Cognitive Disorders

1. Cognitive Disorders Chapter 14

2. Cognitive Disorders aka Organic Brain Diseases � behavioral changes that have a basic in some manner of organic change. Organic Mental Syndrome � psychological or behavioral signs that are of unclear etiology.

3. Delirium Over 2 million elderly individuals annually experience some degree of delirium. A state of confusion and reduced awareness. Common in long-term care facilities for residents over 75 y.o. (approx. 60%). Develops relatively quickly. Cause is some underlying medical condition.

4. 3 Components Perception-reduced ability to distinguish and integrate sensory information. Thinking-fragmented and disorganized, compromising ability to reason, judge, abstract and problem-solve. Memory-unable to register, retain, and recall information.

5. Characteristic Presentations Disorientation. Perceptual disturbances (hallucinations; dreams). Delusional thinking. Agitation. Sleep disturbance. Possible convulsions. Emotional upset.

6. Attentiveness/Wakefulness Reduced alertness. Unable to focus attention. Unable to think in an organized, linear fashion. A dreamlike state; a �clouding� of consciousness.

7. Psychomotor Changes Hyperactive or hypoactive. May alternate between the two. Choreiform movements may be present. Agitation and activity level may increase at night; �sundowner�s syndrome�.

8. Delirium vs Dementia Review comparison on Table 12-1, p. 239. In delirium, consciousness fluctuates. In delirium, attentiveness is unstable. Delirium is relatively short-lived. Delirium develops quickly. Delirium usually traced to recent cause.

9. Dementia Functional declines in multiple cognitive abilities occurring progressively over time. Cognitive impairments in thinking, memory, judgment, insight, and language, accompanied by personality changes. Two major classifications; �cortical� (e.g. Alzheimer�s disease) and �sub-cortical� (e.g. Huntington�s disease) dementias.

10. Incidence Prevalence is 1% of individuals at 65 years and doubles every 5 years of age after 65. Alzheimer�s disease alone effects 4 million individuals in the U.S. Over 60% of nursing home residents are diagnosed with dementia.

11. Alzheimer�s Disease Most common form of dementia in older adults. 1 in 10 individuals over age 65, and nearly 5 out of 10 individuals over age 85, have this type of dementia. Cost of care for those with Alzheimer�s disease in the U.S. represents $100 billion.

12. 1st described by Alois Alzheimer in 1907. Defined by characteristic brain plaques and neurofibrillary tangles. AD also destroys neurtons that secrete acetylcholine, neurotransmitter involved in memory.

13. Signs of Alzheimer�s Disease Aphasia-loss of language ability. Anomia-progressive difficulty remembering words. Agraphia-progressive loss in ability to express thoughts in writing. Alexia-inability to understand written language.

14. Signs (cont.) Apraxia-loss of ability to initiate purposeful movements (despite intact motor neurons). Agnosia-inability to recognize known objects and people; a �labeling� deficit. Mnemonic disturbance-loss of memory beginning with recent events and progressing backwards to more remote loss.

15. Stages of Alzheimer�s Disease Stage I: -decreased concentration. -difficulty with complex tasks. -time disorientation. -judgment with social propriety declines. -word-finding and object-naming difficulties. -accusatory behavior; mild paranoia. -anxiety an depression. -growing frustration and shame.

16. Stages (cont.) Stage II: -progressive memory loss to more remote events. -inability to recognize family members. -socially unacceptable behavior; poor impulse control. -emotionally labile. -disoriented X3. -misidentification, i.e. strangers appear familiar. -sleep disturbance; less sleep time; wandering. -accidents common.

17. Stages (cont.) Stage III: -hyperorality; binging. -hyperetomorphosis (compulsive touching and examination of objects in the environment). -deterioration in motor skills. -deterioration in emotional responsiveness.

18. Mini-Mental Status Exam Useful tool to establish baseline functioning and track deterioration over time. Max. score is 30 with points assigned to each task in the exam; score is a fracture of number correct over the possible total. Unable to use on patients with significant motor impairment. Average decline of 3 points per year in Alzheimer�s.

19. Dementia with Lewy Bodies aka �Lewy Body Dementia�. 2nd most common dementia after Alzheimer�s. Characterized by build-up of Lewy Bodies-bits of protein collecting in the neurons relating to memory and motor control. �Parkinson-like� or extrapyramidal symptoms with dementia. Confusion, disturbance in consciousness. Fluctuating cognitive abilities; unpredictable episodes of confusion.

20. Lewy Body (cont.) Psychotic symptoms, esp. detailed visual hallucinations. Other psychiatric symptoms; depression, aggressiveness, delusions. Sleep disturbance. Severe sensitivity to neuroleptics with possible life-threatening EPS reactions. Lewy Body Dementia may be co-morbid with Alzheimer�s.

21. Sub-Cortical Dementias Vascular Dementia: -aka Ischemic Vascular Dementia (IVD). -approx. 19% of all dementias. -abrupt onset and episodic with periods of remission. -focal neurological signs, e.g. one-sided weakness and/or emotional outbursts. -brain tissue is destroyed by intermittent emboli.

22. -risk factors are diabetes, hypertension, cardiovascular disease. Parkinson�s Disease: -recently associated with dementia in a minority of individuals. -may also be co-morbid with Alzheimer�s.

23. Huntington�s Disease: -hereditary disease with symptom onset between 40-50 years of age.-characterized by chorea movements (jerky, purposeless movements) and mood disturbances (especially depression). -death usually occurs within 15 years. -currently no meaningful treatment.

24. Pick�s Disease: -cerebral atrophy of the frontal and temporal lobes. -characterized by fluctuating symptoms of hyperverbal speech, elevated mood, anxiety, hyperattentiveness, dullness, inertia. -progressive deterioration leading to impaired memory and speech. -Pick inclusion bodies in the neurons. -death within 7 years of diagnosis.

25. Creutzfeldt-Jakob Disease: -degenerative dementia transmitted by infection. - �prion�-infectious protein as agent of transmission. -rapid onset. -involuntary movements, cerebellar ataxia, myoclonic jerks.

26. -possible genetic susceptibility to infection. -contracted after material from infected host transplanted or injected.

27. Assessment Delirium: -frequently the result of medication effects or combination. -UTIs. -infection. -electrolyte imbalance. -malnutrition. -dehydration. -alcohol withdrawal.

28. Assessment (cont.) -trauma. -substance abuse. Evaluate rapidity of onset. See typical lab. profile, p. 248. Mental status examination, full and mini-. Collateral history-taking.

29. Treatments Grief/loss issues. Supportive care. Respite resources. Symptomatic pharmacology (antidepressants, anti-psychotics, anxiolytics).

30. Acetylcholinesterase inhibitors-inhibits the enzyme that breaks down acetylcholine. Dementia patients have deficits in acetylcholine, necessary for memory, logical progression in thinking. Inhibitors most effective if given early, to slow degeneration (e.g. Cognex, Aricept, Exelon).