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Transcript of © Cengage Learning 2016 Neurocognitive and Sleep-Wake Disorders 13.
© Cengage Learning 2016 © Cengage Learning 2016
Neurocognitive and Sleep-Wake Disorders
13
© Cengage Learning 2016
• Major neurocognitive disorder
• Minor neurocognitive disorder
• Delirium
Types of Neurocognitive Disorders
© Cengage Learning 2016
• Steps in assessment– Gather background information
– Evaluate overall mental functioning, personality characteristics, and coping skills
– Rule out sensory conditions or emotional factors
– Test to pinpoint areas of cognitive difficulty
Assessment of Brain Damage and Neurocognitive Functioning
© Cengage Learning 2016
• Medical tests– EEG
– CT
– MRI
– PET
• Comprehensive baseline assessments– Used to monitor progress or decline in
functioning
Assessment Process (cont’d.)
© Cengage Learning 2016
• For diagnosis, must show significant decline in:– One or more cognitive areas
• Deficits in multiple areas are common
– Ability to independently meet daily living demands
• Clinicians specify underlying medical reason, if known
Major Neurocognitive Disorder
© Cengage Learning 2016
• Decline in mental function and self-help skills– Resulting from major neurocognitive disorder
• Examples of affected areas: memory, problem solving, and impulse control
• Gradual onset and continuing cognitive decline
• Age is strongest risk factor for dementia
Dementia
© Cengage Learning 2016
Areas of Possible NeurocognitiveDysfunction
© Cengage Learning 2016
• Modest decline in at least one major cognitive area
• Individuals able to participate in normal activities– May require extra time to complete tasks
– Overall independent functioning not compromised
• Often an intermediate stage between aging and major neurocognitive disorder
Minor Neurocognitive Disorder
© Cengage Learning 2016
Normal Aging or Neurocognitive Disorder?
© Cengage Learning 2016
• Often goes undiagnosed– Early detection can allow individual to plan for
future care before the disorder progresses
• Sometimes major neurocognitive disorder is downgraded to minor– As a result of recovery from stroke or
traumatic brain injury
Minor Neurocognitive Disorder (cont’d.)
© Cengage Learning 2016
• Acute state of confusion characterized by disorientation and impaired attentional skills– Abrupt onset
• Develops over a period of several hours or days
– Symptoms can be mild or severe
– Psychotic symptoms may be present
– Treatment: identify underlying cause
– Hospitalized individuals and the elderly at increased risk
Delirium
© Cengage Learning 2016
• Result from variety of medical conditions
• Some involve specific events– Stroke
– Head injury
• Some become worse over time
• Neurodegeneration– Progressive brain damage involving death of
brain cells
– Individuals show decline, not improvement
Etiology of Neurocognitive Disorders
© Cengage Learning 2016
Neurodegenerative Disorders
© Cengage Learning 2016
Event Causes of Neurodegenerative Disorders
© Cengage Learning 2016
Multipath Model of Neurocognitive Disorders
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• Traumatic brain injury– Can result from bump, jolt, blow, or physical
wound to the head
• 1.7 million people per year receive emergency care for traumatic brain injury
• Effects can be temporary or permanent
• Neurocognitive disorder diagnosed with:– Persisting cognitive impairment due to a brain
injury
Neurocognitive Disorder Due toTraumatic Brain Injury (TBI)
© Cengage Learning 2016
• Most common type of TBI
• Trauma-induced changes in brain functioning
• Symptoms include headache, dizziness, nausea, and sensitivity to light– Usually temporary (few weeks), but
sometimes last much longer
• Many occur in competitive sports and recreational activities– About half are unreported
Concussion
© Cengage Learning 2016
• Bruising of the brain– Occurs when brain strikes skull with sufficient
force to cause bruising
– Involves actual tissue damage to both side of the impact and opposite side
– Symptoms similar to those of a concussion
• Neuroimaging can detect brain damage and monitor swelling
Cerebral Contusion
© Cengage Learning 2016
• Open head injury
• Brain tissue is torn, pierced, or ruptured
• Immediate medical care involves reducing bleeding and preventing swelling
• Symptoms vary with severity of laceration
Cerebral Laceration
© Cengage Learning 2016
• Progressive, degenerative condition
• Diagnosed in individuals who have had multiple episodes of head injury
• Associated with psychological symptoms and increased risk of dementia
• Four stages of CTE– Each with different symptoms
Chronic TraumaticEncephalopathy (CTE)
© Cengage Learning 2016
• Can result from a one-time cardiovascular event (stroke) or from unnoticed, ongoing disruptions to cardiovascular system
• Often begin with atherosclerosis
• Stroke– Obstruction of blood flow to or within the
brain, leading to loss of brain function
Vascular Neurocognitive Disorders
© Cengage Learning 2016
• Hemorrhagic stroke– Involves leakage of blood into the brain
• Ischemic stroke– Caused by a clot or severe narrowing of the
arteries supplying blood to the brain
– 87% of strokes
• Transient ischemic attack (TIA)– “Mini-stroke” resulting from temporary
blockage of arteries• Symptoms often precede ischemic stroke
Types of Strokes
© Cengage Learning 2016
• Fourth leading cause of death in U.S.– Significant cause of disability
• Can occur at any age– One-third of strokes occur under age 65
• Some risk factors– Cigarette smoking (major contributor)
– Stress
– Poor eating and sedentary lifestyle
– Depression
Stroke
© Cengage Learning 2016
• Use of drugs or alcohol– Can result in delirium or chronic brain
dysfunction
• Mild neurocognitive disorder common with history of heavy substance use– Symptoms continue with initial abstinence but
can improve over time
Neurocognitive Disorder Due to Substance Abuse
© Cengage Learning 2016
• Most prevalent neurodegenerative disorder– Affects more than 5 million Americans
• Involves progressive cognitive decline
• Age a major risk factor
• Clear physiological indicators required to predict whether patients with mild memory impairment will likely develop AD
Neurocognitive Disorder Due to Alzheimer’s Disease (AD)
© Cengage Learning 2016
• Progressive decline in cognitive and behavioral functioning
• Physiological processes that produce AD begin years before onset of symptoms– Early symptoms
• Memory dysfunction, irritability, and cognitive impairment
– Other symptoms that often appear • Social withdrawal, depression, apathy, delusions,
impulsive behaviors, neglect of personal hygiene
• No cure exists
Characteristics of AD
© Cengage Learning 2016
• Memory loss occurs for a variety of reasons– Early symptom of AD
– Gradual loss of brain neurons due to aging
– Temporary conditions• Infections or reactions to prescription drugs
• Older adults continue to generate new brain cells– Brain reorganizes to maximize cognitive
efficiency
Other Factors Affecting Memory Loss
© Cengage Learning 2016
• Shrinkage of brain tissue
• Abnormal structures– Neurofibrillary tangles
• Twisted fibers of tau found inside nerve cells
– Beta-amyloid plaques• Beta-amyloid proteins aggregate in spaces
between neurons
• Brain changes appear years before dementia appears
Alzheimer’s Disease and the Brain
© Cengage Learning 2016
• Believed to be influenced by hereditary and environmental factors– APOE-e4 allele of the APOE gene increases
risk for AD• People with this genotype do not necessarily
develop AD
• Three rare genetic mutations identified for autosomal-dominant AD
• Lifestyle variables associated with stroke and cardiovascular disease– Also affect AD
Etiology of Alzheimer’s Disease
© Cengage Learning 2016
• Link between sleep and amount of beta-amyloid in the brain– Older adults with poor sleep quality or
quantity had more beta-amyloid deposits
Etiology of Alzheimer’s Disease (cont’d.)
© Cengage Learning 2016
• Second most common form of dementia• Characteristics
– Progressive cognitive decline– Unusual movements seen in Parkinson’s
disease– Significant fluctuations in attention and
alertness– Hallucinations– Impaired mobility– Sleep disturbance
Neurodegenerative Disorders Due to Dementia with Lewy Bodies (DLB)
© Cengage Learning 2016
• Lewy bodies– Brain cell irregularities
– Result from the buildup of abnormal proteins in the nuclei of neurons
– Also present in Parkinson’s disease
– When present in the cortex• Deplete the neurotransmitter acetylcholine
– When present in the brain stem• Deplete dopamine
DLB
© Cengage Learning 2016
• Fourth leading cause of dementia
• Several variants depending on affected brain region
• Symptoms– Changes in behavior, personality, and social
skills
– Difficulty with fluent speech or word meaning
– Muscle weakness
– Average age of onset is between 45 and 64
Neurocognitive Disorder Due to Frontotemporal Lobar Degeneration (FTLD)
© Cengage Learning 2016
• Four primary symptoms– Tremor of the hands, arms, legs, jaw, or face– Rigidity of the limbs and trunk– Slowness in initiating movement– Drooping posture, or impaired balance and
coordination
• Motor symptoms evident at least one year prior to notable cognitive decline– Mild cognitive impairment affects about 27
percent of those with PD
Neurocognitive Disorder Due to Parkinson’s Disease (PD)
© Cengage Learning 2016
• Second most common neurodegenerative disorder in the U.S.
• Later stages of PD– Cognitive and behavioral symptoms similar to
those of DLB
• Disorder occurs more frequently in Northern Midwest and the Northeast in urban settings– Raises questions about environmental toxins
Parkinson’s Disease (cont’d.)
© Cengage Learning 2016
• Rare, genetically-transmitted degenerative disorder
• Symptoms– Involuntary twitching movements– Eventual dementia
• Early symptom– Difficulty in executive functioning
• No effective treatment• Death occurs 15-20 years after symptom
onset
Neurocognitive Disorder Due to Huntington’s Disease (HD)
© Cengage Learning 2016
• Cognitive impairment sometimes the first sign of untreated HIV infection– Slower mental processing– Difficulty concentrating
• AIDS dementia complex (ADC)– HIV becomes active in the brain
• Antiretroviral therapies can prevent or delay onset– Brain changes still occur in half of those
taking antiretroviral medications
Neurocognitive Disorder Due to HIV Infection
© Cengage Learning 2016
• Treatment approaches vary widely due to different causes, symptoms, and dysfunctions
• Major interventions– Rehabilitative services
– Biological interventions
– Cognitive and behavioral treatment
– Lifestyle changes
– Environmental support
Treatment Considerations with Neurocognitive Disorders
© Cengage Learning 2016
• Must be comprehensive and sustained
• Physical, occupational, speech, and language therapy– Individual’s commitment and participation in
therapy plays an important role
– Depression, pessimism, and anxiety can stall progress
• Constraint-induced therapy– Repeated and intensive use of affected side
of the body
Rehabilitation Services
© Cengage Learning 2016
• Objective: prevent, control, or reduce symptoms
• Medication– Levodopa increases dopamine availability
– High doses of vitamin E can slow AD progression
– Antidepressants
• Early stages of research into deep brain stimulation
Biological Treatment
© Cengage Learning 2016
• Psychotherapy– Enhance coping and participation in
rehabilitation efforts
– Reduce frequency and severity of problem behaviors
• Meditation and mindfulness-based stress reduction– Reduced brain atrophy
Cognitive and Behavioral Treatment
© Cengage Learning 2016
• Can help prevent or reduce progression of some neurocognitive disorders
• Cardiovascular fitness
• Smoking cessation
• Weight reduction
• Control of blood sugar, cholesterol, and blood pressure
Lifestyle Changes
© Cengage Learning 2016
• Neurodegenerative disorders involving dementia– Irreversible
– Best managed with supportive environment
• Exposure to bright lighting– Improve sleep and decrease agitation and
depression
• Family visits
• Labeling family photos
Environmental Support
© Cengage Learning 2016
• Family and friends who provide care may need support– May feel overwhelmed, helpless, frustrated,
anxious, or angry
• Skilled nursing or assisted-living– Alternatives to individual remaining at home
Caregiver Support
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• Good quality sleep associated with mental and physical resilience
• Most adults need seven to nine hours of sleep per night
• Normal sleep pattern– Non-rapid eye movement (NREM) sleep
– Rapid eye movement (REM) sleep• Associated with dreaming
Sleep-Wake Disorders
© Cengage Learning 2016
• Insomnia disorder– Difficulty in falling asleep or maintaining sleep
– Caused by various factors
• Hypersomnolence disorder– Excessive sleepiness
– Naps do not provide relief from sleepiness
– Sleep inertia• Significant grogginess and impaired alertness
upon waking
Dyssomnias
© Cengage Learning 2016
• Very rare sleep disorder
• Irresistible or overwhelming need for daytime sleep– Even when adequate sleep occurs at night
• Individuals go immediately into REM sleep
• Many individuals experience cataplexy– Sudden loss of muscle function
– Often triggered by laughter, anger, or fear
• Can go undiagnosed for many years
Narcolepsy
© Cengage Learning 2016
• Common breathing-related sleep disorder
• Soft tissue in rear of throat collapses– Obstructs upper airway
– Repeatedly interferes with breathing during sleep
– Brain sends signals to resume breathing• Results in snoring or gasping for breath
• Remains undiagnosed in 80-90 percent of individuals with this condition
Obstructive Sleep Apnea
© Cengage Learning 2016
• Pattern of recurrent sleep disturbance– Caused by disrupted biological sleep-wake
cycle
• Jet lag– Temporary disruption in circadian rhythm
• Shift work can produce problems– Work schedule opposes sleep-regulating cues
associated with sunlight
Circadian Rhythm Sleep Disorder
© Cengage Learning 2016
• NREM sleep arousal disorders– Sleep terrors
– Sleepwalking
• Nightmare disorder– Dreams of danger frightening enough to
produce awakening
• REM sleep behavior disorder– Involves vocalizations and motor behavior
during sleep
Parasomnias
© Cengage Learning 2016
• Causes of sleep problems– Neurological vulnerabilities
– Psychological factors• Stress, anxiety, and depression
– Environmental factors• Noise, light, other stimuli
– Heath or behavioral habits
Etiology of Sleep-Wake Disorders
© Cengage Learning 2016
• Dyssomnias– Tend to be associated with lifestyle and
psychological factors
• Parasomnias– Less known about etiology
• Many with sleep disorders have family members with sleep difficulties
Etiology of Sleep-Wake Disorders (cont’d.)
© Cengage Learning 2016
• Maintaining a regular sleep-wake cycle
• Exercising regularly
• Avoiding caffeine, naps, and heavy meals
• Avoiding alcohol and nicotine within two hours of sleep
• Relaxed frame of mind– Minimize worry about not sleeping
• Eliminating distractions from bedroom
Treatment of Sleep-Wake Disorders
© Cengage Learning 2016
• Cognitive-behavioral therapy– Effective for treatment of insomnia
• Sleep apnea treatments– Losing weight, side sleeping
– Continuous positive airway pressure mask
• Medications– Clonazepam
– Melatonin
– Variety of sleep-inducing medications
Treatments (cont’d.)
© Cengage Learning 2016
• Medical professionals continue to emphasize lifestyle changes to reduce vulnerability
• Research efforts– Identification of early biomarkers for
neurodegenerative diseases
– Therapies to stop degeneration once it has begun
– Relationship between sleep impairment and psychiatric disorders
Contemporary Trends and Future Directions
© Cengage Learning 2016
• How can we determine whether someone has a neurocognitive disorder?
• What are the different types of neurocognitive disorders?
• What are the causes of neurocognitive disorders?
• What treatments are available for neurocognitive disorders?
• What do we know about sleep disorders?
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