What happens when something goes wrong…... Identify manifestations of abnormalities in brain...
Transcript of What happens when something goes wrong…... Identify manifestations of abnormalities in brain...
What happens when something goes wrong…..
Identify manifestations of abnormalities in brain function associated with aging.
Explore interventions and treatments to maximize functioning when pathology is present.
DeliriumDepressionDementia
Delirium is often unrecognizedDelirium might be the only indication of
a life threatening conditionExtremely important to identify
Approximately 14-80% of hospitalized elderly patients experience an episode of delirium
Can represent a medical emergency and is a potentially reversible condition
Requires immediate interventions to prevent permanent disability and health risks including death
increased length of hospitalization and increased hospital mortality rates of approximately 25-33%
greater intensity of nursing care more frequent use of physical restraints greater in-hospital functional decline greater health care costs worse outcomes in severe delirium especially
at 6 months (e.g., ADL and ambulatory decline, nursing home placement and death)
Disturbance in attention (reduced ability to direct, focus, sustain, and shift attention)
and awareness (reduced orientation to environment)
Develops over a short period of time, a change from baseline, fluctuates during the course of a day
An additional disturbance in cognition (memory deficit, disorientation, language, visuospatial ability, or perception)
The disturbances are not better explained by another preexisting, established, or evolving neurocognitive disorder
Evidence from history, physical exam, or lab findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or is due to multiple etiologies
1) Acute onset and fluctuating course 2) Inattention 3) Disorganized thinking 4) Altered level of consciousnessDelirium requires the presence of 1
and 2 plus either 3 or 4
Hyperactive◦Agitated◦Restless◦Yelling
Hypoactive◦Inactivity◦Withdrawal
Mixed
Hardest to recognize May look like depression Subdued, quiet Extremely important to recognize and
look for medical cause
Chronological age – very young and very old Sensory deficits Dehydration Sleep disturbances Pre-existing dementia Cognitive impairment Immobility or use of restraints Medications–anticholinergic meds Metabolic abnormalities Comorbidities Presence of urinary catheter Under and over treatment of pain Withdrawal
First have to recognize it Search for underlying cause Environment conducive for orientation Maintain safety and comfort Encourage mobility – avoid bedrest Environment conducive for sleep Optimize hearing and vision Avoid dehydration Avoid catheters Avoid deliriogenic medications Maximize the familiar and avoid distractions
Most common psychiatric condition affecting older adults
“Common cold” of psychiatry Leading cause of disability in the US and
the world (NIMH) Often under-diagnosed and under-treated
Robs elderly of late life satisfactionCauses impairment in cognitive, social
and personal functioning Involves undue suffering for patient
and often their familyCauses excess morbidity and mortalityCould be a symptom of an underlying
medical condition
Increased risk of suicide Increased economic burdenCould lead to substance abuse or
misuseTreatment is often very effective
In older adults, depression may mask, or be masked by, other physical disorders.
Is difficult to disentangle depression from the many other disorders affecting older people
Of the 35 million over age 65 in US, 2 million meet criteria for major depression and another 5 million have depressive symptoms
One primary care study found that 11% of depressed patients were adequately treated, 34% were inadequately treated, and 55% received no treatment.
At least 5 symptoms must be present in the same 2-week period and must include either◦1) Depressed mood◦2) Loss of interest or pleasure
3) Change in appetite or weight4) Insomnia or hypersomnia5) Psychomotor agitation or retardation6) Fatigue or loss of energy7) Feelings of worthlessness or guilt8) Difficulty with thinking or
concentration9) Thoughts of death or suicide
Elderly may not admit or report sadness In general, elderly are less verbal about
feelings May be masked by somatic complaints
◦Common are headache, nausea, constipation, anorexia, “Just don’t feel well,” GI upset, pain
◦Preoccupation with physical health
Less interest in hobbies or recreational activities
Daily chores left undone Social withdrawal Less interest in sex May neglect personal hygiene or
appearance Less able to experience pleasure
Most often, decreased appetite but may be increased
Monitor weight May complain that food has no taste At risk for dehydration, electrolyte
imbalance, and malnutrition
Insomnia or hypersomniaEarly morning awakeningMiddle insomniaWaking too early
Agitation – restlessness, irritable, appear anxious and distressed, hand wringing
Slowness in movement, slowed speech, latency of response
Tired and worn out Everything is just too much effort Poor time management Apathetic “It’s too much work.”
Blames self for things done and undone Feelings of being of “no value” Hopelessness, worry Future is bleak Self-reproach, critical of self and others “Don’t spend time with me; I’m not worth it.” May be delusional
Slowed thinking Inability to focus or concentrate Indecisive Feels confused and bewildered Ruminations about insignificant problems Negativity
Weary of lifeLife isn’t worth living “I’d be better off dead.” “You’d be better off if I weren’t here.”Passive suicide◦Refuse to eat◦Refuse medications
Interaction of biological and psychosocial factors
Possible genetic contribution Reaction in response to losses Unresolved grief Physical illnesses may lead to depression Medications may cause symptoms of
depression
Involve the person’s family Obtain an evaluation by a professional Every interaction has the potential to help Communicate a caring attitude Support and encourage Provide opportunity for social interactions Involve in scheduled or structured activities Spend time with the person and listen
Encourage physical activityMobilize support systemsMonitor physical health◦Medication monitoring◦Nutrition and weight◦Sleep ◦Comfort and relaxation◦Management of pain
Beware of being “too cheerful”
Antidepressant medications take time to exert a therapeutic effect
Monitor for suicidal thoughts, especially as depression starts to improve
Promote a positive attitude toward the future – “I know that you feel this way now, but you won’t always.”
Remember that depression is usually very treatable over time
A subjective state of dysphoric apprehension or expectation accompanied by physiological responses
Symptom of many disorders including depression, dementia, delirium
Primary symptom of anxiety disorders
Excessive worry that person finds difficult to control
Complaints of shakiness, restlessness, jitteriness, jumpiness, trembling, tension, irritability, impatience, poor concentration, memory problems, unrealistic fears
Feeling of impending doom Anticipation of the worst that could happen
Physical symptoms including:◦palpitations, chest pain◦dizziness, lightheadedness◦tingling, numbness◦stomach upset, diarrhea◦too hot or too cold, sweating◦shortness of breath, sensation of lump in throat or choking
◦sleep disturbance
Medical illnesses ◦hypoglycemia, hyperthyroidism
Medications◦caffeine, stimulants, sympathomimetics
Withdrawal states ◦alcohol, benzodiazepines
Situational anxiety◦going to a dentist, flying
Panic disorderAgoraphobiaPhobiasObsessive-Compulsive disorderPosttraumatic stress disorderAcute stress disorderGeneralized anxiety disorder
Minimize caffeine Social interactionRelaxation techniquesDiversion and recreational activitiesPhysical exerciseCounseling or psychotherapyMedication, if use is justified
Minor Neurocognitive Disorder
Major Neurocognitive Disorder
Complex attention (Sustained and divided attention, processing speed)
Executive ability (Planning and decision making)
Learning and memory (Recall and recognition) Language (Expressive and receptive) Visuoconstructional-perceptual activity
(Construction and visual perception) Social cognition (Emotions and behavioral
regulation)
Evidence of minor cognitive decline from a previous level of performance
Deficits not sufficient to interfere with independence
Deficits do not occur exclusively in context of delirium
Greater cognitive deficits in at least one (typically 2 or more) cognitive domains
Evidences of significant cognitive decline from previous level of performance
Deficits sufficient to interfere with independence
Deficits do not occur exclusively in context of delirium
A chronic, progressive, irreversible, neurological disorder affecting memory, cognition, ability to function, personality, language, and behavior
Preclinical – pathophysiological changes in the brain, but cognitively normal
Mild cognitive impairment due to AD – clinical and research criteria
Dementia due to Alzheimer’s Disease – Possible, Probable, Probable with evidence of AD pathophysiology
Cerebral spinal fluid◦ Phospho-tau concentration elevated◦ Amyloid beta (1-42) peptide reduced◦ AT Index <1 consistent with Alzheimer’s
PET scan with special imaging agent◦ Demonstrates amyloid burden
Blood or urine tests – not available yet
Alzheimer’s is the most common form of dementia
5.4 million people in US have DAT1 in 8 elderly has DATAbout 500,000 Americans <65 years
old have a dementia; 40% of those have DAT
Alzheimer’s is the 6th leading cause of death in the US
Neurofibrillary tanglesAmyloid plaquesCerebral atrophy
Short-term memory- Hippocampus involved
◦Can’t make deposits into “memory bank”◦Like a computer with a faulty save
function◦“Floating” reference point for time
MemoryJudgment and decision makingAbstract thinkingInhibition controlOrganizational skillsMotivation and attention
Personality stabilityEmotionsLanguagePraxisVisual spatial skills
◦Sudden onset◦Step-wise progression◦Focal neurological signs and symptoms◦Evidence of cerebrovascular disease on
brain imaging◦History of hypertension, diabetes,
dyslipidemia, atrial fib, smoking, prior TIAs or stroke
Likely accounts for 75% of vascular dementia cases Affects small arterioles, venules and capillaries in
the brain Hypertension is a major risk factor Seen on MRI as small focal areas of infarction,
hyperintensities, microbleeds, or enlarged perivascular spaces
Subacute symptoms include cognitive impairment (executive dysfunction, slowing of psychomotor speed, memory problems), mood disorders, gait disturbances
Progression less predictable Focus on stroke prevention
◦ Manage hypertension◦ Treat diabetes◦ Lipid lowering agents
Alzheimer’s drugs generally not beneficial
Memory impairment evident with progression, but not always early
Abnormal proteinaceous (alpha-synuclein) cytoplasmic inclusions called Lewy bodies develop in cells throughout the brain
Progressive dementia – deficits in attention, executive function, memory, language and visual spatial abilities
Two of three core features◦Parkinsonism◦Recurrent visual hallucinations◦Fluctuating attention and concentration
Dementia onset before or within one year of parkinsonism onset
Supportive Features◦REM sleep behavior disorder◦Antipsychotic medication sensitivity◦Syncope◦Repeated falls◦Autonomic dysfunction◦Complex delusions
◦Tremor at rest◦Rigidity◦Bradykinesia◦Postural instability◦Usually asymmetric onset of symptoms◦Dementia in 20 – 60%
Multiple System AtrophyCorticobasal DegenerationProgressive Supranuclear PalsyFTD with Parkinsonism
A neurodegenerative disorder affecting the frontal and/or temporal lobes of the brain that presents predominantly with behavioral or language disturbance, with relative preservation of memory and spatial skills early in the illness
-Earlier age of onset - 50% before age 65-Survival 6.6 – 10 years after symptoms onset-Personality changes and decline in social
skills-Impaired executive functions-Emotional blunting; apathy-Behavioral disinhibition; bizarre behavior-Language changes-Prominent temporal and/or frontal atrophy
Behavioral variant – prominent changes in behavior and personality
Progressive nonfluent aphasia – expressive language changes
Semantic dementia – can’t understand words or recognize familiar people and objects
Insidious onset and gradual progression Early decline in social interpersonal conduct Early impairment in regulation of personal
conduct Early emotional blunting Early loss of insight
Decline in personal hygiene and grooming Mental rigidity and inflexibility Distractibility and impersistance Hyperorality and dietary changes Perseverative and stereotyped behavior Utilization Behavior Speech and language changes
◦Rapidly progressive, fatal◦Cognitive and behavioral changes◦Loss of coordination◦Myoclonus◦Spongiform changes in frontal cortex◦A type of prion disease misfolded proteins
◦Autosomal dominant pattern of inheritance◦Defect of chromosome 4◦Basal ganglia affected◦Movement and coordination affected◦Loss of intellectual abilities and emotional
and behavioral disturbances
◦Subdural hematoma
◦Traumatic brain injury
◦Hypoxemic anoxia
◦Alcohol/substance abuse◦Heavy metals◦Carbon monoxide poisoning◦Drugs
◦AIDS dementia◦Viral encephalitis◦Bacterial meningitis◦Neurosyphilis
◦Dementia◦Ataxia◦Urinary Incontinence
◦“Wild, wet, and wacky”
It is important to know what PERSON the disease has, not what disease the person has.
-Sir William Osler 1849-1919
Difficulty learning new things Misplaces items Forgets to tend to appliances Trouble following recipes/directions Can’t remember the date/time Trouble recalling recent events or
conversations Forgets to pay bills or repays Trouble following plot in stories or on TV
Use calendars, notes, remindersWrite important informationRepeat explanations or directionsTry to limit distractions and simplifyOne specific location for keys,
glasses, important itemsSupervise medications, finances, and
for safety needs
Provide reminder cues in conversations or in the environment
Try to endure repetitivenessHelp locate missing itemsMonitor appetite and weightDon’t force reality orientationDiscuss positive memories from the past
Judgment and decision makingAbstract thinkingInhibition controlOrganizational skillsMotivation and attention
Loss of sense of risk and dangerFinancial vulnerabilityDifficulty problem-solvingMay appear more dependent and
indecisiveMay trust strangers or be
“inappropriately familiar”Unable to prioritize activities
Identify surrogate decision maker/s Avoid extended logical explanations Set limits on unrealistic demands Anticipate safety needs and safety proof
surroundings Avoid situations where failure is likely Use distraction rather than confrontation Maintain the person’s integrity
Takes more time to understand Difficulty with time relationshipsTrouble with calculations and moneyUnable to “figure out” complex problemsPoor interpretation of social cuesChange in sense of humor
Allow time to process verbal communication
Be alert for misunderstandings Interpret what is occurring in the
environmentHelp identify the function of objectsUse discretion with humor
More impulsive – desires immediate gratification
Frustrated easily – quick to react May make hurtful/insensitive comments May have inappropriate social behavior Possibility for sexual disinhibition
Anticipate needs and possible overreaction
Maintain a calm environmentDon’t take insensitive comments
personallyUse a matter of fact approach for socially
inappropriate behaviorAssist in covering social “mistakes”
Unable to plan, organize, sequence activities
Don’t remember “how” to get started on tasks
May appear apathetic or disinterestedTrouble following directions
Simplify the environmentContinue with familiar routineProvide structured activities, but be
flexibleBreak tasks into individual stepsGive one-step directions Inconspicuously give cuesAvoid sounding controlling or bossy If resistive, stop and try again later
Problems with initiationCan’t switch mental gears easilyTrouble completing tasks or “gets stuck”Loss of mental flexibilityDifficulty maintaining effortful activitiesDistractibility
Eliminate competing stimuli in the environment
Provide cues and prompts Plan activities that do not require sustained
periods of concentration Attempt distraction if the person is “stuck” Plan frequent rest periods
Problems with◦Stopping◦Starting◦Switching◦Socialization◦Planning◦Judgment
Disinhibited/impulsiveBlurt out socially inappropriate remarksFrontal release signs (grasp reflex,
palmomental reflex)Compulsive eatingUnable to resist impulse to use or touch
objects
Lack of motivationUnable to initiate Inability to maintain effortful behaviorApathy
PerseverationLack of mental flexibilitySelf management difficulty to make
any change Improper emotional responses
Poor interpretation of social cuesDifficulties secondary to lack of motivation, personality changes, and uninhibited behavior
Insensitive to othersUnable to “read” social signals from others
Inability of volitionCannot multitaskNon compliance because can’t plan “Stubborn” – “Uncooperative”
Unable to anticipate consequencesCan’t prioritizeLack empathyLittle or no insight
Personality stabilityEmotionsLanguagePraxisVisual spatial skills
Apathy vs irritabilityParanoiaAbnormal beliefsDelusions or hallucinationsFearfulnessClinging/shadowingAnger/frustration
Try to exhibit the desired demeanorBe aware of your limits and stress levelClearly identify the purpose of caresAvoid arguments about abnormal beliefs
DepressionAnxietyDenial – lack of insightLabile emotionsWithdrawal
Address depression if it is suspectedProvide environmental and
interpersonal supports to minimize fears and anxiety
Distract rather than confrontMaintain a calm, routine, predictable
environmentEncourage social activities
Word-finding problemsTrouble with names – talks “around”
namesLoses train of thought in mid-sentenceCan’t filter out distractions during
conversationsLess use of nounsMay not recognize objects
Approach slowly from the front or side and gain the person’s attention before talking
Speak slowly and clearlyMaintain relaxed body languageFace the person, establish eye
contact, and smile Introduce yourself and call the person
by name
Eliminate distracting background noisesSpeak in low pitched tonesBegin with social conversation or “small
talk”Keep sentences shortKeep to one clearly defined subject at a
time
Use nouns or names rather than pronouns Use the same word every time to refer to
common tasks/objects Avoid open ended questions Limit the number of decisions the person
has to make Accompany verbal communication with
appropriate non-verbal cues
Exaggerate gestures or facial expressions if hearing or vision impaired
Use gentle touch that is not task oriented Break down tasks into individual steps and
ask the person to do one at a time Repeat explanations or directions as
needed Try to match requests to the person’s
current level of functioning
Allow sufficient time for the person to process information
Focus on the feeling tone of the conversation rather than content of words
State positive directions; limit the use of “don’ts”
Talk about pleasant memories from the past
Try supplying a word if it is appreciated Repeat the last few words to help regain
train of thought if blocking is a problem Allow word mistakes to go by “unnoticed” if
the general meaning is understood Inconspicuously give prompts during
interactions
Avoid “quizzing” or forcing a response Make “educated guesses” of what intent
could be if verbal statements are unclear Give reassurance by making general
statements if that provides comfort Use humor appropriately
-Loss of “motor memory”-Need more time to complete tasks-Need assistance with daily tasks-Don’t rush well
Allow more time to complete tasksProvide prompts and step-by-step
directionsDemonstrate the desired actionDo not rush the person
Unaware of relationship to environment◦Might fall◦Unable to find way or gets lost ◦May wander
Geographic disorientation
Evaluate fall risk Use way finding cues Use personal items to help recognize room Be aware of social distance in conversations Avoid abrupt movements toward the person
Aggression/AgitationDelusions/hallucinationsDepressionApathySleep disordersWanderingSexually inappropriate behaviorOthers
Current Alzheimer’s Trials at UNMC
-Prevention Trial-Asymptomatic AD-≥65 years-Monthly IV x 3yr-Solanezumab-a4study.org
Interested? Call 402-552-6241
-Mild AD study-MMSE 20-26-ages 55-90-Monthly IV x 18m-Solanezumab-expedition3study.com
-Moderate AD study-MMSE 12-22-ages 55-85-oral med x 1yr-T-817MA-adcs.org (studies)
University of Nebraska Medical Center