Early Detection of Cognitive Disorders

1. Early Detection of Cognitive Disorders Robin J. Heinrichs, Ph.D., LP Neuropsychologist & Assistant Professor Director of Neuropsychology Laboratory

2. What is cognition? Thinking All the things our brain does to help us do things, learn things, and verbalize and understand others.

3. To name a few … • Learning • Memory • Attention • Speed of processing • Visuospatial abilities • Planning Comprehension Verbal fluency Solving problems Switching between tasks Abstract thinking Sequencing activities

4. Does cognition change with age? • Processing speed … influences … • Attention • Word-finding • Memory • Cognitive flexibility • Less efficient at learning new information • Therefore poorer recall • 30 years and after …

5. Normal/typical aging Not impairment Noticeable Annoying Function fine

6. When to be concerned? • Decline is worsening • Interferes with functioning • Others around us concerned • What could this be? • Dementia

7. What is dementia? Dementia is an enduring decline in cognition that interferes with functioning in everyday living. American Psychological Association

8. Dementia is an enduring decline in cognition that interferes with functioning in everyday living. American Psychological Association Changes are worsening, often gradually over time Different types of dementia follow different patterns of decline

9. Dementia is an enduring decline in cognition that interferes with functioning in everyday living. American Psychological Association Some portion of cognitive abilities have declined Pattern of decline varies depending on the cause Decline is in more than one area of cognition

10. Dementia is an enduring decline in cognition that interferes with functioning in everyday living. American Psychological Association • The change in cognitive functioning must be severe enough to make it harder for the individual to carry out activities of daily living • Managing finances • Managing medication • Maintaining a calendar and going to appointments on time • Preparing meals

11. Dementia is a general diagnosis If decline in cognitive abilities and difficulty functioning are severe enough = Dementia • Cognitive decline that is 2 standard deviations below previous • Decline in more than one cognitive domain A diagnosis of Dementia does not tell you what is causing the decline.

12. Dementia can be caused by many diseases and pathologies that have affected the brain. Knowing the cause tells us what to expect in the future.

13. Early detection benefits Allow the individual to plan and make decisions for themselves before they are unable to do so Allow the patient and family to ensure safety and well-being over time Future – hope is that treatments will be found to intervene early in the disease (pre-clinical)

14. Types of dementia Alzheimer’s disease Frontotemporaldisease Vascular disease Parkinson’s disease Lewybody Other

15. Alzheimer’s disease (AD) The best method of early detection of Alzheimer’s disease and other dementing processes is Neuropsychological assessment. 4 years before diagnosis Poorer memory for new information than others same age = Alzheimer’s diagnosis later

16. Best Predictors of AD – Preclinical Stage • Naming & fluency • Verbal memory • Abstract reasoning • Gradual decline in memory for new = Best preclinical predictor

17. Clinical AD cognitive impairments: Learning and memory Trouble naming and verbal fluency Visuospatial abilities Carrying out tasks (apraxia) Executive functioning (problem-solving, sequencing, set-shifting, concept formation, abstract thinking) Lack of awareness of impairment (agnosia)

18. AD is a disease in which nerve cells in the brain degenerate and die Historically the disease was identified by amyloid plaques and neurofibrillary tangles in the brain upon autopsy Today we think this is late in the disease and these are found in brains without AD Research continues with promise

19. Temporal lobe First notice trouble remembering things - May repeat the same questions or stories Damage to the temporal lobe of brain

20. Frontal lobe • The frontal lobe experiences damage next. • This causes problems with executive functioning. • Focusing • Multi-tasking • Problem solving • Staying on track with a task • Switching between tasks • Abstract thinking • Comprehension of complex information

21. Course of AD: • Gradual decline in abilities • Increasing need for assistance • First with independent tasks - finances and medication management • Then daily tasks like dressing and bathing • Course of disease varies and can range from six to fifteen years.

22. Frontotemporaldisease (FTD) Caused by degeneration and death of nerve cells within the frontal lobes and the temporal lobes. In general caused by loss of neurons and abnormal amounts or forms of tau proteins in the brain. FTD is relatively difficult to diagnose as a decline in memory is not associated. Instead, executive functioning abilities decline.

23. FTD looks different Executive functioning changes: • Focusing without distraction • Planning and sequencing • Solving problems • Comprehending complex information • Multitasking • Focus on unimportant details and missing the big picture Personality changes • Often looks like a psychiatric disorder

24. Of all changes, changes in personality are often the most upsetting to families • Failure to inhibit inappropriate behaviors, e.g. loud, rude comments in front of others that do not bother the patient • Inappropriate sexual comments to others • Flattened reaction to emotional events, e.g. when spouse is upset they do not react • OR … more easily irritated or upset, more often tearful

25. Primary progressive aphasia Form of FTD Trouble coming up with what you want to say. Difficulty finding the right word. Pronunciation problems. Paraphasia; saying words that sound like the one you want. Trouble reading. Difficulty writing.

26. Course of FTD: Gradual decline in cognitive and functional abilities Gradually increasing need for assistance with tasks Because trouble carrying out tasks is primary difficulty, assistance is often needed earlier in the disease Course varies from several years to ten years.

27. Vascular dementia Vascular dementia is caused by cerebrovascular disease through any insult to the brain by blocked blood flow or a bleed within the brain. Terms used include: stroke, transient ischemic attack (TIA), hemorrhage, ischemia, embolism, thrombosis, infarct These events cause brain cells to die in the affected areas. This causes cognitive deficits that coincide with the area of insult.

28. For example, if a blockage or bleed occurs in certain areas of the left hemisphere, patient will have difficulty speaking or understanding what is said. The bigger the area of insult the more cognitive damage. The longer the anoxic insult or the bleed, the greater the cognitive decline.

29. Important! • Cognitive decline in vascular dementia is more sudden than AD or FTD. • Insult … then cognitive decline … then some recovery … left with enduring deficit • Step-wise decline • If no more vascular insults occur cognitive abilities will not decline more. • BUT … past CV disease makes future CV disease more likely.

30. Other causes of dementia Parkinson’s disease – not all incur cognitive decline Huntington’s disease Multiple sclerosis Lewybody disease Anoxic insult

31. Signs to look for Patient or family mention … • Personality change • More irritable • More laid back • Tearful • Disinhibited • Lack of motivation, interest in things • Lack of awareness of any deficits • Difficulty getting along with others • Work is harder now • Poor review or criticism from boss at work

32. Takes longer to figure things out Patient stopped fixing things around house, quit using computer, etc. Patient stopped reading or other activities they used to do Financial problems, late bills or trouble with bank Car accidents or tickets; doesn’t like to drive now Repeating themselves or asking others the same questions; forgetting

33. Then what? • Schedule a neuropsychological evaluation • KUSM Memory and Cognition Clinic • 293-3850 • 7829 E. Rockhill, Wichita KS 67206