1	Delirium, Dementia, & Other Cognitive Disorders Sonia Dhaliwal, M.A. Anticipated Conferral for PhD 2010
2	Overview of Agenda for 5/1/08 Basic Neuroanatomy of how brain works What parts of the brain are involved in Alzheimer's? Differences between Delirium, Dementia & Alzheimer’s How does the patient with Alzheimer’s present? Basic Statistics Clinical Course of the illness The Spectrum of Alzheimer’s Disease 7-stages Q & A J
3	Some useful terms Amnesia: A loss of memory. It can be retrograde (loss of memory for events that occurred before a certain time) or anterograde (loss of ability to form new memories) Aphasia: Disturbance of language use. Due to brain pathology, the patient becomes unable to use words as symbols Apraxia/Agnosia: Inability to recognize familiar objects, even though senses required for this recognition are intact
4	Some Myths about Alzheimer’s Disease Myth 1: Memory loss is a natural part of aging. Myth 2: Alzheimer’s disease is not fatal. Myth 3: Only older people can get Alzheimer's Myth 4: Drinking out of aluminum cans or cooking in aluminum pots and pans can lead to Alzheimer’s disease Myth 5: Flu shots increase risk of Alzheimer’s disease Myth 6: There are treatments available to stop the progression of Alzheimer's disease
5	“Alzheimer’s?” Dr. Alois Alzheimer, a German doctor. In 1906, Dr. Alzheimer noticed changes in the brain tissue of a woman who had died of an unusual mental illness. He found abnormal clumps (now called amyloid plaques) and tangled bundles of fibers (now called neurofibrillary tangles). These plaques and tangles in the brain are considered signs of AD.
6
7	Brain parts affected by Alzheimer’s Disease
8	Basic Neurophysiology 101 Frontal Lobes: Motor function (i.e., body movements) Problem solving Spontaneity, memory Language, initiation Judgment Impulse control Social and sexual behavior
9	Basic Neurophysiology Cont’d “Behavioral spontaneity” (Kolb & Milner, 1981): --Individuals with frontal damage displayed: Fewer spontaneous facial movements, Spoke fewer words (left frontal lesions) or Excessively (right frontal lesions).
10	Frontal & Temporal Lobes
11	Temporal Lobes What are these lobes responsible for? The temporal lobe is involved in the following: Auditory processing Primary auditory cortex. Semantics both in: Speech &Vision The temporal lobe contains the Hippocampus Memory formation as well.
12	Quick Guide to Cognitive Disorders Delirium: A delirium is a rapidly developing, fluctuating state of reduced awareness in which the following are true: Patient has trouble shifting or focusing attention, Patient has at least one defect of memory, orientation, perception or language Symptoms are not better explained by a dementia
13	Types of Delirium Delirium due to a General Medical Condition Caused by brain trauma (i.e., subdural haematoma, extradural haematoma or concussion. Infections (i.e., Malaria, Meningitis, Typhoid fever) Epilepsy Endocrine disorders (i.e., Thyroid disorders, Hypoglycemia) Toxicity from medications/poisons (i.e., mercury, carbon monoxide)
14	Cont’d Substance-Induced Delirium Alcohol: (i.e., withdrawal, Alcohol abuse, subdural haematoma due to head injury) I.e., Traumatic brain Injury Sedative drugs: drugs which depress or slow the CNS [i.e., Diazepam (valium), Chlordiazepoxide (Libirum)]
15	Dementia A dementia differs from a delirium in the following ways: Memory loss as well as (aphasia, amnesia & apraxia) Impairment in the ability to focus or shift attention is NOT prominent Dementia is relatively fixed It is not usual for patients to recover from dementia
16	Types of Dementia Dementia of the Alzheimer’s Type: Most common cause of senility. Progresses inexorably. More than half the dementias are of this type
17	Cont’d Vascular Dementia: Due to brain disease, patients suffer from memory loss & other cognitive abilities. 10-20% of dementias are of this type.
18	Cont’d Dementia Due to Other General Medical Conditions: Brain tumors (i.e., infection by a slow virus) Head Trauma Human Immunodeficiency virus (HIV) disease Huntington’s disease (i.e., ED, degeneration of brain cells) Parkinson’s disease (i.e., loss of dopamine-producing brain cells) Pick’s disease (i.e., degenerative brain disease, neurons swell) Common toxins causing dementia result from kidney & liver failure.
19	Cont’d Substance-Induced Persisting Dementias: 5-10% of dementias are related to prolonged use of alcohol, inhalants or sedatives
20	Dementia of the Alzheimer’s Type Most common type of senility It affects about 3% of people over the age of 65 It is especially common in patients over 40 who have Down syndrome First sign is an apparent change in personality Existing personality traits become more apparent i.e., more obsessional, secretive, or sexually active Apathy, emotional lability or loss of acute sense of humor Memory loss (the ability to remember information learned within the previous few minutes).
21	Dementia of the Alzheimer’s type Cont’d Patients may forget names or re-ask questions that have just been answered. Immediate memory (information just been presented) & Remote memory (information learned years ago) are well preserved Loss of executive functioning (i.e., lack of spontaneity, repeatedly getting lost, difficulty adapting to new environments). Aphasia à difficulty finding words to express themselves, conversation rambles, reading & writing deteriorate
22	Dementia of the Alzheimer’s Type Cont’d Agnosia appears as difficulty recognizing a new acquaintance, later family members may not be recognized. Apraxia may appear as clumsiness or trouble dressing Many patients experience hallucinations or illusions. May become suspicious and develop paranoia About 20% have depression, experience insomnia or anorexia Typical Alzheimer’s patient lives 6-8 years after the disease begins.
23	The 7 Stages of Alzheimer’s Disease Stage 1 à No Impairment (normal function) Present as “normal” during a medical interview Stage 2 àVery mild cognitive decline (may be normal age-related changes or earliest signs of Alzheimer’s disease) Memory Lapse Forgetting familiar words, objects
24	Stages Continued Stage 3 à Mild Cognitive Decline Friends & family members notice the deficiency Common Difficulties include: Word or name finding problems Performance issues in social or work Reading a passage and retaining little information Losing or misplacing a valuable object Decline in ability to plan or organize Stage 4 à Moderate cognitive decline Clear cut deficiencies in the following areas: Decreased knowledge of recent occasions or current events Decreased capacity to perform complex tasks, such as planning dinner for guests, paying bills and managing finances
25	Stages Continued Stage 4 continued Reduced memory of personal history. The affected individual may seem subdued and withdrawn, especially in socially or mentally challenging situations. Impaired ability to perform challenging mental arithmetic-for example, to count backward from 75 by 7s.
26	"Stage 5 à Moderately severe..." Stage 5 à Moderately severe cognitive decline (Moderate or mid-stage Alzheimer's disease) Major gaps in memory and deficits in cognitive function emerge Become confused about where they are or about the date, day of the week or season Be unable during a medical interview to recall such important details as their current address Need help choosing proper clothing for the season or the occasion
27	Stages Continued Stage 6 à Severe cognitive decline (Moderately severe or mid-stage Alzheimer's disease) Memory difficulties worsen Significant personality changes emerge Lose most awareness of recent experiences and events as well as of their surroundings Experience disruption of their normal sleep/waking cycle Have increasing episodes of urinary or fecal incontinence Suspiciousness and delusions (e.g., believing that their caregiver is an impostor); hallucinations (seeing or hearing things that are not really there); or compulsive, repetitive behaviors such as hand-wringing or tissue shredding
28	Stages continued Stage 7 à Very Severe cognitive decline Final stage, lose ability to respond to environment Lose ability to speak Lose ability to control movement Frequently individuals lose their capacity for recognizable speech, although words or phrases may occasionally be uttered
29
30	More Brain Changes
31	Progression through the brain
32	Clinical Course of the illness 1. 1 to 3 years of GROWING forgetfulness 2. 2 to 4 years of increasing disorientation, loss of language skills & inappropriate behavior. Hallucinations & delusions also appear at this stage. 3. Final period of severe dementia, disorientation and complete loss of self-care
33	Criteria for Dementia of the Alzheimer’s Type Patient has developed problems with thinking, as shown by both these: Impaired memory (can’t learn new information or can’t recall information previously learned) At least one of these: Aphasia Apraxia Agnosia Impaired executive functioning Symptoms impair work or social functioning, and each indicates decline in level of functioning
34	Cont’d Decline in mental functioning gradually gets worse These impairments are not due to any other disorder that causes dementia: Central Nervous System Disease Systemic disease Substance-related disorders These impairments do not occur solely during a delirium Are not better explained by a depressive disorder or Schizophrenia.
35	Risk Factors Age ? Likelihood doubles every 5 years after the age of 65 Family History ? Risk increase with more than one family member Genetics Risk genes increase the likelihood of developing a disease, but do not guarantee it will happen. Scientists have so far identified one Alzheimer risk gene called apoliprotein E-e4 (APOE-e4). Head Injury ? Wear a helmet!
36	"“" “I have a disease, but I also have a lot of other things” -Teri Garr- (American Actress)
37	Questions & Answers
38	"Thank You" Thank You