife,Susanna she stand up 14 time and his,caretaker helps her counts her let her,to bet again,in the beginning I thought I have a lot,of time she can no more speak she can,only walk she can only listen,I made in my life a lot of decision but,this is the hardest part,for Susanna I think it would see the,best to stay here,with a team of three good caretakers,it’s the best thing for her here,I feel a bit guilty even if have stayed,here already 16 weeks with her it’s it’s,very hard to believe,coming up the final chapter on our,journey into dementia and the painful,reality setting in stay with us,with her husband of 41 years on his way,back to Switzerland Susanna is alone in,Thailand for the first time confronted,with the reality of dementia later on,they cannot reflect anymore that what’s,going on now is much easier for them,Comfort may come when the memories fade,but all reminders of the past haven’t,disappeared for everyone here in the,same complex as Susanna Elizabeth is,comforted by the familiarity of her,granddaughter in Calgary thank you okay,fine I’m on all day that awareness of,her old life means this new one in,Thailand doesn’t feel quite right how,are you homesick Oh sick Oh,gates gates tchau tchau,wicked both of you have a good time,bye-bye thank you,at Oak View place in Winnipeg its,Donna’s turn to say goodbye,hi dad hi it’s Donna yeah yes yes I came,to visit you Mary looks like you had a,haircut recently yeah hi buddy,mm-hmm well I just came into town to,visit to see you and mum and I’m gonna,go back to Vancouver yeah okay dad maybe,there’s some little some little sliver,of him in there that once in a while you,know can see the light can see that,we’re there can see that mom is there,and gives him some comfort,the pain of this disease is often felt,more by family who still hold the,memories instead of those who’ve lost,them it’s not the mom you knew before,it’s not some mom you knew before and I,think that’s the hard part you know it’s,that’s yes that even sharing memories,now looking at pictures you can tell,she’s not yeah she doesn’t recognize you,anymore yeah anyway thank you for being,so patient,oh she did it dark pleasure okay mom,well I’m gonna go for now okay I’m gonna,come and visit again okay,I’ll see you again soon okay okay okay I,love you bye,yeah,really hope there will be a cure but the,scientists say that will take some well,maybe 30 years I do this to have to the,fresh air and the moving maybe we,started some revolution about a new way,of thinking about quality of life in 20,years or so maybe I’ll be living here,and I want quality of life too,no matter the city the country the,people around them the closing days for,someone with dementia all end the same,in an unrecognizable place surrounded by,strangers,where is my family in Switzerland and,Canada,it’s a minute of you children why am I,here so many nothing connects you okay,okay,now where am I now Kylie Thailand,hi,come and fetch love of its urge the,committee to Lou I’ll bring her back,hold up then I have to leave so every,week now Mao Zedong is warning but um,pay me to hospital English record – way,to go why do I not come and why do I,live in sweet habits good ok,since we began our program an hour ago,another 900 people have been diagnosed,with dementia they will join the ranks,of people lined up for long term care in,Canada the demand is expected to,increase tenfold in the next generation,costing almost 300 billion dollars a,year that’s more than the entire revenue,of the country today we’ll be right back,tonight marks the end of another,award-winning season for us here at,sixteen by nine if you happen to have,missed any of our episodes this year,they’re now all up on our website global,sixteen by nine com,here’s a quick glimpse of what you can,find there,I have no desire to ever go back and,live there I don’t I don’t think I could,there was two Saints one don’t let the,bedbugs bite and they beat us and,Hillier was a doughnut the boogeyman get,you any got us,we will not have women being blamed for,rape anymore,what do you think was going on there,they were abducting him,without question punch it,I’ve always been attracted to the,loudest fastest hardest thing,did you is that the machine gun loading,zero and that is our broadcast for,tonight,I’m Carolyn Jarvis from everyone here at,sixteen by nine thanks for watching and,have a great weekend,Oh
Good afternoon I think I think we’ll get,started I’m Dave Rubin I’m a,geriatrician and as a geriatrician I,care for only older people my oldest,patient is almost a hundred and one and,my youngest who I call my pediatric,patients is in her late 60’s oh just a,child and if you’re going to care for,older people as a as a geriatrician,you’re going to have a lot of patients,who have Alzheimer’s and other dementias,so here at UCLA we’re trying to do,something very different and I’ll,explain a little bit more about this,towards the end of the talk but we’re,trying to provide comprehensive,coordinated care so it’s it’s not just,about the patient it’s not just about,the disease it’s about the experience of,the entire family and in going through,this journey so as part of this we’re,having a lecture series and this is one,of a number that we’ll be repeating and,that will be ongoing with some,replacements and some new ones and this,is kind of the overview lecture so we’re,going to talk about what is dementia and,delighted that you could come today so,it’s going to what we’re going to cover,here is first of all what is dementia,and what is not dementia because there’s,a lot of things that that people think,might be dementia but really aren’t how,do you make the diagnosis and what are,the different causes so something that,patients sometimes even students,frequently asked me is you know is it,Alzheimer’s disease or is it dementia,and we’ll talk about those kind of,differences and what’s the umbrella and,what’s the underneath the umbrella what,are the natural history of and,consequences of dementia and then we’ll,talk about kind of the management of,dementia,we’ll have time for questions so I like,to call dementia the gray plague I,really yes yes because as we get gray as,we get gray we have much more likelihood,of getting dementia now everybody has,probably heard of some patients who earn,their 40s and early 50s and such that,have very early onset dementia and those,are very rare they do happen and they’re,very rare and they tend to beeps and,tend to be familial but they are they,are rare more commonly are the other,variety of dementia that are age,associated so here we have if you’re 65,to 75 years of age dementia is still an,uncommon disease it’s still quite an,uncommon disease as we get older our,likelihood of having dementia is is,increased so that by the time people are,in their 90’s virtually half so if you,have a couple that’s both in their 90’s,the odds are that one of them will,probably have dementia and the other,thing that tells us is that none of us,this is what I tell the students all the,time even the students who are college,students is that dementia and,Alzheimer’s disease in 2012 affects,everybody and if it’s not you or your,loved one it’s your parent your spouse,your cousin your father your grandparent,somebody you know is going to be,affected by this disease it’s that,common right now 5.4 million Americans,have Alzheimer’s disease which is one,kind of dementia and over the next ten,to fifteen years that’s expected to,increase to about 13 million so this is,something that’s really growing in the,numbers of people who have this disease,so what is dementia dementia and this is,the definition that doctors use for,diagnosing dementia this is right out of,the textbook and I’m going to explain it,to you,it’s an a a chronic acquired decline in,memory and at least one other cognitive,function so memory is a part one of the,hallmark features of dementia so,somebody’s a behaving behave bizarrely,or this or that and they don’t have,memory problems it probably isn’t,dementia the other things they have is,aphasia and that’s that’s difficulty,with communication we commonly see this,and people have less language or empty,speech it will be very fluent and,talking with you but if you were to,transcribe it there’s really not much,content or they can’t remember simple,names we’ll get to that in a few moments,apraxia that’s motor recognition a motor,execution and these are things that,normal tasks that used to be able to do,but they can no longer do agnosia not,recognizing things that they would,normally recognize as their work I was,just reading a book where somebody,didn’t a patient didn’t even recognize,her own children and sometimes you see,that and then executive function this is,synthesis the what we do in our daily,lives the tasks that we do in our daily,lives require synthesis of data from a,lot of different things what we’re,hearing what we’re seeing what we’re,reading what’s going on outside what the,environment is like how hot it is and,being able to integrate all of that,together to complete our tasks and this,has to be sufficient to interfere with,daily life so it has to get in the way,so you can have a lot of these things,very mildly if they don’t get in the way,it’s probably not dementia and sometimes,I will tell patients and we’ll talk,about this in just a couple minutes is,that you know is a good chance that you,may be developing dementia but you don’t,have dementia yet,so things that aren’t dementia one is,something we call delirium which is also,called an acute confusional state and,this happens very frequently especially,in the hospital not only in the hospital,that can happen when people get really,sick from other conditions usually in,the hospital and it is frequently caused,by medications or acute illnesses such,as a pneumonia or other kinds of,infection and it usually resolves and,many cases are probably preventable so,let me tell you a little bit more about,this let me give you a classic example,classic example is the patient gets sick,has a bladder infection or pneumonia and,you go into the hospital to visit your,loved one and they’re confused and,they’re swatting at things and they’re,picking at things they don’t know where,they are or after they’ve had surgery,that get very very confused that is what,we call delirium delirium is really,scary if you’ve ever seen especially in,someone that you love it’s a very scary,condition but the good news is that,delirium generally resolves now those,people who develop delirium there’s some,controversy that might be higher risk of,for developing dementia in the future,but the delirious case is is something,that tends to resolve depression,sometimes depression looks a lot like,dementia there’s a lot of sadness and,and people are kind of withdrawn and,they may have anxiety and they have poor,concentration and they are not thinking,very well they just don’t seem to be,themselves they may complain that they,can’t focus or they can that their,memory isn’t good and on the other hand,when you do formal testing of them that,in fact they do pretty well on the,testing and particularly if somebody’s,orientation is intact they know where,they are they know what date it is if,they those kinds of things are tip offs,now let me just say this is a little bit,gets a little complicated is that some,time,people who have Alzheimer’s disease will,present with symptoms that look a lot,like dementia like depression which you,do a lot like depression but depression,can look like dementia and not be,dementia a third one thing that looks,like dementia that is really very,important and this is something that,there’s a lot more literature about now,is something called mild cognitive,impairment okay,mild cognitive impairment patients will,frequently complain of memory and when,we do testing on them in fact they have,memory deficits they have memory,deficits but they’re not sufficient to,impair with their daily function so the,interesting thing about mild cognitive,impairment and this is kind of a pretty,new diagnosis we’ve just been dealing,with it for the past decade or so is,that it may or may not represent a,transition state for any person to,dementia so you go from having normal,cognitive function to mild cognitive,impairment to dementia three stages,there now the tricky thing about mild,cognitive impairment is that each year,somebody has mild cognitive impairment,about 10 to 15 percent of them will,progress on to dementia so after about,five years about half of progressed and,about half haven’t so what I’ll tell,patients and their family is that you,know there’s something going on here we,don’t we can’t say that it is dementia,yet but we’re going to have to monitor,your pretty closely and see what happens,can I tell them frankly that it’s about,a 50/50 chance that this can progress to,dementia it’s also important because at,present we don’t have any any,medications for mild cognitive,impairment so if you knew you had a,50-50 chance of to progressing you’d,like to do something to prevent that and,we just don’t have anything at this,point,for that yeah why don’t we hold the,questions till the end and then what we,show plenty of time so the last one that,is not dementia is normal aging so,normal aging is frequently when the,patient is more concerned than the,family generally when patients present,with dementia a lot of times the,patient’s families will tell me that,they’re very concerned if somebody can,describe the details of their,forgetfulness so for example if you say,if a patient comes to me and says you,know I’m really worried about my memory,and my wife told me to go to the grocery,store and she wanted me to buy three,things he wanted me to buy a tomato she,wanted me to buy bananas she wanted me,to buy toilet paper and she wanted me to,buy shaving cream and I only remembered,three of those that is not that’s normal,aging that’s normal aging and people who,have normal aging have intact recent,memory for important events so if if,there was an earthquake last week or,heat spell or something like that that,was really important evident every,buddy’s lips you remember those things,but word finding difficulties are part,of this tip of the tongue tip of the,tongue you know it’s on the tip of my,tongue I just can’t get it out that is,normal aging and one way to think about,this is that people with normal aging do,really well on multiple type of multiple,choice questions did you give them 3 or,4 things they’ll always get the answer,right no problem and I know I’m not that,I’m not that old I’m older than I look,but when I travel frequently and do and,get some jetlag and things like that I,have word finding difficulties and,normal aging once again with normal,aging function is preserved still able,to do the things,so how do we make the diagnosis the,first thing we do is we do some,screening tests and this is generally,done by the primary care physician,sometimes in even at senior centers and,these are very simple tests one of the,ones we use very commonly is a three,item recall so I’m going to ask you to,remember three items from a a ball a,flag and a tree can you repeat those,okay and I’m going to make sure that,you’ve got them so we will make sure,that you really register so repeat them,again for me okay so I’m going to ask,you about them in a few minutes,so don’t forget them the mini cog exam,it does the same thing a three item,recall but adds a clock as well and,drill being able to draw a clock,actually is a very interesting and a,very complicated task if you think what,it takes to draw a clock a lot of the,things that happen when people get,demented make it impossible for them to,do so so they have to have good visual,spatial stuff they have to be able to,construct remember that apraxia we were,talking about the motor skills and they,have to have executive function,functioning they have to be able to plan,where the numbers go so when you ask,people to draw a clock sometimes they,they get into trouble because they don’t,adequately plan where the numbers are go,so you’ll see 1 2 3 4 5 6 7 8 9 10 11 12,oh we got all this space here with,nothing or they Monday I was seeing a,patient who probably had some early,dementia and she drew a clock for me and,had 16 numbers she just kept going so,gently in that upper quadrant between,9:00 o’clock and 12 o’clock because of,poor planning poor executive function,they get into trouble two or three items,all right see so no dementia here so,that’s the three item recall and that is,also the mini cog examination another,one is called the mini-mental State,Examination and that’s a 30 item battery,that goes through some of these things,in greater detail in addition to the,memory and in addition to in that case,draw drawing Pentagon’s it asks for,serials taking segue serial 7s 100 minus,7s 93 minus 7 is 86 dot dot and it also,has a lot of orientation questions,what’s the name of this place what floor,are we on what city what County what,state and these are our screening tests,with these do for us as Docs is raise,the suspicion that something is wrong,here now these tests are actually pretty,accurate at saying that there’s,something wrong but they don’t make the,diagnosis to make the diagnosis of,dementia you have to go on to the next,step so the next step is a clinicians,examination and that can be from a,general internist or geriatrician or a,neurologist or psychiatrist who takes,does a physical examination a more,in-depth mental status examination,determines what the functional status,etc one of the things as a as a,clinician is pretty seasoned at this I,would say that about 90% of the time I,can make the diagnosis in my office,about 90% of time I can tell somebody,has dementia or not that other 10% may,10 to 20% there’s something called,neuropsychological testing which dr.,Linda Ercoli who just walked in leads to,the neuropsychological program here and,what the neuropsychological testing are,those kinds of tests we just talked,about but instead of being 10 to 15,minutes of testing they’re generally,several hours and really are very good,at detecting where the deficits are and,frequently I am these exceptionally,valuable as a clinician because they,tell people what they can do and what,they can’t do because of their deficits,so they tend to be very valuable in,establishing the diagnosis and,determining where the deficits are,we also do some blood tests and some,imaging tests to exclude medical,conditions that might be contributing so,things like low thyroid sometimes,vitamin deficiencies can be contributors,to cognitive impairment they’re not,causes of dementia per se but they can,be things that look like dementia and,finally imaging so imaging we’re talking,about certain kinds of x-ray tests and,it turns out that if I was giving this,talk decade ago would be very simple we,didn’t have much in the way of imaging,but now we have CT scans and we have MRI,scans and we have PET scans and we have,SPECT scans we have all these different,kinds of tests and they all do a little,bit differently and depending upon kind,of what the suspicion is for the type of,dementia those tests are generally done,so they’re done for two reasons one,reason is to exclude things that can,cause picture that looks like dementia,so for example sometimes you’ll have and,it’s rare a tumor that can cause it can,cause symptoms that look like depression,or something called normal pressure,hydrocephalus which is a rare condition,but can cause symptoms that look like,dementia the other tests some of the,more recent tests like the PET scanner,can actually tell you where where the,problem is and frequently people feel,pretty comfortable making the diagnosis,of Alzheimer’s disease depending upon,where these PET scans light up now with,these these imaging studies the advanced,imaging studies such as the PET scanners,there are certain criteria under which,Medicare will cover them and certain,ones that they won’t so you have to talk,with your doctor about that but the,other ones the MRI tests and the other,tests are mostly covered by Medicare,so what are the causes of dementia so,what I tell patients is the the big,umbrella is dementia so and that’s that,definition we talked about earlier that,acquired progressive deficit of memory,and other cognitive functions the most,common is Alzheimer’s disease and it’s,estimated that sixty to eighty percent,is Alzheimer’s disease and the second,most common is vascular dementia and by,vascular dementia it’s really a very,complicated number of conditions so,vascular dementia can be one or more,large strokes that people have or,sometimes they’re very many many many,very small strokes we all think about,strokes as living in weakness or slurred,speech of those kinds of things but in,fact the very small strokes that you,have may not show any of those motor,problems but may just affect memory,there are a feature called dementia with,condition called dementia with Lewy,bodies and that is closely related and,may or may not be the same disorder or,ends of a spectrum of Parkinson’s,disease with dementia and this these are,each of these dimensions have a little,bit of a different flavor to them with,dementia with Lewy bodies people tend to,have fluctuating mental status they tend,to have very prominent visual,associations with it so for example a,lot of my patients who have this disease,will complain of seeing red men or blue,men and they’re not necessarily scary,they would they will have these kind of,visual types of disturbances these also,tend to be very sensitive to certain,medications that do not agree with these,misdiagnosis frontal temporal dementia,is another kind of dementia that,presents a little differently it doesn’t,have quite so much memory problem,although there are have to be memory,problems but the big issue here tends to,be changes in personality people tend to,be very aggressive or in contrast,sometimes people who are develop this,disease become much more passive I had a,patient a number of years ago was a very,very sad case of a woman who had frontal,temporal dementia and she was she just,didn’t she was very withdrawn didn’t,speak a lot and and I talked to her,daughter and I said well you know this,is just a terrible disease but one of,the things that that if there’s any,consolation that your mom is very sweet,she’s not aggressive and it’s at that,and the woman burst out in tears you,just started crying she said my mother,was never sweet she said yeah so this,change in personality toxic metabolic,disorders those are generally not,dimensions per se although they,occasionally can be and they tend to be,some of the rarer dementia and other,movement disorders those are generally,with Parkinson’s disease now if you add,these up guess what they’re more than,100 percent and the reason why they’re,more than 100 percent is that sometimes,these different-colored causes of,dementia more than one can occur in the,same person and in particular vascular,dementia and Alzheimer’s disease,frequently occur in the same patient so,we have a name for this we call it mixed,dementia,so let’s talk about Alzheimer’s disease,because it’s the most common and things,that increase the risk of developing,Alzheimer’s diseases we said earlier the,older you are the more likely your,chances are of developing this disease,family history so family history this is,something that comes up all the time in,my practice is that a patient develops,Alzheimer’s disease and has a terrible,course with it and the family members,will say cheesed the children,particularly it’s just what’s going to,happen to me and in fact the family,history of Alzheimer’s disease is not,all that strong unless it’s early onset,Alzheimer’s disease if somebody develops,Alzheimer’s disease in their 40s or,early 50s you know then you tend to see,that really strong family history but,the fact there it is a familial but it’s,not that strong in in older people there,is a gene called apoe4,that’s not commercially available it’s,done mostly in research that gives you,it puts people at a higher risk people,who develop depression in late life are,at higher risk and this is really very,interesting because that depression that,they develop in late life may in fact be,early Alzheimer’s disease let me give,you an example the person is a neighbor,of mine who I saw was referred to me,because of a of a positive PET scan she,was in a research study she had a,positive PET scan that it showed that,she had Alzheimer’s disease and I,examined her and this was very very very,early Alzheimer’s disease and for my,examination and I was putting on my best,examination she looked like she had,depression and I couldn’t detect any,cognitive impairment so that those,patients may actually have early,Alzheimer’s disease some factors that,reduce risk if you have this gene,profile of a po2 is reduces your risk,Mediterranean diet and higher physical,activity,lead to reduced risk there haven’t been,strong studies saying that if you,actually intervene and put people on,Mediterranean diets or get them to,exercise it would prevent the,development but in large studies looking,at populations these are less likely so,this is a very very very simple slide to,try to explain least one of the leading,hypothesis of losing the theories about,why people develop Alzheimer’s disease,let me just say and I was reading about,this in boning up for this talk today is,that there are a lot of different,theories about why people develop,Alzheimer’s disease and there’s still a,fair amount of uncertainty in fact,there’s a lot of uncertainty but one of,the theories is that this is a protein,here which is called the a P P or they,call amyloid precursor protein that all,of us have and this an led precursor,protein for some reason or another gets,snipped and get snipped and a piece get,cut out and get snipped right there and,then begins to accumulate and that,accumulates as what they call amyloid,plaques and those amyloid plaques build,up and can cause a couple of things that,can call it to cell death or it can get,into it interfere with the process of,neurotransmission so the way our brains,work all of our brains work is chemicals,and one of the chemicals that is really,very important is something called,acetylcholine it’s a neurotransmitter,it’s it’s like the electricity that goes,into the brain it’s one of many and that,is one of the ways in which we treat,dementia is with drugs that try to,increase acetylcholine,so the consequences of these,beta-amyloid accumulation are something,called neurofibrillary tangles and here,instead of having nice clean cells that,one cell touches the other cell what you,get is kind of the scarring kind of,picture with tangles in it they look,like almost like a spiderweb and the,cells stop talking to each other and,with the loss of neurotransmitter as I,mentioned and sometimes in this disease,or one of the other ways we’re treating,it is that the wrong transmitter which,is called glutamate causes further,injury to cells now let me just say that,these are only a couple of ways in which,cells are damaged and and some of the,ways in which the pathology of,Alzheimer’s disease and the reason why I,mention these two in particular is,because the current treatments are for,the most part aimed at these correcting,these deficits but I’ll also say that,there are other theories there are other,theories and there are some problems,with these theories so from a clinical,perspective the kinds of things that we,see with patients with Alzheimer’s,disease is loss of memory that is the,hallmark of this disease loss of,language and one of the things I,frequently will do is something called,an animal naming test animal naming test,goes like this I said I’m going to send,you to the zoo or a farm or jungle and I,just want you to start naming animals,let’s start naming them so they’ll say,you know a dog a cow Raph an elephant,pig and you know normally if somebody,going to identify about 18 animals in a,minute that’s pretty pretty much normal,once you get below 10 it’s pretty,clearly abnormal and what you tend to,see with patients with Alzheimer’s,disease is they tend to recycle these,animals so they’ll say a dog,cow,fish an elephant cow a dog because they,don’t have that language they’ve lost,the language visuospatial we’ve already,done this when we talked about the clock,or the intersecting Pentagon’s one thing,to mention and this is where,neuropsychological testing really comes,into play is that many of our patients,at least many of my patients are people,who are very highly educated a number of,years ago I had a patient who was a,college president,so this person’s IQ was exceptionally,high and did very well in some of these,basic questions so would you have to,dial it up and there’s with the drawing,stuff you can get very very complicated,there’s some very difficult tasks higher,level the executive functioning types of,tasks remember we talked about the,planning of the clock but another one is,out simply I asked people I’m going to,send you to the grocery store I’m going,to ask you to make change for me once,you buy some bread for me bread 75 cents,a loaf I want you to buy two loaves from,it’s I’m going to give you two dollars,how much change you get back okay I’m a,simple grocery store would you have to,manipulate information to be able to do,that and finally we talked about apathy,apathy is incredibly important in,Alzheimer’s disease it’s not Universal,but many times you’ll you’ll see this,kind of apathy so last year the,Alzheimer’s Association with the federal,government we defined how we think about,Alzheimer’s disease and put it into,three categories preclinical so this is,it’s felt and there’s some pretty,interesting data particularly from a,study that was done I think in Iceland,where they took a look at people who had,very early onset dementia that was kind,of familial people and that they could,find some changes in the biochemistry,and the chemicals there and sometimes in,the structure you know decades,beforehand decades,for him so that there is a period of,time when people are functioning very,very well they don’t even have mild,cognitive impairment and the feeling is,that some of the underlying changes in,the chemicals of the brain and in the,structure of the brain have already been,occurring the second level is MCI we,talked about mild cognitive impairment,and these are people who have,demonstrable physical findings memory,findings but has not impaired yet with,function and the third level is people,who have full-blown Alzheimer’s disease,now the trend now is towards identifying,biomarkers and biomarkers can help in,the preclinical stages to see if we can,get earlier treatment to prevent this,disease and this is mostly in clinical,studies and trials it’s not ready for,clinical usage and an MCI these,biomarkers may say that,remember we said 5050 might be able to,help identify which 50% are going to,progress to really having Alzheimer’s,disease in which 50% are not going to,progress and then for those people who,have what looks like Alzheimer’s disease,that the biomarkers may be helpful in,saying jeez no this is in Alzheimer’s,disease it’s something else so that’s,that’s where the field is going so what,happens here with Alzheimer’s disease,the first is the disease progress the,Dedes universally progress and it,progresses on the mini-mental State,Examination on the average of about,three to four points per year that’s a,30 item scale so over about a 10 year,period this is pretty common over about,a ten year period you go from being,where you were to really having,essentially no cognitive function,essentially no concrete function now let,me just say this is incredibly variable,I’ve had patients who have declined very,rapidly over a year to two years with,Alzheimer’s disease and I’ve had,patients 1516 years down the road and,and their disease has not progressed but,thinking about it is kind of an 8 to 10,year horizon so this is a long-haul,disease this is the long course disease,and we’re going to talk about that in a,few moments now that’s that’s one of the,devastating components so the other are,the the other symptoms that are,associated with this,and by psychotic symptoms sometimes,these can be hallucinations or or marked,disorientation or seeing things that,experience things that other people,don’t it’s in the minority but,occasionally we do see that depressive,symptoms are quite common and agitation,or aggression this is something that’s,almost almost universal at some time,where people will get agitated they’ll,also get very suspicious some of the,kinds of things that you tend to hear,about fact the two most common are that,people are stealing from them people,accuse people of stealing especially,caregivers and sometimes the caregivers,are stealing but most of the time it’s,it’s the disease and the other is,infidelity so you know you have this,this person who is dementia and the,caregivers it’s very frail older person,and she says there she is she’s running,all around on me and that’s that’s just,a very common non cognitive behavioral,symptom,survival’s about 9 to 12 years and,Alzheimer’s disease of the other,diseases of different causes tends to,have the best survival because the other,ones are generally associated with other,problems for example vascular dementia,those people have bad blood vessels not,only in the brain but in the heart and,you know vessels of the legs and,people who have Lewy body dementia or,dementia with Parkinson’s disease,generally the Parkinson’s disease is the,thing that really gets them into bigger,trouble so management falls into two,categories first is managing the disease,and the second is managing the patient,and both are important both are,important managing the disease will talk,about the cholinesterase inhibitors and,memantine those are the only two classes,of drugs that are available right now,other than clinical trials and we’ll,talk a lot about managing the patient,and that’s managing the other diseases,they have caregiver support which is,probably the most important thing I’m,going to talk about some behavioral,therapies and pharmacological management,of complications we have to mention that,at least briefly although it’s not our,top choice and then something that’s,exceptionally important is advanced,planning managing the disease colon,ester ACE inhibitors there are three out,on the market now aricept razza Dean and,exelon are the the trade names and the,generic names are there in regular font,they not only benefit Alzheimer’s,disease they have some effect in Lewy,body dementia whether they’re effective,in vascular dementia is still pretty,controversial but many of the patients,with vascular dementia have mixed,dementia and they seem to be helpful in,dementia Parkinson’s disease but as I,alluded to earlier and this is really,important is that these drugs do not,prevent the progression of mild,cognitive impairment to to Alzheimer’s,disease that’s been studied a number of,times now and they just don’t work at,that level now these drugs are not home,run drugs they just aren’t home run,drugs and way I like to tell my patients,and their families is that if this is,the slope of the decline of patients,with Alzheimer’s disease what these,drugs may do is to slow the slope,instead of being quite so rapid it’s it,takes longer about 50% of patients it,tends to work in terms of slowing,progression and about 10 to 25% and I’ve,seen this a few times and sometimes it’s,really valuable patients actually,improve on these drugs those people are,quite lucky and then conversely about,another quarter or so there’s no,response to them whatsoever they just,don’t help at all there’s some evidence,that suggests that some of the,behavioral symptoms may improve that’s,not quite as consistent to the other,data and some people decline rapidly,when the when the drug is discontinued,and that’s sometimes how we find out,that the drug that’s been working is,that it doesn’t seem to be working it,doesn’t seem to be working as we give it,a trial off the drug and you find the,patient declines pretty dramatically,start the drug back memantine in,contrast to the cholinesterase,inhibitors is really reserved only for,people who have pretty severe dementia,it’s not really for early dementia and,it works differently the acetylcholine,the cholinesterase drugs cause more,acetylcholine that’s that,neurotransmitter that got depleted what,memantine does it’s very interesting it,protects brain cells from damage from,glutamate as that other transmitter that,that can be toxic what this does is,slows the rate of cognitive and,functional decline and frequently it,will improve behavioral symptoms that,tends to be a little bit more of its,niche but not entirely 100% the FDA,approves this only for moderate to,severe Alzheimer’s disease whereas the,cholinesterase inhibitors improve,approved for mild moderate and severe,now what happens if you add the two and,here the data are pretty controversial,some studies have shown better outcomes,than either one alone but some more,recent studies have shown that the,addition of the memantine to the,cholinesterase inhibitor may not have,that much benefit as a clinician I’m,willing to try both and see if it helps,in late stage dementia but at some point,for all of these drugs that reaches the,point when people are very very late in,their disease we don’t think it’s,benefiting them that much it’s time to,do a trial off the medicine so these are,things that don’t work these are things,that have been thought of and got some,headlines in the New York Times and such,and when you trust them further they,don’t do so well so none of the vitamins,b6 b12 vitamin E or folate none of,they’ve all been tried and none of them,have worked very well ginkgo there was a,lot of press about this about a decade,ago and when they first study showed a,lot of benefit and then tried to repeat,that replicated findings couldn’t do it,none of the hormones testosterone,estrogen they originally thought was,going to help cognition and now they,think it may actually make it worse the,statins these are the drugs like lipitor,that we take frequently for high,cholesterol and heart disease prevention,they thought that they might work for,for Alzheimer’s disease prevention not,so aspirin and other drugs like aspirin,ibuprofen motrin advil those kinds of,things do not prevent Alzheimer’s,disease or treat it and finally vaccines,and there’s been some interesting,studies with vaccines initially that,were quite promising in mice and then,when they did them in in humans a couple,of things happen one these were very,early studies so not a whole lot of,people but they found that some of the,the changes the biochemical changes that,you would see in some of the debris,that’s collected in the brain of,Alzheimer’s disease,less so it actually did would have,supposed to do these vaccines,however the cognition didn’t change so,it fixed the the in the pathway but it,didn’t fix the memory problem and then,there were some complications so it,never made it to primetime it never was,released there’s still work going on,with vaccines and maybe something we’ll,see in the next decade or so so the rest,of the stuff is managing the patient and,this is a lifelong disease this is not,like having a disease that’s going to,last week month year generally this is a,long-haul disease and I like to tell,patients and families you play the ball,where it lies,okay and what I mean by this is if it’s,early in the disease I like to get the,patient involved making helping making,decisions if it’s late in the disease,then we have to work and and and decide,what the patient others have to help,decide what the patient would want we,always aim for the highest level of,Independence that works for everyone and,my strong belief is that Alzheimer’s is,not a disease of the patient Alzheimer’s,and dementia Alzheimer’s disease and,dementia are diseases of the family,because everybody is in this and it’s,got to work for everyone,it’s got to work for everyone because if,the caregivers get burned out it doesn’t,really help the patients it just doesn’t,managing hot-button items such as,driving this is something that as a,physician I’m required to report,patients who have dementia and are,driving I’ve had some patients at my,throat actually with our hands around my,neck,threatening me because I was going to,report them and I just I just say you,know this is my job as a doctor I have,to do this managing other diseases and,then managing the symptoms we’ll talk,about that in just a moment,caregivers caregivers are the most,important resource that a demented,patient has,much more important than certainly than,the doctors over 50% of caregivers,develop depression this is a tough,disease and that’s why I say it’s not,only the patient it’s the patient and,the families the more knowledgeable and,more empowered the caregiver is the,better care the patient will receive and,there are specific caregiver training,programs offered by the Alzheimer’s,Association and other community partners,that we can help steer people to in fact,we’re going to be offering one here at,UCLA getting next month,yeah and the carrier there are many,caregiver resources that are available,through the Alzheimer’s Association,other community resources we here at,UCLA have a beyond Alzheimer’s support,groups that meet here in Westwood on,Monday evenings and in Santa Monica on,Thursday evenings and these are free of,charge and Linda leads co-leads one of,them and Patti Davis President Reagan’s,daughter co-leads them at both both,locations they are free of charge,managing behavioral and psychological,complications this is the agitation the,aggression the paranoia those kinds of,things and our preference is to do that,with the behavioral approaches,identifying what the behavior is and how,to respond to it so people keep asking,the same questions over and over again,you get in here you’re getting annoyed,because they don’t listen they don’t,seem to listen how do you deal with that,if people are wandering how you deal,with that those they’re getting,aggressive if you’re trying to bathe the,person and they start scratching at you,and stuff like how to deal that the,answer is generally not medicine,occasionally we will need medicines,sometimes depression antidepressants it,turns out that the antidepressants don’t,work as well in patients with dementia,as they do in patients without dementia,they may help with some symptoms such as,problems with sleep or problems with,appetite,but they don’t work quite as well and,then there’s a whole class of drugs,called antipsychotics and respiratory,typing olanzapine are the generic names,but you may have heard them as seroquel,or psych Rexha or respiratory that are,out there and the bottom line is they’re,not very effective in big studies when,you compare people they tend not to be,very effective and they also have the,potential for side effects they can,cause increased risk of dying from,either stroke or heart attack about,three or four percent higher risk they,can cause issues of some other cardiac,conduction problems but that said that,said for some patients there is some,benefit and I’ll have to just tell you,that I’ve had some patients that a small,dose of one of these medicines means,that the patient is in firing the,caregivers it means that the person can,still stay at home so we use these,judiciously we try not to use them as,much as possible but in some cases,they’re helpful advanced planning so if,the dementia is early or if it’s mild,cognitive impairment we always try to,get the patient involved in the,decision-making the first thing is very,important is to establish a surrogate so,if the person’s disease progresses and,they’re no longer able to make decisions,for themselves who do they want to make,those decisions to identify that person,because as we all know sometimes you’ve,got a big family not everybody in the,family sees things the same way so the,person needs to identify who the right,person to speak to beginning financial,planning early and anticipating long,term care needs,once again you’re talking about a,disease that on average is you know,eight to ten years and if you’re going,to need caregivers how long is how long,are you going to have those kind of,resources or do you have those kind of,resources one of my patients who has,vascular dementia with a lot of,complications she’s just been really,difficult to manage her she has 24-hour,caregivers and she’s going to a day care,program and all of this and her son says,I’ve got I got four years this that’s,how much I can afford four years of this,kind of care and then we’re gonna have,to think about something different so,that kind of planning ahead is really,important a couple of milestones these,are milestones I tell my patients,families is these are these are things,when bridges have been crossed that are,telling you that things are closer to,the end the first is when they stop,walking when somebody stops walking who,has Alzheimer’s disease or another,dementia you realize it’s probably,getting pretty close to the end and when,they stop eating then it tends to be,very close to the end we and our,practice do not offer g-tubes you know,feeding tubes for people with dementia,most of the data and it’s not perfect,studies but the data seems to suggest,that that doesn’t improve the quality of,life and doesn’t prolong the life for,very long either so we just don’t don’t,offer them there are some hope on the,horizon there are a variety of different,treatments and prevention strategies in,the pipeline the optimal care is,probably going to be multimodal some,medications a lot of behavioral stuff,and it’s likely to be there’s some false,starts and some unfulfilled promises,there have been a number of very,promising drugs that have been tested,and they’ve gotten to these clinical,trials and thus far they’ve pretty much,all bombed out every summer around July,or the National Alzheimer’s,international Alzheimer’s disease,meetings and it always hits the news,about the drugs that just aren’t going,to make it so I just want to spend the,last couple of minutes and I know only,have a few minutes talking about a new,program we’ve done at UCLA and this is,the UCLA Alzheimer’s and dementia care,program and it works with primary care,physicians to care for dementia of,patients and their families,it starts out with an in-person,90-minute to essentially assessment of,what the needs for that individual,patient is and what the,resources because everyone patients with,Alzheimer’s disease are like snowflakes,everyone is different everyone is,different and then developing and,implementing individualized dementia,care plans and monitoring response in,progress so it’s a custom-made for that,person and that family in that situation,to try to get the best outcomes and that,is actually provided to the primary care,physician who has input into it and,approves the plan,it also gives 24-hour 7-day a week 365,days a year access for problems and,assistance and advice but it doesn’t,take over the care of the patient you,stay with your primary care doctor what,patients get from this program and,families counseling and education,linkage to UCLA programs such as support,groups and education linkage to,community based services we have five,partners in the community Alzheimer’s,Association oh pica wise and healthy,aging Lisa’s place and Jewish Family,Services or our community-based partners,and all the patients have ongoing,follow-up and intervals depending upon,the care plan most commonly our dementia,care manager who’s a nurse practitioner,will get in touch with people a week or,two weeks afterwards say did you have,any problems implementing this plan how,can we help you how are things going to,develop that relationship to be a part,of this program first people have to,have dementia diagnosis they have to be,a UCLA patient this is something that’s,offered by UCLA for and not in a nursing,home we’ve one of the goals of this,program is to prevent people from going,into a nursing home some components such,as the support groups it’s such like,that are open to anyone but for this,program the idea is it can be an,assisted living or at home but that’s,where we want to try to prevent them,from having me institutionalized they,need to be referred by a physician and,this is a referral number three,zero three one nine three two two and,our dementia care managers a nurse,practitioner named Leslie Everson that’s,her phone number as well as well as her,email address we have high hopes for,this program this program is being,offered at no additional cost other than,what medicare covers we’ve gotten some,support from the federal government and,including a large grant we’ve had a,number of our patients who have been,philanthropic people who have had this,family members with these diseases and,say they want to give back and most of,the program or a good bit of the program,is actually supported by donations so we,are offering all these services at no,charge to patients so in conclusion the,dementia is an epidemic particularly,among the oldest old many diseases have,symptoms of dementia but are not,dementia so we have to know that you’re,dealing with this diagnosis,history-taking and the mental status,examinations are still critical at,elements and diagnostic testing is,important but generally doesn’t give us,many surprises physicians can do a lot,more for dimension than we could decade,ago but the drugs to to prevent the,disease progressing and treating,complications are really somewhat,limited behavioral management and,caregiver support are essential and,those are the key components of managing,these disorders and the the rescue the,the Hail Mary the things that are going,to cure this disease are still a long,way off so we have to play the ball,where we lie where it lies right in 2000,well so I’m going to stop here and I’d,love to answer questions I know that,some came in people running down notes,and so it’s like that but now’s a good,time to answer questions and I don’t,want this talk to be pessimistic it’s,not supposed to be what it is is kind of,a getting everybody on the same page,talk with the idea is this is what we’ve,got to do this is the task Atlanta hand,and we need to approach it,so you had a question earlier on yeah,your person have been seen by a,geriatrician neuro psychiatrist all the,ones that you mentioned a to get an,accurate diagnosis in going yeah so at,this point this is one of the things,about the UCLA Alzheimer’s and dementia,care program is that many of the,components in fact reps most of the,components that we’re the primary care,physician may have some lack of,expertise this is kind of a wrap around,to make sure those are so I don’t I’m,not sure that you need to see a,geriatrician or a geriatric psychiatrist,if you have if you’re involved in that,program yeah yeah oh she can’t access,UCLA yeah so in those cases somebody’s,outside of UCLA typically I would if a,geriatrician is available geriatricians,this is kind of our bread and butter you,know we just do a lot of this kind of,stuff I would say 30 to 40 percent of my,patients have dementia something I see,every day most primary care physicians,you know it’s ten percent of their,elderly practice or less it’s very very,uncommon sometimes neurologists are very,good at managing this and sometimes,psychiatrists are very good at managing,it and the other thing is there’s a lot,of good community resources Alzheimer’s,Association has chapters versus,virtually everywhere and that’s also a,very good place to start because much of,this is really about about caregiving,and behavioral treatments,yeah what is your feeling about,they really don’t Stu no yeah yeah and,that sometimes you know they’re there no,fixed rules there are no fixed rules I,have patients who don’t know their,diagnosis and and even if they did they,probably wouldn’t retain it for very,long but if it’s going to be something,that’s going to to irritate people,aggravate them exacerbate these symptoms,it’s probably not it’s not really worth,it yeah yeah yeah and sometimes it,really is a case-by-case basis he knows,that there’s something going on uh and,that you know that’s something we can,live with yeah there’s there’s no need,to you know put a Scarlet Letter on,their chest saying Alzheimer’s disease,yeah yeah yeah so that once again that,tends to be on a case-by-case basis and,generally most of the primary care,physicians are pretty good about knowing,when to bring in the consultants and you,know I get my hand slapped by probably,some of my partners and colleagues but,I’m a firm believer in in patient,empowerment and by patient empowerment I,mean not only patients but also of their,family members and proxies is if you,think something’s not not right you know,it bring it up bring up your head up to,you you know maybe maybe this person lrc,a neurologist maybe this person ought to,see a gyrators and maybe this person,ought to see a psychiatrist and you know,sometimes as a physician I say you know,that’s a–that’s a pretty good idea I,didn’t think of that,or I might say you know I just don’t,think they’re going to add that much but,it’s it’s it’s incumbent upon you if,you’re concerned to bring it up,an example persons doing fine and then,someone passes away yeah and we see this,a lot I mean I’ve seen it actually even,when someone loses the pet yeah it’s,like it’s like a person and you know,many times what we’ll do in those kind,of cases is will based on the change and,what that person was like now we might,say we might treat empirically now that,might get them and started on either,kind of a counseling session even though,they’re not asking for it but you’ve,seen these kinds of changes yeah other,yeah yeah someone sent me a clip yeah,regarding coconut oil and Alzheimer’s,yeah I know about this I know about this,and we have seen many many things like,this insulin there’s did you guys,reading about the insulin I mean there’s,you know they’re almost anything and,there’s a reason for this,there’s a reason for this is because we,are seeking we saying as a society or,seeking a panacea we want to pull,something out of the air that says,cheese we were missing it all along and,it was coconut oil that’s going to,prevent this or going to fix it and the,problem with those kinds of things is,they get tested sometimes a fair amount,of money gets put into them and they,tend not to work it’s it tends to be,it’s a more complicated safety test my,understanding was there have not been,any tests that they’re studying ketones,esters for Parkinson’s yeah there were,no NIH studies regarding ketones esters,for Alzheimer’s patients no there aren’t,alright and yeah there will be if it,generally makes the the headlines in the,newspaper somebody gets a study to study,it and the tradition the history has,been that these tend to make a lot of,newsprint get tested and then go by the,wayside ginkgo biloba was the classic,example,now they have Maxo know which is yeah,Exxon is another one yeah farm it’s,answer to the over-the-counter version,exactly curcumin those are in test right,now so you all of these things are kind,of the great white hope but you know,we’re dealing with the disease right now,with our patients and our family members,and those things that they happen you,know eight or ten years down the line it,takes a good five to six years to even,find out whether these things work or,not so yeah maybe you know there’s,always room for hope this is Pandora’s,box,there’s always room for hope but in,while we’re waiting for the hope do we,need it we need to do our homework we,need to get involved and work on this,disease and it’s it’s the people in this,room it’s the caregivers who really need,to get energized with this yeah,[Music],yeah yeah,yeah yeah yeah yeah so there’s two,questions one is about you know did,something earlier happen that caused,this and and the answer is yeah,sometimes that happens sometimes and and,there’s this really if it’s something,that happened that it was a heart-lung,machine if it was somebody who’s a boxer,earlier in their life or you know there,are things that happen and you know that,those are the that’s our cross to bear,and there’s no we can’t go back in time,and change any of that yeah yeah yes,yeah,yeah,yeah yeah and it it really is on a,case-by-case basis and sometimes what,the best approach is similar to how we,treat mild cognitive impairment and say,you know at this point we can’t say too,much but the most important thing is not,to not to forget about this is to come,back in a year and see what’s happened,and frequently when I refer to dr.,Kelly’s group and get neuropsychological,testing they say geez we can’t establish,the diagnosis of dementia at this point,but let’s have the patient retested in,another year and the important thing is,not to forget about it is is them as to,monitor it the other thing we don’t want,to do is to call things too early,because you know otherwise you’re just,giving people medicines that aren’t,going to help them yeah generally the,killing these drugs are tolerated pretty,well there they’re not they’re not real,bad drugs but they’re but people do get,complications of them side effects some,of the ones that are mostly gia many of,them are GI the constipation or diarrhea,sometimes they get nightmares and bad,dreams and sometimes it can also rarely,cause slowing of the heart frequently,what will happen is when we start people,we also have people on a low dose of,them and after about a month we increase,it and when we go up to the higher dose,they can’t tolerate the higher dose and,then we can go back to a lower dose and,they’re able to tolerate it and,occasionally we can switch from one of,these anti-cult cholinesterase,inhibitors to a different one and have a,less of a side effect profile yeah,if they came along and said to take one,of those drugs,my concern is it creating more trouble,yeah well it’s a really good question,it’s a really good question and in,England England they’ve been slower to,adopt these medicines they’re a little,more suspicious this is Big Pharma just,trying to make money and in fact there,was just a recent study the past couple,of months that I thought was very very,interesting where they stopped these,drugs and they saw what happened these,people and the people who were on the,cholinesterase and evers who stopped the,drugs they declined though they actually,really did decline so I think I think,the drugs by and large if you take that,caveat that about half it slows the,disease maybe 10 or 25 percent increases,cognition the other quarter it doesn’t,really do anything but they probably are,worth the benefit you know worth and,what we do and I do this in my practice,all the time is that that people aren’t,tolerating the drugs we stopped them,yeah if you don’t want the disease you,want the Cure to be worse than the,disease,[Music],yeah so so so yeah so the answer is I,generally follow the FDA’s guidelines,and I do not treat unless somebody has a,diagnosis of dementia so if it’s mild,cognitive impairment I don’t treat there,are some physicians who do I don’t think,they have much ground to stand on and if,it’s mild or moderate I don’t use,memantine I don’t use an amend I just,use a cholinesterase inhibitors and if,they don’t tolerate them I stop them,yeah and some don’t some just don’t,spell rate them how long does it take,for this,good question that’s really a good,question because what happens is that in,most cases it just slows that slope so,they are declining still but the rate of,decline is is less most people will say,three to six months and generally you,expect on some of these tests a certain,amount of natural history decline and if,the decline is less than that I tend to,keep them on it yeah but it’s it’s it’s,a it’s a judgement call it really is a,judgment call so we expect to decline to,be like this and if it’s less than that,if the client is only like this I tend,to keep them on the drug yeah last,question,yeah that’s that’s a really good,question yeah so earliest stage,milestones are kind of the milestones,that that lead us to really making the,diagnosis of dementia is is if they are,not functioning well in their current,lifestyle one things I always ask about,is is driving near misses accidents,those kinds of things now I have to,report either way but I generally if,it’s mild dementia what happens is that,people can actually go to the DMV get,retested and keep their licenses but if,they’re having near misses and stuff,like that I generally tell them they’ve,earned the right to not drive yeah well,thank you guys so much,and it was so hollow genetic about it,you know this is so hard to find and the,parking and such but but you guys were,great and good luck with it and if you,folks are being cared for by UCLA or,loved ones in care but the Alzheimer’s,in dementia care program we have up any,flyers I think on that here too the,package oh yeah grab grab a packet and,we will,do our best to try to help your loved,ones and help you folks thank you so,much thank you,[Music],you
your heart supplies blood to the entire,body including your brain through a,network of blood vessels known as your,circulatory system but if blood can’t,get to your brain because blood vessels,are damaged or blocked or if blood leaks,into the brain your brain cells can die,this can lead to vascular dementia blood,vessels can become damaged over time,because of a fatty buildup or be blocked,by a clot which causes a stroke or,series of mini-strokes a number of,factors increase the risk of damaging,your blood vessels or can lead to a,bleed in the brain such as smoking high,blood pressure high cholesterol poorly,controlled diabetes excessive alcohol,and obesity,bran has recently been diagnosed with,vascular dementia he’s been experiencing,memory loss difficulty problem-solving,and his family have noticed personality,changes however the symptoms of vascular,dementia vary for everyone depending on,which area of the brain are suffering,from a loss of blood supply wrong,controls his blood pressure and,exercises more as research as shown this,can help brain function he also takes,part in social activities to help with,communication and memory with your,continued support we’re funding research,to understand more about vascular,dementia but unfortunately there is,currently no cure,however as Ron has been diagnosed early,he has a range of information and,support available to him and those,around him one in six people over the,age of 80 have dementia vascular,dementia is the second most common type,of dementia after Alzheimer’s disease,more information on vascular dementia,can be found at VHF dot org dot uk’,VHF beat heart break from vascular,dementia beat heart break forever
good morning my name is dr. Steven Chen,I may use geriatric psychiatrist here at,UCLA and the topic I’m going to present,today is on vascular dementia so for,those of you who may have participated,in our webinars before and and to those,who are joining us new you can post,questions you can ask questions using,Twitter or or commenting on facebook,using the hashtag UCLA and D chat if,you’re on Twitter okay so what is,vascular dementia I I sort of designed,this talk for family for caregivers for,people who live who work at facilities,who might care for some of these,patients so what is vascular dementia,I’ll start first by talking about what,vascular dementia is not it’s unlike,Alzheimer’s disease unlike,frontotemporal dementia or Lewy body,dementia,the problem with vascular dementia is,not in the brain it’s not with those,other types of dementias,the problem is within the brain cells or,between the brain cells with faster,dementia the problem actually starts,with the blood vessels that that supply,the brain with blood and oxygen so,usually there’s the the types of,vascular problems or blood supply,problems in vascular dementia are what,we call ischemia or inadequate blood due,to narrowing of the arteries or,sometimes there can be a bleed that,causes disruption of blood supply to the,oxygen and that leads to death of or our,injury of brain cells,causing dysfunction of those particular,that particular part of the brain so you,can have either large single strokes,that can affect brain function you can,also have what we call micro vascular,injuries or a diseased small where small,vessels are involved and small parts of,the brain are damaged over a longer,period of time and they may not be,noticeable they may not manifest as what,you might expect from a stroke it may be,a very very subtle or what we call,subclinical type of injury they don’t,really have any clinical symptoms,associated with that until they,accumulate gradually over time so so,this problem with the vascular or blood,supply to the brain can sometimes lead,to dementia and that’s where we have,cases of vascular dementia and what is,dementia some of you may have,participated in some of our other,webinar series webinars in this series,know that the dementia is defined as an,impairment in memory or other cognitive,functions as well as impairment in one’s,functioning so not only do they have,memory impairment or problems with word,finding or maybe finding their way,around or disorientation but also with,problems with daily activities so,problems with say managing finances or,driving or running errands that’s what,we mean by functional impairment what,are some of the common clinical features,of vascular dementia usually there’s,some abrupt onset and symptoms so,there’s the patient is doing fine they,seem normal and then there’s an abrupt,change in their ability to remember,or ability to think and then over time,there can be a stepwise decline as you,as the patient experiences either small,or large vascular events or even strokes,and this commonly can affect one’s gait,or ability to walk it can affect other,motor abilities such as fine motor you,know motor coordination it can also,affect one’s ability to control bladder,or bowel so that can lead to,incontinence and then it can also affect,one’s mood the patient might seem a,little bit more have a little bit more,uncontrolled trouble controlling their,mood or their affect so they might,actually you know laugh or cry,inappropriately or at for no apparent,reason how common is vascular dementia,well in the United States vascular,dementia represents the second most,common type of dementia Alzheimer’s,disease is by far the most common type,of dementia comprising a but roughly,two-thirds of cases but vascular,dementia comes second representing,somewhere between ten and twenty percent,of all cases of dementia and amongst the,elderly seventy plus your year old,people about 4.2 percent have vascular,dementia vascular dementia is more,common in men than in women it’s also,more common in African Americans as well,as Asians suggesting there may be some,genetic component to to the risk but,there may also be some associated,lifestyle factors as well we know that,so in Japan vascular dementia is,actually the most common type of,dementia we may,we think that maybe diet is is an,important factor interestingly Hawaiians,who are of Japanese descent so they,maybe they have they share some of the,genes with their Japanese relatives but,they also have a different diet a,different lifestyle their risk for,vascular dementia is actually somewhere,in between people who are Japanese,living in Japan and people who are not,Japanese living in the u.s. so I’d like,to compare vascular dementia to,Alzheimer’s disease to sort of give a,sense as to how these two are different,so with faster dementia as as I said in,the first slide are caused by strokes,both large and small that lead to to,damage or dysfunction of parts of the,brain and whereas in Alzheimer’s disease,it’s related to problems with the brain,cells and also the the actual brain,tissue parts of the brain that lie,between cells the onset of vascular,dementia is usually abrupt whereas with,Alzheimer’s it’s more insidious and and,maybe it just kind of creeps up on you,and then over time with vascular,dementia you might see a stepwise,decline as opposed to Alzheimer’s,disease it is more of a gradual,progressive course both vaster dementia,and Alzheimer’s patients will experience,memory loss however they may be at the,earlier stages there may be some,distinction in the type of memory loss,and Alzheimer’s patients tend to be more,amnestics so they’ll have trouble,remembering words or remembering events,even if you give them clues or hints,embassador dementia they are able to,store the memory or in,code the memory they just have,difficulty recalling the memory or,retrieving the memory so if you in a,typical test in the office we might give,them three words to remember and the,people with vascular dementia won’t will,have difficulty remembering the words,but if you give them clues they will,often be able to then retrieve that,those words both types of dementia can,are associated with psychiatric symptoms,including depression and apathy anxiety,agitation one distinction between,vascular dementia and Alzheimer’s is,that depression tends to be more common,and vascular dementia,whereas in Alzheimer’s disease apathy or,a lack of motivation or interest is is,more more common this slide shows a,comparison of MRIs of a patient with,vascular dementia and a patient with,Alzheimer’s disease and so the the,distinctions that I’d like to point out,are highlighted by the arrows so for,vascular dementia the red arrows are,pointing to the the white parts of the,brain these are changes this is what,happens to brain tissue when there has,been some disruption of vascular supply,so this is what this is what strokes,would look like over time on MRI whereas,the on the bottom set of slides a,patient with Alzheimer’s disease the,yellow arrows point to the spaces the,black spaces in between the what we call,gyri of the brain so in between brain,and that’s cerebrospinal fluid so that,has really no you know that’s,what fills up the brain when there’s,loss of brain tissue and in Alzheimer’s,disease there is a trophy or a shrinking,of brain tissue and so what fills that,up is is CSF which is in black so you,see I’m sorry I don’t have a comparison,to a normal patient or a patient without,Alzheimer’s disease but what what the,arrows illustrate are a enlargement of,CSF space so the first one are an,enlargement of what we call sulci and,then the the next slide is in the next,two slides are enlargement of ventricles,that contain cerebrospinal fluid makes,dementia so what do we mean by mixed,dementia it basically means a,combination of vascular dementia and,Alzheimer’s disease many people with,vascular dementia will also have,Alzheimer’s disease so on this Venn,diagram to the right illustrates first,of all the the larger proportion of,patients who have Alzheimer’s disease,and there’s an overlap with some portion,of vascular dementia patients who have,both and that is what we refer to as a,mixed dementia vascular dementia and,Alzheimer’s disease though they do have,distinctions they also share some,similar risk factors age is the largest,risk factor for both the presence of,hypertension and diabetes as well as,obesity are also shared risk factors for,both Alzheimer’s disease and vascular,dementia and then the final point on the,slide is this to show that the someone,with who has Alzheimer’s disease,the course of their illness can very,much be affected by the presence of,vascular disease so in the red you see,what a typical course of someone with,only vascular dementia might be it’s a,sort of a stepwise decline in the dark,blue is an illustration or a schematic,of how a typical course Alzheimer’s,disease might progress just gradually,and progressively and then someone with,mixed dementia you’ll see will progress,gradually at some points and then have,some stepwise decline in between which,results in a overall more rapid,progression of their dementia and then,you can have someone with very clean,Alzheimer’s disease without any vascular,disease that would progress more slowly,so again the the progression of,Alzheimer’s can either be accelerated or,slowed down depending on how much,vascular disease there is what can we do,about vascular dementia well first of,all the bad news there is no cure and,there is no fda-approved medication to,treat faster dementia however more so,than the other types of dementia is,faster dementia is preventable and we do,this by trying to control risk factors,for stroke if one has elevated blood,pressure or cholesterol or diabetes man,optimal management of those conditions,should reduce the risk for developing,vascular dementia also evaluation for,heart disease is also very important,because our,any certain types of heart disease can,increase risk for developing clots and,those clots can travel from the heart to,the brain and cause a stroke so it’s,very important also not only to look at,overall vascular health but also,cardiovascular health or issues related,to keeping the heart healthy there are,data that suggests that cholinesterase,inhibitors which include an episode or,aricept rivastigmine or exelon as well,as memantine or namenda there there are,data that suggest that these agents are,effective in at least temporarily,improving memory or thinking and in,patients with vascular dementia we may,not be able to cure or necessarily treat,and effectively treat vascular dementia,but it is important to try to treat the,psychiatric symptoms that may emerge,over the course of the illness again a,couple slides ago I mentioned depression,is quite common and vaster dementia so,if the patient develops depression on,top of vascular dementia it should be,treated with typically with,antidepressants though at this point,there are not very good studies that,show that treating patients with,vascular dementia and depression are,effective but I think they are worth,worth prescribing and finally just like,with all the other types of dementia,that affect the patient’s functioning,it’s important to and it’s important to,provide support not only for the patient,but also for the caregiver and to have a,good evaluation of the environment,some of the behavioral disturbances or,psychiatric symptoms that are associated,with all the dimensions are often the,most challenging aspect of managing,these illnesses and they don’t respond,very well to some of our medications,they do respond to modifying the,environment so that the patient and the,caregiver are well supported that the,patient has what they need in their,everyday lives to do not become agitated,or upset or depressed so things like,making sure that they have the,appropriate stimulation at home or in,the facility making sure that all of,their needs are met basic things like,hunger and thirst and going to the,bathroom,so just like with all the other,dimensions the management of vascular,dementia is no different in terms of,support for the patient and the,caregiver and the environment so this,concludes my presentation again a,reminder if you’d like to ask questions,please use the hashtag UCLA MD chat on,Twitter or our comment on our Facebook,page,so I’ll just take a look at some of the,questions that have been fed through,sorry they’re quite of okay so first,question are there any lifestyle factors,that might help prevent faster dementia,yes we think so,and they are the same factors as what we,think might prevent or at least slow,down the progression of Alzheimer’s,disease and those things are,common-sense things like daily exercise,a healthy diet ones one that includes,multiple servings of fruits and,vegetables each day staying active both,mentally and socially in addition to,physical exercise second question what,type of doctors should I consult with if,I think my loved one has vascular,dementia well I’m a geriatric,psychiatrist I certainly sealed a number,of patients who have vascular and mixed,dementia so one option is to see a,geriatric psychiatrist I know not not,all parts of the country have have,access to geriatric psychiatrists a,psychiatrist an adult psychiatrist who,may have experience with with the,geriatric population who maybe visits,skilled nursing facilities or assisted,living facilities where this is a very,common problem may also be a good idea,geriatric medicine doctors these are,doctors who are internists but also have,received specialty training and,geriatric medicine they are also seeing,a lot of these patients and and may have,some good ideas about,management and an evaluation also,neurologists these are doctors who,specialize who are trained and all sorts,of brain illnesses including Alzheimer’s,and vascular dementia so they would be,another very good resource if you have,if you know of someone who might have a,vascular dementia okay,it looks like those are all the,questions that we have so I want to,thank you very much for participating in,today’s webinar and if you have,additional questions you can certainly,continue to later on you can certainly,continue to tweet them or or add them to,comments on our Facebook page thank you,very much