PS3013: Clinical Psychology

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PS3013 Clinical Psychology

• Dementias
• Dr Claire Gibson
• cg95_at_le.ac.uk
• School of Psychology, Leicester

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Overview

• Aging
• Dementia
• Defining/Classifying
• Identification
• Causes
• Treatment/Interventions

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Normal Aging

• 1 population aged 60-70 suffer from dementia
• 18-85 population suffer from dementia by age of
  85
• Clinical need to distinguish between age-related
  dementia and pathological causes of dementia,
  e.g. AD

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Aging cognitive changes

• Cognitive changes
• Long-term memory, problem solving (habitual)
• Novel reasoning, efficiency of solving new
  problems
• New learning, abstract and complex new problem
  solving, behavioural speed,
• Individual variation
• Inevitable consequence of aging
• Other factors?

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Aging brain changes

• Gross changes
• Decreased size
• Flattening of cortical surface
• Increasing amounts of intracranial space
• Neuroanatomical changes
• Loss of neurons,
• Changes in neuronal size,
• Altered dendritic processes
• Tangles and plaques
• Neurotransmitter changes depression, memory
  problems
• Not uniform

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Dementia - Clinical Challenge
Patient with cognitive dysfunction
Incipient Dementing Disease
Increasing Age
Mild Cognitive Impairment (MCI)
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Mild Cognitive Impairment (MCI)

• Concept is clinically important
• Slowly developing memory impairment
• Clinically manifest dementia absent
• Preserved activities of daily living
• High rate of progression MCI ? AD
• Early identification
• Stabilise symptoms?
• Delay progression to dementia?

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If it is dementia, what sort of dementia is it?
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Defining Dementia

• De apart, away
• Mens mind
• Progressive decline in cognitive functioning
  beyond that expected for normal aging
• Memory, attention, language, problem solving

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Defining Dementia

• non-specific term
• Symptoms reversible or irreversible (gt10)
• a cluster of behavioural symptoms that may or
  may not point to a disease

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Causes of dementia
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Classification of dementia

• Cortical vs. subcortical
• Static vs. progressive
• Reversible vs. irreversible

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1. Cortical vs. subcortical

• Cortical cerebral cortex e.g. AD
• Subcortical white matter, neuronal connections
  between cortical areas and gray matter structures
  below the cortex e.g. PD, HD
• BUT too restrictive, refer to PRIMARY area of
  damage rather than EXCLUSIVE area of damage

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2. Static vs. Progressive

• Progressive ALL dementias that result from a
  disease process
• Static result from a neurotoxic substance (e.g.
  alcohol) or infection (e.g. herpes encephalitis)
• Progression repeated neuropsychological
  treatment, family/carers,

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3. Reversible vs. irreversible

• Reversible delirium or dementia?
• Delirium does not dementia
• Delirium transient cognitive problem associated
  with an acute confusional state
• Delirium and dementia memory impairments and
  disorientation
• A true reversible dementia patient must show
  dementia in absence of delirium

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Clinical Assessment

• To determine IF dementia is present
• If so, what TYPE of dementia is it?

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Clinical Assessment

• Biological Assessment
• Brain Imaging
• Neurochemical Assessment
• Neuropsychological Assessment
• Psychophysiological Assessment
• Psychological Assessment
• Clinical Interviews
• Psychological Tests

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1. Biological Assessment

• Brain Imaging
• CT Scan
• MRI structural functional
• Pet scan

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1. Biological Assessment

• Neurochemical Assessment
• Amount of neurotransmitter, quantity of
  neurotransmitter receptors,
• PET scanning
• Post-mortem
• Metabolites
• Urine, blood, CSF

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1. Biological Assessment

• Neuropsychological Assessment
• Neuropsychologist
• Psychological testing
• Psychophysiology
• Bodily changes
• Autonomic nervous system (ANS)

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2. Psychological Assessment

• Clinical Interview
• how respondent answers (doesnt answer)
• great skill
• rapport
• Empathy (humanistic therapists)
• Structured Interviews
• e.g. Structured Clinical Interview (SCID) for
  DSM-IV, Spitzer, Gibbon Williams, 1996

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2. Psychological Assessment

• Psychological Tests
• Standardised procedures
• Intellectual function
• WAIS, NART
• Memory and learning
• Rivermead, WMS, Fuld
• Language
• Executive function
• frontal lobe, Wisconsin card Sort, Trail Making
  Test

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Pathological causes of dementia

• Alzheimers Disease (AD)
• Parkinsons Disease (PD)
• Huntingtons Chorea (HC)
• Reversible dementia

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Alzheimers Disease (AD)

• Alois Alzheimer
• Cortical dementia, irreversible
• Most devastating and prevalent of dementias
• 50 of all diagnosed dementias

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Alzheimers Disease (AD)

• Degenerative brain disorder
• Unknown origin
• Progressive memory loss, motor deficits, eventual
  death
• 1st identified 100 yrs incidence ? ? -
  diagnosis, aging population
• Sufferers and carers

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Alzheimers Disease (AD)

• Occurrence
• 7 of population over age of 65
• 40 population over age of 80
• 18 million people worldwide
• 1 million people UK

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Alzheimers Disease (AD)

• Early signs
• 7 of population over age of 65
• 40 population over age of 80
• 18 million people worldwide
• 1 million people UK

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Alzheimers Disease (AD)

• Symptoms
• Memory impairment
• Progressive memory loss (initially declarative
  and episodic)
• Loss of function
• Insight, judgement, language (words, names)
• Personality changes
• Apathy social withdrawal, depression

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Alzheimers Disease (AD)

• Pathology
• 1. Atrophy
• 2. Histopathological features
• 3. Neurotransmitters systems

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Alzheimers Disease (AD)

• 1. Atrophy

AD severe degeneration of the hippocampus,
cerebral cortex and ventricular enlargement
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AD brain regions
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Alzheimers Disease (AD)

• 2. Histopathological features
• A. Plaques

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Alzheimers Disease (AD)

• 2. Histopathological features
• B. Neurofibrillary Tangles

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Alzheimers Disease (AD)

• 3. Neurotransmitter Systems
• Acetylcholine (Ach)
• Basal Forebrain Cholinergic Complex
• Neurons nucleus basilis of Meynert, diagonal
  band of Brocas area, globus pallidus
• Axons hippocampus and cerebral cortex
• Ach involved in learning and memory (PS2014/8)
• Others glutamate, catecholamines, somatostatin,
  corticotrophin

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Causes of AD (PS2014/8)

• Early onset
• Hereditary
• gene mutations on chromosomes 1, 14 or 21
• lt5 cases
• lt60 yrs of age
• Late-onset
• Majority cases
• gt60 yrs ages
• Most cause unknown

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Subcortical Dementias

• Do affect cortical functioning
• However, structures predominantly damaged
  subcortical
• Examples
• Parkinsons Disease (PD)
• Huntingtons Disease (HD)

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Parkinsons Disease

• Does not always dementia
• 40 PD patients criteria for dementia
• 12 PD patients aged 50-60
• 70 PD patients aged over 80
• Is PD the cause of dementia?

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Parkinsons Disease

• Loss of dopaminergic cells in substantia nigra
• Presence of Lewy bodies

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Parkinsons Disease

• a behavioural syndrome characterised by motor
  symptoms of tremor, rigidity, slowness of
  movement
• Visual spatial deficits (without motor component)
• Executive dysfunctions
• difficulty in tests that require strategy shifts
  to solve problems
• word finding
• Memory
• relatively spared, although deficits in
  organisation and retrieval of declarative memory
• Depression
• disease or medication?

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Huntingtons Chorea (HC)

• Rare
• Progressive, subcortical dementia
• Hereditary

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Huntingtons Chorea (HC)
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Huntingtons Chorea

• Difficulties associated with frontal lobe
  functioning and motor functioning
• Motor
• Chorea twisting, writhing movements of face and
  body
• Cognitive
• Memory retrieval problems
• Poor ability to differentiate what they know and
  dont know
• Affective disturbance depression, high suicide
  rate, anxiety, aggresiveness

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Reversible Dementia

• Benign Tumors
• Chronic subdural haemotoma
• Metabolic and endocrine disorders
• Wilsons disease
• Infections
• HIV

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Dementia - Interventions

• Pharmacological Interventions
• e.g. AD may slow progression from mild to
  moderate severity (Aricept)
• Non-pharmacological interventions
• Reality Orientation (RO) (Holden Woods, 1995)
  environmental changes consistency from staff
• Extensive memory aids, orientation sessions (with
  whiteboard), personal diaries for recording
• Holden Woods review of 21 studies consistent
  improvements in verbal orientation variable
  generalisability to other cognitive function
  questionable translation to behavioural/functional
  change
• Music interventions (Sherratt et al., 2004)

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Mental Health Problems

• Dementias - 5 aged 65, 20 over 80.
• Some individuals showing little deterioration for
  up to 4 years
• Diagnosis clearer in mod/severe category
• Cognitive changes universal, other common
  features include challenging behaviours, anxiety,
  hallucinations, depression.
• Latter contribute more to carer strain

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Reminiscence Therapy

• Remembering the past positive experiences
• Individual/group sessions
• Increase well-being/provide pleasure
• Impact?
• Other benefits
• Pre-morbid aspects of personality

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Dementia and depression

• Similar symptoms?
• Frequently co-exist
• Depression or dementia?
• Accurate diagnosis
• Uncertainty
• Depression may exacerbate dementia
• Behavioural changes

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Carers

• Caring most challenging part of the lifespan
• Primary (time, effort, energy) vs secondary
  (family and job conflict, self-esteem, loss of
  self) stressors
• Mediated by coping and actual/perceived support
• Emotional distress mediated by previous
  relationship with carer, gender, views of
  reciprocity
• Increasing use of non-familial care
• Maintenance of individual in community
• Institutional care and impact on staff (empathy,
  burnout)
• Elder abuse

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References(all available online via Athens
logon)

• Cooper, S. Greene, J.D.W. (2005). The Clinical
  Assessment of the Patient with Early Dementia.
  Journal of Neurology, Neurosurgery and Psychiatry
  76 (Suppl V), v15-v24.
• Douglas, S., James, I. Ballard, C. (2004)
  Non-pharmacological interventions in dementia.
  Advances in Psychiatric Treatment, 10, 171-179.
• Jelic, V., Kivipelto, M. Wonblad, B (2006)
  Clinical trials in mild cognitive impairment
  lessons for the future. Journal of Neurology,
  Neurosurgery Psychiatry, 77, 429-438.
• Nordberg, A. (2004) PET imaging of amyloid in
  Alzheimers disease. The Lancet Neurology, 3,
  519-527.
• Sherratt, K., Thornton, A. Hatton, C (2004).
  Music interventions for people with dementia a
  review of the literature. Aging and Mental
  Health, 8, 3-12.
• Abnormal Psychology textbook - see module
  homepage for recommendations