Abnormal Brain Changes

1. Abnormal Brain Changes What happens when something goes wrong…..

2. Objectives • Identify manifestations of abnormalities in brain function associated with aging. • Explore interventions and treatments to maximize functioning when pathology is present.

3. The Three D’s • Delirium • Depression • Dementia

4. Delirium • Delirium is often unrecognized • Delirium might be the only indication of a life threatening condition • Extremely important to identify

5. Delirium • Approximately 14-80% of hospitalized elderly patients experience an episode of delirium • Can represent a medical emergency and is a potentially reversible condition • Requires immediate interventions to prevent permanent disability and health risks including death

6. increased length of hospitalization and increased hospital mortality rates of approximately 25-33% greater intensity of nursing care more frequent use of physical restraints greater in-hospital functional decline greater health care costs worse outcomes in severe delirium especially at 6 months (e.g., ADL and ambulatory decline, nursing home placement and death) Delirium in older adults results in:

7. Delirium DSM-5 • Disturbance in attention (reduced ability to direct, focus, sustain, and shift attention) and awareness(reduced orientation to environment) • Develops over a short period of time, a change from baseline, fluctuates during the course of a day

8. Delirium DSM-5 • An additional disturbance in cognition (memory deficit, disorientation, language, visuospatial ability, or perception) • The disturbances are not better explained by another preexisting, established, or evolving neurocognitive disorder

9. Delirium DSM-5 • Evidence from history, physical exam, or lab findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or is due to multiple etiologies

10. Confusion Assessment Method (CAM) • 1) Acute onset and fluctuating course • 2) Inattention • 3) Disorganized thinking • 4) Altered level of consciousness Delirium requires the presence of 1 and 2 plus either 3 or 4

11. Types of Delirium • Hyperactive • Agitated • Restless • Yelling • Hypoactive • Inactivity • Withdrawal • Mixed

12. Hypoactive Delirium • Hardest to recognize • May look like depression • Subdued, quiet • Extremely important to recognize and look for medical cause

13. Chronological age – very young and very old Sensory deficits Dehydration Sleep disturbances Pre-existing dementia Cognitive impairment Immobility or use of restraints Medications–anticholinergic meds Metabolic abnormalities Comorbidities Presence of urinary catheter Under and over treatment of pain Withdrawal Delirium – Causes and Risks

14. Treatment of Delirium • First have to recognize it • Search for underlying cause • Environment conducive for orientation • Maintain safety and comfort • Encourage mobility – avoid bedrest • Environment conducive for sleep • Optimize hearing and vision • Avoid dehydration • Avoid catheters • Avoid deliriogenic medications • Maximize the familiar and avoid distractions

15. Depression • Most common psychiatric condition affecting older adults • “Common cold” of psychiatry • Leading cause of disability in the US and the world (NIMH) • Often under-diagnosed and under-treated

16. Important to recognize depression because • Robs elderly of late life satisfaction • Causes impairment in cognitive, social and personal functioning • Involves undue suffering for patient and often their family • Causes excess morbidity and mortality • Could be a symptom of an underlying medical condition

17. Important to recognize depression because • Increased risk of suicide • Increased economic burden • Could lead to substance abuse or misuse • Treatment is often very effective

18. Depression • In older adults, depression may mask, or be masked by, other physical disorders. • Is difficult to disentangle depression from the many other disorders affecting older people

19. Statistics • Of the 35 million over age 65 in US, 2 million meet criteria for major depression and another 5 million have depressive symptoms • One primary care study found that 11% of depressed patients were adequately treated, 34% were inadequately treated, and 55% received no treatment.

20. Criteria for Major Depression • At least 5 symptoms must be present in the same 2-week period and must include either • 1) Depressed mood • 2) Loss of interest or pleasure

21. Major Depression • 3) Change in appetite or weight • 4) Insomnia or hypersomnia • 5) Psychomotor agitation or retardation • 6) Fatigue or loss of energy • 7) Feelings of worthlessness or guilt • 8) Difficulty with thinking or concentration • 9) Thoughts of death or suicide

22. Low Mood • Elderly may not admit or report sadness • In general, elderly are less verbal about feelings • May be masked by somatic complaints • Common are headache, nausea, constipation, anorexia, “Just don’t feel well,” GI upset, pain • Preoccupation with physical health

23. Decreased Interest • Less interest in hobbies or recreational activities • Daily chores left undone • Social withdrawal • Less interest in sex • May neglect personal hygiene or appearance • Less able to experience pleasure

24. Appetite Changes • Most often, decreased appetite but may be increased • Monitor weight • May complain that food has no taste • At risk for dehydration, electrolyte imbalance, and malnutrition

25. Sleep Disturbance • Insomnia or hypersomnia • Early morning awakening • Middle insomnia • Waking too early

26. Psychomotor symptoms • Agitation – restlessness, irritable, appear anxious and distressed, hand wringing • Slowness in movement, slowed speech, latency of response

27. Lack of energy • Tired and worn out • Everything is just too much effort • Poor time management • Apathetic • “It’s too much work.”

28. Feelings of worthlessness/guilt • Blames self for things done and undone • Feelings of being of “no value” • Hopelessness, worry • Future is bleak • Self-reproach, critical of self and others • “Don’t spend time with me; I’m not worth it.” • May be delusional

29. Difficulty with concentration • Slowed thinking • Inability to focus or concentrate • Indecisive • Feels confused and bewildered • Ruminations about insignificant problems • Negativity

30. Thoughts of death or suicide • Weary of life • Life isn’t worth living • “I’d be better off dead.” • “You’d be better off if I weren’t here.” • Passive suicide • Refuse to eat • Refuse medications

31. Causes of Depression • Interaction of biological and psychosocial factors • Possible genetic contribution • Reaction in response to losses • Unresolved grief • Physical illnesses may lead to depression • Medications may cause symptoms of depression

32. Interventions for Depression • Involve the person’s family • Obtain an evaluation by a professional • Every interaction has the potential to help • Communicate a caring attitude • Support and encourage • Provide opportunity for social interactions • Involve in scheduled or structured activities • Spend time with the person and listen

33. Interventions for Depression • Encourage physical activity • Mobilize support systems • Monitor physical health • Medication monitoring • Nutrition and weight • Sleep • Comfort and relaxation • Management of pain • Beware of being “too cheerful”

34. Interventions for Depression • Antidepressant medications take time to exert a therapeutic effect • Monitor for suicidal thoughts, especially as depression starts to improve • Promote a positive attitude toward the future – “I know that you feel this way now, but you won’t always.” • Remember that depression is usually very treatable over time

35. Anxiety • A subjective state of dysphoric apprehension or expectation accompanied by physiological responses • Symptom of many disorders including depression, dementia, delirium • Primary symptom of anxiety disorders

36. Symptoms of Anxiety • Excessive worry that person finds difficult to control • Complaints of shakiness, restlessness, jitteriness, jumpiness, trembling, tension, irritability, impatience, poor concentration, memory problems, unrealistic fears • Feeling of impending doom • Anticipation of the worst that could happen

37. Symptoms of Anxiety • Physical symptoms including: • palpitations, chest pain • dizziness, lightheadedness • tingling, numbness • stomach upset, diarrhea • too hot or too cold, sweating • shortness of breath, sensation of lump in throat or choking • sleep disturbance

38. Potential Causes of Anxiety • Medical illnesses • hypoglycemia, hyperthyroidism • Medications • caffeine, stimulants, sympathomimetics • Withdrawal states • alcohol, benzodiazepines • Situational anxiety • going to a dentist, flying

39. Anxiety Disorders • Panic disorder • Agoraphobia • Phobias • Obsessive-Compulsive disorder • Posttraumatic stress disorder • Acute stress disorder • Generalized anxiety disorder

40. Interventions for Anxiety • Minimize caffeine • Social interaction • Relaxation techniques • Diversion and recreational activities • Physical exercise • Counseling or psychotherapy • Medication, if use is justified

41. DSM 5 – Neurocognitive Disorders • Minor Neurocognitive Disorder • Major Neurocognitive Disorder

42. DSM-5 Cognitive Domains • Complex attention (Sustained and divided attention, processing speed) • Executive ability (Planning and decision making) • Learning and memory (Recall and recognition) • Language (Expressive and receptive) • Visuoconstructional-perceptual activity (Construction and visual perception) • Social cognition (Emotions and behavioral regulation)

43. Minor Neurocognitive Disorder • Evidence of minor cognitive decline from a previous level of performance • Deficits not sufficient to interfere with independence • Deficits do not occur exclusively in context of delirium

44. Major Neurocognitive Disorder • Greater cognitive deficits in at least one (typically 2 or more) cognitive domains • Evidences of significant cognitive decline from previous level of performance • Deficits sufficient to interfere with independence • Deficits do not occur exclusively in context of delirium

45. Alzheimer’s Disease A chronic, progressive, irreversible, neurological disorder affecting memory, cognition, ability to function, personality, language, and behavior

46. Three Stages of Alzheimer’s Disease • Preclinical – pathophysiological changes in the brain, but cognitively normal • Mild cognitive impairment due to AD – clinical and research criteria • Dementia due to Alzheimer’s Disease – Possible, Probable, Probable with evidence of AD pathophysiology

47. Biomarkers – used in research • Cerebral spinal fluid • Phospho-tau concentration elevated • Amyloid beta (1-42) peptide reduced • AT Index <1 consistent with Alzheimer’s • PET scan with special imaging agent • Demonstrates amyloid burden • Blood or urine tests – not available yet

48. Alzheimer’s Disease • Alzheimer’s is the most common form of dementia • 5.4 million people in US have DAT • 1 in 8 elderly has DAT • About 500,000 Americans <65 years old have a dementia; 40% of those have DAT • Alzheimer’s is the 6th leading cause of death in the US

49. Pathophysiological Changes • Neurofibrillary tangles • Amyloid plaques • Cerebral atrophy

50. Brain Functions Affected Short-term memory - Hippocampus involved • Can’t make deposits into “memory bank” • Like a computer with a faulty save function • “Floating” reference point for time