Aging

1
Aging Cognition
2
Parts of the Brain
3
Age-related Changes

• Changes that were once thought to be age-related
  now are thought to be disease-related
• Some of the normal aging changes in the brain are
  similar to the disease-related changes

4
Age-related Changes (contd)

• about 40 of people 65 will have slight
  changes to memory
• only about 1 of these will progress to dementia
  each year

5
Cognitive Functioning

• Fluid Intelligence
• Includes abstraction, calculation, common sense,
  breadth of knowledge
• Begins to decline in early adulthood
• Depends on a persons inherent abilities, such as
  memory, pattern recognition and the CNS
• Implications slower processing time. Older
  persons need more time to process and react to
  information

6
Cognitive Functioning (contd)

• Crystallized Intelligence
• Includes vocabulary, general information,
  understanding social interactions, ability to
  evaluate experiences
• Includes the cognitive skills that are acquired
  through culture, education, information learning,
  and other life experiences

7
Cognitive Functioning crystallized intelligence
(contd)

• Associated with wisdom, judgment and life
  experiences
• Continues to develop throughout adulthood does
  not change with age

8
Risk Factors that affect Cognition
9
Risk Factors that affect Cognition (contd)
10
Forms of Cognition/Cognitive Impairment
AAMI
CIND
MCI
Dementias
Delirium
Sundown
Depression
CJD
Lewy body
AD
MID
Picks
11
Age-Associated Memory Impairment
12
Cognitive Impairment no Dementia
13
Mild Cognitive Impairment(MID)
14
Definition of Dementia

• a chronic deterioration of intellectual function
  and other cognitive skills severe enough to
  interfere with the ability to perform activities
  of daily living
• (Merck Manual of Diagnosis Therapy, 2000)

15
The Dementias

• Dementia is not a single disease, but a syndrome
• More than one type can exist at one time
• Diagnosis tends to be misused and overused

16
Prevalence of Dementia

• -- of those 85 years and who suffer from
  dementia, almost 50 live in the community
• -- those 85 who have dementia and live in the
  community
• - 45.5 have mild dementia
• - 44.5 have moderate dementia
• - 10.0 have severe dementia
• -- the prevalence of dementia rises with age

17
Definition Diagnostic criteria for Dementia

• Development of multiple cognitive deficits
  manifested by both
• 1. memory impairment (impaired ability to
  learn new information or to recall previously
  learned information)

18
Criteria for dementia (contd)

• 2. One (or more) of the following cognitive
  disturbances
• --Aphasia (language disturbance)
• -- Apraxia (impaired ability to carry out motor
  function despite intact motor function
• --Agnosia (failure to recognize or identify
  objects despite intact sensory function)
• --Disturbance in executive functioning

19
Criteria for dementia (contd)

• B. The cognitive deficits in criteria A1 and A2
  each cause significant impairment in social or
  occupational functioning and represent a
  significant decline from previous level of
  functioning.
• (DSM-IV)

20

• Misdiagnosis may occur because of

21
What is it like to become increasingly forgetful?
What is it like to become increasingly forgetful?

• Hes not himself somehow
• She never used to be like that
• How do people with early dementia see
  themselves?

22
Types of Dementia (contd)

• Irreversible
• Alzheimer disease
• Lewy body dementia
• Picks (frontal lobe dementia)
• Multi-infarct dementia
• Parkinsons
• Creutzfeld Jakob disease

23
Alzheimer disease
24
Pathophysiology of A.D.

• The presence of neurofibrillary tangles and
  neuritic plaques
• 1) neuritic plaques increase in number and are
  abnormally distributed
• 2) neurofibillary tangles abnormal bundles
  of protein ( B amyloid) that interfere with nerve
  functioning

25
(No Transcript)
26
Pathophysiology of A.D. (contd)

• 3) decrease in neurotransmitter acetylcholine
• 4) several point mutations in the gene coding
  of ApoE (it is involved in synaptic repair)
• 5) accumulation of homocysteine

27
(No Transcript)
28
Risk Factors for AD
29
Diagnosis of AD
30
Probable Diagnosis of AD
31
Stages of AD
32
Stages of AD (contd)

• Stage 1

33

• Stage 2

34

• Stage 3

35
Assessing for Dementia

• ?Patient history
• ?Collaborative history
• ?Physical Examination
• ?Laboratory tests
• ?Assessment tools

36
Mini Mental State Examination

• Assessment tool -- MMSE
• Score below 24 are considered indicative of
  cognitive impairment
• Education and culture can affect test results

37
Interventions

• No treatments to cure the disease
• Strategies to support and sustain
• Primary objective is to maintain abilities as
  long as possible
• Careful attention to factors that create excess
  disability

38
Interventions

• Steps to consider
• Define the behavior
• Assess the physical cause
• Review environment
• Review psychiatric status
• Institute behavioral approaches
• Initiate drug therapy

39
Multi-infarct Dementia (MID)
40
MID (contd)

• Diagnostic criteria for MID
• Abrupt onset with focal neurological signs and
  symptoms
• Stepwise decline with a fluctuating course
• History of TIAs, hypertension, strokes, diabetes
  mellitus, vasculitis and cardiac arrhythmias,
  family hx of strokes

41
MID (contd)

• Risk factors
• Hypertension -- age
• Diabetes -- gender
• Heart disease -- race
• Heredity
• Overweight

42
Types of Dementia

• Reversible
• Delirium
• Depression

43
Deliriumacute confusional state

• A disturbance of consciousness with reduced
  ability to focus, sustain, or shift attention
• Marked contrasts in levels of awareness/alertness
• Difficulty maintaining or shifting attention and
  difficulty with concentration

44
Delirium (contd)

• Change in cognition
• Memory deficits
• Disorientation
• Language disturbance
• or
• Development of a perceptual disturbance that is
  not better accounted for by a pre-existing,
  established, or evolving dementia.

45
Delirium (contd)

• The perceptual disturbance includes
• Disordered thinking with or without frank
  psychotic symptoms
• Hallucinations and illusions occur in 40 of
  cases
• Usually visual
• Auditory and tactile hallucinations can also occur

46
Delirium (contd)

• Acute onset and fluctuating course
• Develops over a short period of time
• Tends to fluctuate during the course of the day
• Drowsiness, hypervigilence, lucidity, and
  agitation may occur within a short period of time
• Sleep-wake cycle disturbances and sundowning

47
Delirium (contd)

• 4.General medical condition
• -- medical condition
• -- substance intoxication
• -- substance withdrawl
• -- multiple etiologies

48
Delirium (contd)

• Prevalence
• Acute geriatric unit -- 42 of patients were
  delirious during their hospital stay
• Medical units 10-15 are delirious on
  admission 15-20 are delirious while in hospital
• Surgical units 10-15 post-op 30-50 for those
  with hip replacement

49
Delirium (contd)

• Over 100 causes

50
Delirium (contd)
51
Delirium (contd)

• 3 types of delirium
• Hyperkinetic
• Hypokinetic
• Mixed delirium

52
Assessing

• History from patient and family
• Physical examination
• Laboratory tests
• Assessment tools

53
Assessment tools

• Mini Mental State Examination (MMSE)
• Confusion Assessment Method (CAM)

54
Interventions

• Behavioral
• Functional
• Cognitive/emotional
• Environmental
• Pharmacotherapy

55
Depression

• Characterized by feelings of sadness, despair,
  and discouragement
• The most common psychiatric illness from
  adolescence to old age
• Prevalence varies depending upon gender, age,
  living situation, criteria used

56
Depression (contd)

• Types of depression
• A group of disorders that vary in severity
• Classified into types based primarily on
• Symptoms
• Duration
• Severity

57
Depression (contd)

• Types of depression
• Major depression
• Dysthymia
• Adjustment disorder with depressed mood

58
Major Depression (contd)

• Depressed mood
• Loss of interest/pleasure in activities
• and
• 3. Change in appetite, usually weight loss
• 4. Insomnia or hypersomnia
• 5. Psychomotor retardation or agitation
• 6. Fatigue or loss of energy
• 7. Feelings of worthlessness excessive or
  inappropriate guilt
• 8. Diminished ability to think or concentrate
• 9. Recurrent thoughts of death or suicide

At least 5 symptoms must be present for at least
2 weeks and 1 2 must be present
59
Suicide and Older Adults

• Suicide among seniors is a significant social
  concern in Canada
• Suicides tend to be lethal
• Suicide rate for white oldest, old men is
  higher than the general population

60
Depression Older Adults
It is not a natural consequence of aging
Older adults tend to deny Feelings of depression
distress
Dx more difficult because of presence of
chronic illness
Pseudomentia
61
Assessing

• Patient history (medical social)
• Physical examination
• Laboratory tests
• Medication review
• Alcohol history
• Collaborative history
• Assessment tools

62
Assessment Tools

• Mini Mental State Exam (MMSE)
• In some cases depression can mimic dementia
• If MMSE score gt 23 administer GDS
• If MMSE score lt 23 establish whether this is an
  acute change in mental status

• Geriatric Depression Scale (GDS)
• 2 versions (long short)
• Cut off score on short form is 8
• The higher the score the more likely the person
  is experiencing depression

63
Goals of Treatment
64
Treating Depression

• Complex and multifaceted involving
• Cognitive therapy
• Behavioral/functional interventions
• Emotional/social treatment
• Pharmacotherapy
• Electroconvulsive therapy (ECT)