Manifestation of Novel Social Challenges of the European Unionin the Teaching Material ofMedical Biotechnology Master's Programmesat the University of Pécs and at the University of DebrecenIdentification number: TÁMOP-4.1.2-08/1/A-2009-0011

COGNITIVE AND AFFECTIVE DISORDERS IN THE ELDERLY

Márta Balaskó and Gyula BakóMolecular and Clinical Basics of Gerontology – Lecture 18

Manifestation of Novel Social Challenges of the European Unionin the Teaching Material ofMedical Biotechnology Master's Programmesat the University of Pécs and at the University of DebrecenIdentification number: TÁMOP-4.1.2-08/1/A-2009-0011

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Aging-associated cognitive, affective changesIn healthy aging overall intellectual performance does not necessarily deteriorate.Various cognitive functions decline, while others improve: • Activity requiring quick reactions and or high degree

precision grow weaker.• Decrease in speed of processing, working memory,

inhibitory function and long-term memory are seen.• Wise consideration based on experience, the ability to

understand and learn from new experience is maintained.

TÁMOP-4.1.2-08/1/A-2009-0011Aging-associated cognitive, affective and psychiatric disorders (outline) • Dementia

- Neurodegenerative disorders leading to dementia (Alzheimer’s disease)

- Non-Alzheimer dementias (vascular dementia, organic brain disorders)

- Delirium- Amnestic syndromes

• Alcohol abuse and consequences• Affective disorders: depression

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Dementia: definition and prevalenceDefinitionA serious loss of cognitive ability with maintained vigilance.Dementia is a clinical diagnosis.Impairments affect: •memory (disturbed recognition: agnosia),•speech (aphasia), language,•judgement,•emotional control,•behavior,•attention ,•abstract thinking,•executive functions (apraxia), that causes disruption in relationships and social functions.

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Dementia: prevalence and most frequent formsPrevalenceIt affects 1% of population at the age of 60, prevalence doubles every year.It reaches 10 % at 65 years, and 35% above 90 years. Most prevalent dementias• Senile dementia of the Alzheimer type

(Alzheimer’s disease) 60%• Non-Alzheimer dementias (organic brain disorders)• Delirium• Amnestic syndromes

TÁMOP-4.1.2-08/1/A-2009-0011Senile dementia of the Alzheimer type (SDAT, Alzheimer’s disease) 1 DefinitionA (premature) progressive age-associated loss of cognitive functions (in middle-aged and older) also involving affective and behavioral disturbances.Risk factors• age 65 years• female gender• low education level (primary school drop-outs: 2×

risk)• positive family anamnesis: 4× risk• head trauma: 2× risk• smoking, metabolic syndrome X, atrial fibrillation,

stroke, alcohol consumption, genetic predisposition

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Prevalence of Alzheimer’s disease

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60-64 65-69 70-74 75-79 80-84 85+ 95+

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TÁMOP-4.1.2-08/1/A-2009-0011Senile dementia of the Alzheimer type (SDAT, Alzheimer’s disease) 2CharacteristicsLoss of neurons, synapses and atrophy in the cerebral cortex and certain subcortical regions (temporal and parietal lobes, parts of the frontal cortex)Pathogenesischolinergic theory: reduced synthesis of the acetylcholinebeta-amyloid: dense and insoluble deposits of amyloid beta precursor protein (APP) fragments form senile plaques around neurons initiating damage tau protein misfolding : intracellular neurofibrillary tangles cause microtubules to disintegrate, damaging the neuron’s transport systemInflammation, oxidative stress, accumulation of aluminium in brain, etc.

TÁMOP-4.1.2-08/1/A-2009-0011Senile dementia of the Alzheimer type (SDAT, Alzheimer’s disease) 3Phases1 Mild cognitive impairment, preclinical stage

a gradual, hidden, progressive onset may last for 7-8 years symptoms (memory loss) are mistaken for stress and aging

2 Early stageincreasing forgetfulness, difficulties with language, executive functions, agnosia, apraxia, personality changes

3 Moderate stagedependency increasesdifficulty with speech, pathological behavior (agression) and confusion, delusions

4 Advanced stage complete dependency, verbal output decreases, pronounced memory decline, patients get bed-ridden, death

TÁMOP-4.1.2-08/1/A-2009-0011Senile dementia of the Alzheimer type (SDAT, Alzheimer’s disease) 4PrognosisAverage survival is 7 years. Most common causes of death: pressure ulcers, pneumoniaTreatmentNo drug has been shown to cure the disease or delay

progression.Some drugs alleviate symptoms:• acetylcholinesterase inhibitors • glutamate NMDA receptor antagonistA safe, emotionally supportive environment, physical exercise, optimal diet may improve quality of life of the patient.

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Non-Alzheimer dementias (organic brain disorders)Characteristics•Symptoms may resemble those of Alzheimer’s disease• Onset is usually different, changes may occur

suddenly or they may not be progressive over time• In case of metabolic or infectious causes progression

may be stopped, even some alleviation of the symptoms is possible.

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Causes of non-Alzheimer dementiasIntracranial:Degenerative disordersParkinson’s, Pick, LewyHuntingtonVascular, post-stroke states Space occupying lesionsPost-trauma statespolytrauma (boxing, liver)subdural hematoma,hemodialysisInfectious agents AIDS, prion (Creutzfeldt-Jakob),neurosyphilis, Lyme disease

meningitis

Extracranial:Poisons

alcohol, drugs, medications

CO poisoningGenetic, metabolic causesWilson’s, hypoglycemiasOrgan failuresTumor, metastases failure,renal failure, hydrocephalus

heart failure, thyroid disorders

Deficienciesvitamin B12-, folic acid-,

niacin deficiency

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Delirium: definitionCharacteristics• It is a clinical syndrome characterized by inattention

and acute severe (reversible) cognitive dysfunctions• In the young, high fever, severe alcohol intoxication,

severe metabolic disturbances, etc. may cause delirium

• In the elderly, functional reserve capacity of the brain declines , therefore many milder disorders may lead to delirium

• Delirium affects 14–56% of all hospitalized elderly patients. Postoperative delirium occurs in 15–53% of surgical patients over 65 years, and 70–87% among elderly patients admitted to intensive care units.

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Delirium in the elderly: risk factors 1Risk factors• Dementia or cognitive impairment• History of delirium, stroke, neurological disease, falls• Multiple comorbidities• Male gender• Chronic renal or hepatic disease• Sensory impairment (hearing or vision)• Immobilization (restraint, catheters)• Medications (sedative hypnotics, narcotics,

anticholinergic, drugs, corticosteroids, polypharmacy, alcohol or drug withdrawal)

• Acute neurological diseases [acute stroke (usually right parietal), meningitis, encephalitis]

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Delirium in the elderly: risk factors 2Risk factors• Intercurrent illness

(minor infections, iatrogenic complications, anemia, ordinary volume loss, poor nutrition, fracture, trauma)

• Metabolic derangementsevere hypoglycemia, hyper- or hypotonicity

• Surgery• Alarming environment

(e.g. admission to an intensive care unit)• Pain• Emotional distress• Sustained sleep deprivation

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Amnestic syndromesDefinitionMemory functions are disproportionately impaired compared to other cognitive functions in an otherwise alert patient. The patient can not remember recent events or learn simple tasks, while performing complex tasks learned previously.Most common forms • Wernicke-Korsakoff Syndrome

chronic alcoholism, chronic thiamine deficiency• Transient Amnestic Syndromes

transient cerebral ischemia, migraine, alcohol intoxication (“blackouts”), drugs (e.g. benzodiazepines, barbiturates, ketamine), head injury (concussion)

• Psychogenic amnesiaposttraumatic stress disorder

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Alcohol abuse and consequencesin the elderlyPrevalenceAlcohol abuse and alcoholism are prevalent and under-recognized problems in the elderly. About 6 percent of older adults are considered heavy users of alcohol (13% of men, 2% of women).The majority of older alcoholic persons (around 66%) grow older with early-onset alcoholism, about 34% develop a problem with alcohol in later life.Age-related alterations in pharmacokinetics of alcohol• Gastrointestinal absorption is comparable, distribution is

diminished due to decrease in fat free mass. • Liver perfusion and metabolism in the liver declines

slightly.

higher peak serum alcohol

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Consequences of alcohol abusein the elderly 1ConsequencesAlcohol-induced alterations in drug metabolism:• acute competitive inhibition of drug metabolism

involving the cytochrome P450 system (microsomal ethanol oxidizing system=MEOS), e.g. narcotics, tranquillizers leading to suppression of respiratory center

• chronic upregulation of the cytochrome P450 system enhancing clearance of drugs, e.g. coumarins

Falls may be precipitated by alcohol due to acute ataxia, acute hypotension (vasodilatory and diuretic effect), chronic myopathy, cerebellar atrophy and peripheral neuropathy. These falls may lead to hip fractures!Moderate drinking may exacerbate hypertension, and heavy drinking increases the risk of stroke. Arrhythmia may develop after an alcohol binge.

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Consequences of alcohol abusein the elderly 2ConsequencesIschemic heart disease is responsible for more cardiac deaths among older alcoholics than alcohol-induced cardiomyopathy.Gastrointestinal bleeding are common among older alcoholics.The liver is more susceptible for alcoholic hepatitis, fatty liver or cirrhosis in old individuals. About 50% of elderly patients with cirrhosis die within one year of diagnosis.Elderly patients are more prone to alcohol or its withdrawal-induced delirium .Chronic alcoholism lead to Wernicke encephalopathy (an acute state of confusion, ataxia and abnormal eye movements) and Korsakoff’s syndrome (an isolated memory deficit manifesting in confabulation). Global cognitive impairment and alcohol-related dementia based on profound cerebral atrophy is more common in elderly alcoholics.

Depression in the elderly:definition and characteristicsDefinitionDepression is a state of low mood and aversion to activity. It may can affect the thoughts, feelings, behavior, and physical well-being of the patient. It usually involves feelings of sadness, anxiety, emptiness, hopelessness, worthlessness, guilt, irritability or restlessness. The prevalence of depression among the elderly is increasing.Their treatment presents a big strain on society. Depression in the elderly is seldom properly diagnosed. It does not receive proper attention.

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Depression in the elderly:risk factors It is strongly influenced by such risk factors that become more common with aging:• genetic factors determine susceptibility for depression• neurological changes, • multimorbidity, pain, • impaired function of sensory organs• loneliness, isolation• personal crises, bereavement, anxiety• reduced adaptability• lack of perspectives in life, lack of motivation, • decreased ability to work, • loss of family background, deficiencies of education,

poor social network, negative effects of retirement.

TÁMOP-4.1.2-08/1/A-2009-0011Factors that make the diagnosis of depression especially difficultDiagnostic factors: • There is an overlap between the normal phenomena of

aging and signs of depression. • Clinical characteristics may be misleading. Symptoms may

be suppressed, non-characteristic or associated with somatization (complaining about unreal somatic symptoms) and agitation/anxiety.

• It may occur (in a hardly discernible way) in association with chronic diseases and organic cerebral disorders.

Characteristics associated with the patient: • Losses, bereavement, isolation, shame, refusal of

treatment.• Neither the patient nor the relatives hope for any

improvement with the treatment. Characteristics of health professionals:• Misconceptions related to old age, lack of empathy and

attention.

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Depression: prognosisPoor prognosis, danger signs of suicide:• advanced age at the onset of depression,• presence of anxiety in past medical history, • personality disorders, • alcohol abuse, • psychotic signs, • cognitive impairment, • organic cerebral disorders, loneliness, poor social

circumstances, • delayed treatment, inadequate management

TÁMOP-4.1.2-08/1/A-2009-0011Differential diagnosis of depression (pseudodementia) and dementiaPSEUDO-DEMENTIA• keeps complaining• communicates in detail• “I don’t know”• does not want to do

DEMENTIA• does not complain• poor communication• replies with mistakes• eager to cooperate