Understanding Cognitive Understanding Cognitive DisordersDisorders

Developed by DATA of Rhode Island through a special grant from the RI Department of Human Services

GoalsGoals

To familiarize trainees with common types To familiarize trainees with common types of cognitive disordersof cognitive disordersTo improve trainee understanding of the To improve trainee understanding of the functional impairment of persons with functional impairment of persons with cognitive disorderscognitive disordersTo identify common co-occurring other To identify common co-occurring other disordersdisordersTo identify how approaches to persons To identify how approaches to persons with cognitive disorders may be modifiedwith cognitive disorders may be modified

DefinitionDefinition

Cognitive disordersCognitive disorders = disorders in which = disorders in which the central feature is the impairment of the central feature is the impairment of memory, attention, perception, and/or memory, attention, perception, and/or thinking processes.thinking processes.Cognitive disorders sometimes underpin Cognitive disorders sometimes underpin other mental disorders such as other mental disorders such as depression, paranoia and hallucinationsdepression, paranoia and hallucinationsSome disorders are transient and others Some disorders are transient and others are persisting and progressiveare persisting and progressive

BackgroundBackground

Used to be called “organic brain disorders”Used to be called “organic brain disorders” Meant a dysfunction of the brainMeant a dysfunction of the brain

Today are referred to as “cognitive disorders”Today are referred to as “cognitive disorders” Better reflects nature of problemsBetter reflects nature of problems Person with cognitive disorder often requires some Person with cognitive disorder often requires some

accommodation in approach and planningaccommodation in approach and planning Certain types of disorders may require immediate Certain types of disorders may require immediate

medical attentionmedical attention

Screening for Cognitive Disorders Screening for Cognitive Disorders

Mental Status : brief interview used to Mental Status : brief interview used to assess cognitive disordersassess cognitive disorders

5 major components:5 major components:1.1. Appearance and behaviorAppearance and behavior

2.2. Mood and affectMood and affect

3.3. ThoughtThought

4.4. PerceptionPerception

5.5. Sensorium and IntellectSensorium and Intellect• SensoriumSensorium = consciousness and awareness of = consciousness and awareness of

surroundingssurroundings

Cognitive DisordersCognitive Disorders

There are multiple types of cognitive disorders. There are multiple types of cognitive disorders. These include:These include:Delirium, dementia including traumatic brain injury Delirium, dementia including traumatic brain injury and development disabilitiesand development disabilities

DeliriumDelirium

1.1. FeaturesFeatures• KeyKey feature is disturbed consciousness feature is disturbed consciousness• Associated features include:Associated features include:

Clouded sensorium – no clear awareness of Clouded sensorium – no clear awareness of surroundingssurroundings

Problems with attentionProblems with attention

Disturbance in memoryDisturbance in memory

Incoherent speechIncoherent speech

Perceptual disturbances (e.g., hallucinations)Perceptual disturbances (e.g., hallucinations)

Delirium (cont.)Delirium (cont.)

CourseCourse• Acute onset (within hours or days) and Acute onset (within hours or days) and

transient course (days to a few weeks)transient course (days to a few weeks)No such things as life-long deliriumNo such things as life-long delirium

• Can be superimposed on another disorder Can be superimposed on another disorder (e.g., dementia)(e.g., dementia)

Course (cont.)Course (cont.)

Tends to occur more in certain people:Tends to occur more in certain people: ElderlyElderly Medically ill (e.g., cancer; AIDS)Medically ill (e.g., cancer; AIDS) DementiaDementia Substance AbusersSubstance Abusers

Delirium (cont.)Delirium (cont.)

3.3. CausesCauses• Drugs: intoxication, withdrawal, poisonDrugs: intoxication, withdrawal, poison

Delirium tremensDelirium tremens = tremors and vivid = tremors and vivid hallucinations of vermin associated with alcohol hallucinations of vermin associated with alcohol withdrawalwithdrawal

• MedicationsMedications• InfectionInfection• Head injuryHead injury• Various kinds of brain trauma (e.g., stroke)Various kinds of brain trauma (e.g., stroke)

Delirium (cont.)Delirium (cont.)

4.4. Responding to DeliriumResponding to Delirium• Attending to precipitating problemAttending to precipitating problem

Treating medical condition; counteracting effects Treating medical condition; counteracting effects of substance withdrawal; using antipsychotic medof substance withdrawal; using antipsychotic med

Recognizing people at risk and paying special Recognizing people at risk and paying special attention to those cases to avoid deliriumattention to those cases to avoid delirium

Usually requires professional interventionUsually requires professional intervention

DementiaDementia

1.1. FeaturesFeatures• KeyKey feature of most dementia is gradual feature of most dementia is gradual

impairment of multiple cognitive abilities impairment of multiple cognitive abilities including memory, language, and judgmentincluding memory, language, and judgment

With impaired social/occupational functioningWith impaired social/occupational functioning• Often global cognitive impairment – (e.g., Often global cognitive impairment – (e.g.,

vocabulary and language)vocabulary and language)• First signs: personality change and memory First signs: personality change and memory

lossloss

Dementia (cont.)Dementia (cont.)

2.2. Statistics and courseStatistics and course• Incidence is highest in older adults, but can Incidence is highest in older adults, but can

onset at almost any ageonset at almost any age• Not accurate to give one prevalence rate, Not accurate to give one prevalence rate,

because it differs by age group:because it differs by age group:65-74:65-74: 1.29%1.29%

75-84:75-84: 3.83%3.83%

85+:85+: 10.14%10.14%

Statistics Statistics

Incidence is the same for males and Incidence is the same for males and femalesfemales

Onset varies by type of dementiaOnset varies by type of dementia e.g., Alzheimer’s vs. vascular dementiae.g., Alzheimer’s vs. vascular dementia

People over age 75 at increased risk for People over age 75 at increased risk for dementiadementia

Dementia (cont.)Dementia (cont.)

3.3. Example: Alzheimer’s Disease (most Example: Alzheimer’s Disease (most common)common)

A.A. Development of multiple cognitive deficits Development of multiple cognitive deficits manifested by both:manifested by both:1)1) Memory impairmentMemory impairment

2)2) One (or more) of the following:One (or more) of the following:a)a) AphasiaAphasia

b)b) ApraxiaApraxia

c)c) AgnosiaAgnosia

d)d) Disturbance in executive functioningDisturbance in executive functioning

Criteria (cont.)Criteria (cont.)

B. Significant impairment and declineB. Significant impairment and decline

C. Gradual onset and continuing declineC. Gradual onset and continuing decline

- Rule out other dementias and mental - Rule out other dementias and mental disorders (depression)disorders (depression)

Alzheimer’s (cont.)Alzheimer’s (cont.)

Onset usually in 60’s or 70’sOnset usually in 60’s or 70’s Early signs in 40’s and 50’s (presenile Early signs in 40’s and 50’s (presenile

dementia)dementia)

Definitive diagnosis can only be made on Definitive diagnosis can only be made on autopsy where confirms:autopsy where confirms:

1.1. Gross atrophy of the brainGross atrophy of the brain

2.2. Neurofibrillary tanglesNeurofibrillary tangles

3.3. Senile plaquesSenile plaques

Dementia (cont.)Dementia (cont.)

4.4. Causes of dementiaCauses of dementia• Direct cause linked to type of dementiaDirect cause linked to type of dementia

Plaques and tangles Plaques and tangles Alzheimer’s Alzheimer’s

Blocked artery Blocked artery vascular dementia vascular dementia• Genetic factors linked to some dementiasGenetic factors linked to some dementias

Multiple genes Multiple genes Alzheimer’s risk Alzheimer’s risk

Single dominant gene Single dominant gene Huntington’s disease Huntington’s disease• Head trauma (Traumatic Brain Injury)Head trauma (Traumatic Brain Injury)

Causes (cont.)Causes (cont.)

Vascular dementia can be influenced by Vascular dementia can be influenced by diet as well as genetic factors (link to heart diet as well as genetic factors (link to heart disease)disease)

Psychosocial factorsPsychosocial factors Higher education level is associated with Higher education level is associated with

lower dementia risklower dementia risk Social resources and family support can Social resources and family support can

improve life for patients with dementiaimprove life for patients with dementia

Dementia (cont.)Dementia (cont.)

5.5. Treatment of dementiaTreatment of dementia• Limited – some drugs can improve cognitive Limited – some drugs can improve cognitive

functioning, but only temporaryfunctioning, but only temporary• Psychosocial treatmentsPsychosocial treatments

Memory walletMemory wallet

Memory skills trainingMemory skills training

Teach to use navigational cues to avoid getting Teach to use navigational cues to avoid getting lostlost

In more progressed cases, more active care In more progressed cases, more active care giver roles requiredgiver roles required

Traumatic Brain Injury (TBI)Traumatic Brain Injury (TBI)

50 to 70% of persons with TBI resulting in 50 to 70% of persons with TBI resulting in hospitalization are intoxicated at the time of the hospitalization are intoxicated at the time of the injuryinjury

50% of TBI survivors return to alcohol and/or 50% of TBI survivors return to alcohol and/or drug use after the injurydrug use after the injury

TBI occurs in about 2% of populationTBI occurs in about 2% of population

TBI is heavily associated with certain types of TBI is heavily associated with certain types of other disorders including substance abuse, other disorders including substance abuse, personality disorder and ADHDpersonality disorder and ADHD

Developmental DisabilityDevelopmental Disability

A condition that begins before the age of 21 and A condition that begins before the age of 21 and is likely to continue indefinitly. is likely to continue indefinitly.

Caused by a mental or physical impairmentCaused by a mental or physical impairment

Results in substantial impairment in functional Results in substantial impairment in functional abilities including language, learning, decision abilities including language, learning, decision making, self care and other areas.making, self care and other areas.

Types of disabilities include: Mental retardation, Types of disabilities include: Mental retardation, autism, cerebral palsy and other disordersautism, cerebral palsy and other disorders

Developmental Disabilities and Developmental Disabilities and Cognitive FunctioningCognitive Functioning

Cognitive issues in various levels of mental Cognitive issues in various levels of mental retardationretardation

Cognitive issues in Autism Spectrum DisorderCognitive issues in Autism Spectrum Disorder

Cognitive issues in Asperger’s DisorderCognitive issues in Asperger’s Disorder

Cognitive issues in Pervasive Developmental Cognitive issues in Pervasive Developmental DelayDelay

Cognitive issues in childhood TBICognitive issues in childhood TBI

Cognitive issues in lead poisoning, drug Cognitive issues in lead poisoning, drug addiction in-utero, fetal alcohol syndromeaddiction in-utero, fetal alcohol syndrome

Learning DisabilitiesLearning Disabilities

Defined:Defined: a disorder in one or more of the a disorder in one or more of the basic basic psychological processespsychological processes involved in involved in understanding or in using written or spoken understanding or in using written or spoken language. A learning disability may manifest language. A learning disability may manifest itself in an itself in an imperfect abilityimperfect ability to to listen, think, speak, listen, think, speak, read, write, spell, or do mathematical read, write, spell, or do mathematical calculationscalculations

Common Learning Disabilities: ADHD, Dyslexia, Common Learning Disabilities: ADHD, Dyslexia, developmental reading and writing disorders developmental reading and writing disorders

Common co-occurring mental Common co-occurring mental disordersdisorders

It is estimated that 40% or more of persons with It is estimated that 40% or more of persons with cognitive disorders have other mental disorders. cognitive disorders have other mental disorders. These include:These include:Depression and anxiety (most common)Depression and anxiety (most common)Substance Dependence (particularly with Substance Dependence (particularly with persons with TBI)persons with TBI)Persons with milder levels of mental retardation Persons with milder levels of mental retardation are at higher risk of substance abuseare at higher risk of substance abusePersons with cognitive disorders are at higher Persons with cognitive disorders are at higher risk of victimization and traumarisk of victimization and trauma

Impact of Cognitive ImpairmentImpact of Cognitive Impairment

Neuropsychological deficits contribute to Neuropsychological deficits contribute to the inattention, distractibility and apparent the inattention, distractibility and apparent lack of motivation early in services.lack of motivation early in services.

Understanding the cognitive weaknesses Understanding the cognitive weaknesses and strengths is useful for making and in and strengths is useful for making and in providing realistic with realistic providing realistic with realistic expectations about service goals and expectations about service goals and expectations.expectations.

Lessons Learned about persons Lessons Learned about persons with cognitive disorderswith cognitive disorders

Slowed mental processing = increased stress and Slowed mental processing = increased stress and anxiety anxiety

Word finding difficulty = decreased verbal Word finding difficulty = decreased verbal communicationcommunication

Poor retrieval = loss of learned informationPoor retrieval = loss of learned information

Executive difficulty = poor self-cueing, difficulty with Executive difficulty = poor self-cueing, difficulty with understanding, empathy, planning and problem understanding, empathy, planning and problem solvingsolving

Executive difficulty = poor impulse control, failure to Executive difficulty = poor impulse control, failure to learn from negative experience, poor self guidance.learn from negative experience, poor self guidance.

Practical tips for interviewing a Practical tips for interviewing a person with Cognitive Disordersperson with Cognitive Disorders

Often persons with cognitive disorders experience a high Often persons with cognitive disorders experience a high degree of shame and embarrassment about their limitationdegree of shame and embarrassment about their limitationListening Skills (LISTEN CAREFULLY)Listening Skills (LISTEN CAREFULLY) Look at the person to whom you are speakingLook at the person to whom you are speaking Interest yourself in the conversationInterest yourself in the conversation Speak less than half the timeSpeak less than half the time Try not to interrupt or change the topicTry not to interrupt or change the topic One question at a timeOne question at a time Simple and clear languageSimple and clear language Clarify what is saidClarify what is said Notice body language and facial expressionNotice body language and facial expression Don’t rely on verbal instructions or promisesDon’t rely on verbal instructions or promises Use visual aids to support learning and retentionUse visual aids to support learning and retention

More TipsMore Tips

Break tasks into smaller steps, and give Break tasks into smaller steps, and give directions verbally and in writing;directions verbally and in writing;giving the clients more time to finish certain giving the clients more time to finish certain tasks that may require reading or writing;tasks that may require reading or writing;Make sure the person with reading problems has Make sure the person with reading problems has written materials read out loud so they better written materials read out loud so they better understandunderstandMake sure the person with listening difficulties Make sure the person with listening difficulties has materials in writinghas materials in writingWhen possible allow the person to review When possible allow the person to review information with a trusted other personinformation with a trusted other person

Modifying services for persons with Modifying services for persons with cognitive impairmentscognitive impairments

ModelModel Concent. Concent. ImpairmntImpairmnt

MemoryMemory

ImpairmntImpairmnt

ExecutiveExecutive

ImpairmntImpairmnt

MotivatiionalMotivatiional Summarize:Summarize:

Verbal Cues,Verbal Cues,

NonverbalNonverbal

CuesCues

Familiariza-Familiariza-tion, notes, tion, notes, audio tape, audio tape, rehearsal, rehearsal, homeworkhomework

Role rever.Role rever.

Paper/pen Paper/pen problem problem solvingsolving

CoachingCoaching

BehavioralBehavioral Repeat infoRepeat info

Use Use Nonverbal & Nonverbal & verbal verbal cueingcueing

Provide Verbatim Provide Verbatim written materialswritten materials

Memory booksMemory books

HomeworkHomework

CoachingCoaching

Role PlaysRole Plays

SummarySummary

Cognitive disorders involve an impairment Cognitive disorders involve an impairment of memory, attention, perception, and of memory, attention, perception, and thinking that represents an impairment in thinking that represents an impairment in functioningfunctioning

With adaptations of services and approach With adaptations of services and approach persons with disabilities can successfully persons with disabilities can successfully participate in services participate in services

QUESTIONSQUESTIONS