Identifying and Understanding the Neuropsychological Symptoms of Dementia

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Identifying and Understanding the
Neuropsychological Symptoms of Dementia
Woman driving with door open

• Dr. Christine Cauffield
• Cauffield Associates, LLC
• drcauffield_at_aol.com

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Key Symptoms of Cognitive Impairment

• Memory Loss
• Language Disturbance
• Decline in Judgment and Reasoning
• Personality Change    

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Brief Look at Human Brain

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Brief Look at Human Brain

• Frontal Lobe - Executive Functioning
• The Frontal Lobe controls abstract reasoning,
  planning, judgment, evaluation, volition, control
  of complex movement, expressive language (speech
  and writing), goal-directedness of actions,
  flexibility in thinking and behavior, and social
  appropriateness.  One third of human brain
  volume.
•  

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Brief Look at Human Brain

• Temporal Lobe-Emotion
• The Temporal Lobe controls hearing and
  higher-order auditory processing, oral language
  comprehension (left hemisphere), musical
  appreciation (right hemisphere), verbal memory
  (left hemisphere), and visuo-spatial memory
  (right hemisphere), emotional experience and
  expression. 

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Brief Look at Human Brain

• Parietal Lobe-Sensory
• Appreciation of bodily sensation, sensory-motor
  integration, body image, arithmetic (left
  hemisphere) and spatial (right hemisphere)
  reasoning, integration and interpretation of
  input from the different senses.
• Occipital Lobe-Vision           
• Vision and higher-order visual processing,
  reading (left hemisphere), recognition of faces
  (right hemisphere).     

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Brief Look at Human Brain

• Left Hemisphere - Language
• Depressive, dysphoric emotional syndromes
• Verbal, analytic, and mathematical functions
• Right Hemisphere
• More manic-euphoric, increased unawareness and
  denial of disability
• Visuo-spatial, musical, some forms of emotional
  functioning

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Symptoms of Cognitive Deficits

• Impairments include the following
• Sensation
• Perception
• Attention
• Concentration
• Language
• Memory
• Visuospatial Integration
• Thinking and Planning

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Symptoms of Cognitive Deficits

• Patients perform better with tasks and situations
• that are familiar rather than new, structured vs.
• open-ended, and specific vs. ambiguous.

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Common Neuropsychological Conditions

• Aphasia - Deficits in speaking, writing, reading
  or understanding speech of others
• Aprosodias - Deficits in expressing emotional
  tone of communication
• Apraxias - Higher-order disorders of coordination
  and motor planning (gait disturbances)

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Common Neuropsychological Conditions

• Agnosias - Deficits in recognizing or discerning
  the meaning of sounds, sights, objects, or people
  
• Retrograde Amnesia Loss of memory for events
  immediately preceding the trauma/insult
• Anterograde Amnesia - Disturbance in forming new
  memories after the trauma/insult

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Dementia

• There are over 30 types of dementia and many
• follow different courses of progression and/or
• recovery, depending on type and location of brain
• insult.

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Dementia

• Common Dementias include
• Vascular Dementia
• Alzheimer's Disease
• Korsakoff Syndrome
• Additionally, dementia is often a concomitant
• condition with many medical conditions, including
• Parkinson's Disease, Multiple Sclerosis, Brain
• Tumors and Open and Closed-Head Injuries.

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Dementia

• Clinical Presentations
• Frontal Lobe Disinhibition
• Emotional Dysregulation
• Incontinence
• Latency
• Anomia
• Transient Ischemic Attack-symptom reports
• Sense of smell/taste
• La Belle Indifference
• Denial/Lack of Insight

• Hypersexuality
• Depression
• Fatigue
• Attention, judgment, reasoning
• Right side/Left side deficits
• Obsessive-Compulsive behaviors
• Perseveration
• Confabulation

Variations of clinical presentation will occur,
based on type and location of insult/injury, as
well as pre-existing cognitive and personality
traits.
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Key Clinical Assessment QuestionsIt is
important to determine history of the following

• Surgeries-Anoxia
• Substance use/abuse-alcohol and illicit
• Recreational accidents-skiing, diving, etc.
• Depression
• Trauma-link to neurobiological and
  endocrinological changes in brain

• Coma, loss of consciousness-duration, treatment
  received, date(s)
• Falls
• Automobile accidents
• Sports accidents-football, soccer, boxing, etc.
• Family violence
• Domestic violence

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Community Referral Sources

• Neuropsychologist for accurate assessment and
  diagnosis
• Psychiatrist
• Geriatrician
• Neurologist
• Senior Centers, Alzheimer's Resource Centers, and
  other Community resources
• Memory Disorder Clinics
• Cognitive Rehabilitation Centers
• Other required specialists - Family therapists,
  etc.

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Treatment Options

• Psychotherapeutic and rehabilitation efforts
• that address
• Cognition
• Emotion
• Behavior
• .

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Treatment Options

• Cognitive Rehabilitation - trains patient to use
  intact
• Cognitive modalities to compensate for impaired
• functions
• Visuospatial impairment-patient taught verbal
  strategies
• Memory impairment-structured activities
  hierarchically so each event is cue for next
• Challenging behaviors-psychopharmacology and
  psychotherapy when appropriate
• .

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Family/Caregiver Stress

• 23, or 22.4 million households, are involved in
  caregiving to persons aged 50 or over.
• More than one quarter (26.6) of the adult
  population has provided care for a chronically
  ill, disabled, or aged family member or friend
  during the past year.
• Approximately 75 of those providing care to
  older family members and friends are female
  most likely a daughter.

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Family/Caregiver Stress

• An average of 18 to 20 hours per week is spent by
  caregivers providing care to older adults.
• Caregivers spend an average of 4.5 years
  providing care.
• 46 59 of caregivers are clinically depressed.

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Family/Caregiver Stress

• Caregivers use prescription drugs for depression,
  anxiety, and insomnia 2 to 3 times more than the
  general population
• The average age of caregivers is 60 with a range
  of ages 19 to 98.
• Of those working, 18 quit their jobs and another
  42 reduced their work hours.

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Identifying and Understanding the
Neuropsychological Symptoms of DementiaPresented
by Dr. Christine Cauffield August 16,
2010Case Study

• Mr. Brown, a 78 year old male, resides in a
  VA nursing home.  He was married 48 years, and
  his wife died of breast cancer 10 years ago.  She
  suffered for 3 years, and Mr. Brown was the
  primary caretaker prior to her death.  His
  daughters, age 45 and 47, report that their
  parents had a loving and devoted relationship,
  with no history of domestic or family violence. 
  Mr. Brown was born in Philadelphia, Pennsylvania,
  first born of three siblings.  He completed a 4
  year college degree in finance, and served 3
  years in the Korean war, where he saw active
  combat.  Upon his return, he was employed as a
  chief accountant for Exxon Corporation, and
  received numerous promotions.  After a 40 year
  career with Exxon, he retired at age 65.  His
  health issues include high blood pressure,
  diabetes, memory loss and depression.  A CT scan
  in 2007 revealed evidence of cva in temporal lobe
  region. His daughters were no longer able to care
  for Mr. Brown, and he was placed in the nursing
  home in 2007.  They visit regularly, as do
  extended family members.

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Identifying and Understanding the
Neuropsychological Symptoms of DementiaPresented
by Dr. Christine Cauffield August 16,
2010Case Study Contd.

• The Nursing Director on the unit has
  reported that Mr. Brown has been inappropriately
  touching other residents genital areas, and has
  been fondling himself.  She reports that Mr.
  Brown has frequent angry outbursts, and "cries at
  the drop of a hat."  She states that he is a
  "dirty old man" and has removed him from all
  social areas, including the dining room to
  "protect the other residents".  You have been
  requested to evaluate Mr. Brown, as the daughters
  have threatened to sue the nursing home due to
  their displeasure with the Nursing
  Director.What other information would you
  gather?What tests, if any, would you order?What
  is your initial hypothesis regarding his
  presenting problems?What clinical interventions
  would you recommend?Other thoughts, comments?

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Identifying and Understanding the
Neuropsychological Symptoms of Dementia
Resources www.medicinenet.com
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Identifying and Understanding the
Neuropsychological Symptoms of Dementia
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A Brief Look at Head Trauma

• Head Trauma-Traumatic Brain Injury (TBI) most
  common cause of brain damage
• Modern medical techniques saving many accident
  victims who 10-20 years ago would have succumbed
• Falls Most common cause of head injuries
  incurred by infants and young children and by
  persons age 64 and older
• Accidents involving motor vehicles account for
  approximately half of all head injuries in the
  other age groups
• Except over age 75 age group, males sustain
  injuries twice as frequently as women

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A Brief Look at Head Trauma

• Additional risks factors for falls and assaults
• Lower SES
• Unemployment
• Lower educational levels

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A Brief Look at Head Trauma

• Assaults accounts for 25-40 of brain injuries
  and include
• Blows to head
• Penetrating weapons
• Sports/recreational activities
• On the job injuries
• Closed Head Injury
• Majority of head trauma
• Skull remains intact and brain is not exposed
• Open Head Injury-Skull is penetrated

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A Brief Look at Head Trauma

• Behavioral Effects dependent on
• Severity of injury
• Site of lesions
• Premorbid personality

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A Brief Look at Head Trauma

• How injury occurred (MVA, blow to head, missile)
• Severity
• Site of focal damage

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A Brief Look at Head Trauma

• Risk Factors
• Coma Duration Poor Predictor for many patients
  with brief coma period (20-30 minutes) but good
  predictor for more severe injuries
• Internal bleeding (2 or more days later)
• Delayed trauma including intracerebral hematoma
  (DTICH)

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A Brief Look at Head Trauma

• Glascow Coma Scale (GCS) Classification system
  that measures presence, degree and duration of
  coma.
• Patients with left lateralized penetrating wounds
  to brain more likely to suffer LOC than those
  with injuries on right side
• Duration shorter for those with right sided
  lesions
• Alcohol intoxication can lower Glascow Coma Score

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A Brief Look at Head Trauma

• Penetrating/Open Head Injuries
• Amount of damage determined by amount of energy
  translated to the brain- Clean Wounds
• Significant tissue damage tends to be
  concentrated in path of intruding object
• Surgical cleansing of wound (debridement)
  typically removes damaged tissue along with
  debris.
• Most of brain remains in tact
• Circumscribed focal lesion usually produces
  relatively circumscribed predictable cognitive
  losses.

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A Brief Look at Head Trauma

• Penetrating Object can also cause diffuse damage
  as a result of
• Shock waves and pressure effects
• Extent and severity depend on physical affects
  such as speed, wobble and malleability of the
  penetrating object
• Low velocity considered under 1000ft/sec typical
  of civilian bullets and older military missiles
• More extensive damage results in hemorrhages,
  ischemia (absence of normal blood flow in
  effected area), edema (tissue swelling)
• Extensive damage and velocity of penetrating
  objects exceeds 1,000ft/sec as in modern weaponry

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A Brief Look at Head Trauma

• Closed Head Injury Brain damage occurs in 2
  stages
• Primary Injury-damage occurs at time of impact
• Second Injury-effects of the physiological
  processes set in motion by primary injury

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A Brief Look at Head Trauma

• Primary Injury Common Symptom Patterns
• Static Injury Relatively still victim receives
  blow to head
• Point of impact (Coup) followed by rebound
  effects (Countrecoup)
• Brain sustains bruise or contusion in area
  opposite blow
• Coup and Contrecoup lesions account for specific
  and localized behavior changes that accompany
  closed head injuries

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A Brief Look at Head Trauma

• Whiplash Acceleration/Deceleration forces
  resulting in rapid flexion-extension movement of
  the neck
• Effects of acceleration/deceleration is called
  concussion-does not require direct impact to head
• Hemorrhages create hemotomas-swellings filled
  with blood within the skull

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A Brief Look at Head Trauma

• Secondary Injury May be as destructive if not
  more, of brain tissue as the accident's immediate
  effects
• Most prominent processes are
• Hemorrhages
• Tissue Swelling
• Alterations in blood volume and blood flow

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A Brief Look at Head Trauma

• The collection of edema (collection of fluid in
  and around damaged tissue) produces increased
  intracranial pressure (ICP) which produces
  swelling.
• Swelling compounds whatever damage has taken
  place to brain tissue
• Heightened ICP is most frequent cause of death in
  closed head injuries
• ICP tends to be strong predictor of severe
  chronic impairment
• Control of intracranial pressure is the most
  important medical consideration in the acute care
  of head trauma

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A Brief Look at Head Trauma

• Additional Risk Factors
• A single traumatic injury to the brain doubles
  risk for future head injury
• Two brain injuries raises risk eightfold
• Contact sports-high risk- soccer, boxing,
  football
• Pre-injury alcohol abuse-poorer outcomes for
  recovery

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A Brief Look at Head Trauma

• Case Study Mike S.
• Mike is a 28 year old male who was struck by
  lightening and fell from a work station eight
  feet above ground, striking the left side of his
  head. His neuropsychological test results
  displayed only mild language deficits and all
  aspects of response speed, motor control, and
  attention, concentration, and mental tracking
  were above average.
• However, he could no longer perform complex
  mechanical construction work and he failed on an
  aptitude test of visuographic functions and had
  difficulty with block and puzzle construction.
  His wife complained that he had become
  insensitive to her emotional states as well as
  socially inappropriate.
• Based on this information, what does this pattern
  suggest?

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A Brief Look at Head Trauma

• Presented by
• Dr. Christine Cauffield
• President and CEO
• Cauffield and Associates, LLC.
• For a copy of this presentation
• Email drcauffield_at_aol.com