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