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What happens when something goes wrong…..
Identify manifestations of abnormalities in brain function associated with aging. Explore interventions and
treatments to maximize functioning
when pathology is present. Delirium Depression Dementia Delirium is often unrecognized Delirium might be the only indication of a life threatening condition Extremely important to identify 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 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) 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 An additional disturbance in cognition (memory deficit, disorientation, language, visuospatial ability, or perception) Thedisturbances are not better explained by another preexisting, established, or evolving neurocognitive disorder 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 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 Hyperactive ◦ Agitated ◦ Restless ◦ Yelling Hypoactive ◦ Inactivity ◦ Withdrawal Mixed Hardest to recognize May look like depression Subdued, quiet Extremely important to recognize and
look for medical cause
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 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 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 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 Increased risk of suicide Increased economic burden Could lead to substance abuse or
misuse Treatment is often very effective 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 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. Atleast 5 symptoms must be present in the same 2-week period and must include either ◦ 1) Depressed mood ◦ 2) Loss of interest or pleasure 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 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 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 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 Insomnia or hypersomnia Early morning awakening Middle insomnia Waking too early Agitation– restlessness, irritable, appear anxious and distressed, hand wringing Slowness in movement, slowed
speech, latency of response
Tired and worn out Everything is just too much effort Poor time management Apathetic “It’s too much work.” 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 Slowed thinking Inability to focus or concentrate Indecisive Feels confused and bewildered Ruminations about insignificant problems Negativity 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 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 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 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” 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
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 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 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 Medical illnesses ◦ hypoglycemia, hyperthyroidism Medications
◦ caffeine, stimulants, sympathomimetics
Withdrawal states
◦ alcohol, benzodiazepines Situational anxiety
◦ going to a dentist, flying
Panic disorder Agoraphobia Phobias Obsessive-Compulsive disorder Posttraumatic stress disorder Acute stress disorder Generalized anxiety disorder Minimize caffeine Social interaction Relaxation techniques Diversion and recreational activities Physical exercise Counseling or psychotherapy Medication, if use is justified Minor Neurocognitive Disorder
Major Neurocognitive Disorder
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) 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 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 A chronic, progressive, irreversible, neurological disorder affecting memory, cognition, ability to function, personality, language, and behavior 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 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 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 Neurofibrillary tangles Amyloid plaques Cerebral atrophy 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 Memory Judgment and decision making Abstract thinking Inhibition control Organizational skills Motivation and attention Personality stability Emotions Language Praxis Visual spatial skills ◦ Sudden onset ◦ Step-wise progression ◦ Focal neurological signs and symptoms ◦ Evidence of cerebrovascular disease on brain imaging ◦ History of hypertension, diabetes, dyslipidemia, atrial fib, smoking, prior TIAs or stroke Likely accounts for 75% of vascular dementia cases Affects small arterioles, venules and capillaries in the brain Hypertension is a major risk factor Seen on MRI as small focal areas of infarction, hyperintensities, microbleeds, or enlarged perivascular spaces Subacute symptoms include cognitive impairment (executive dysfunction, slowing of psychomotor speed, memory problems), mood disorders, gait disturbances Progression less predictable Focus on stroke prevention
◦ Manage hypertension ◦ Treat diabetes ◦ Lipid lowering agents Alzheimer’s drugs generally not beneficial Memory impairment evident with progression, but not always early Abnormal proteinaceous (alpha-synuclein)
cytoplasmic inclusions called Lewy bodies
develop in cells throughout the brain Progressive dementia – deficits in attention, executive function, memory, language and visual spatial abilities Two of three core features
◦ Parkinsonism ◦ Recurrent visual hallucinations ◦ Fluctuating attention and concentration Dementia onset before or within one year of
parkinsonism onset SupportiveFeatures ◦ REM sleep behavior disorder ◦ Antipsychotic medication sensitivity ◦ Syncope ◦ Repeated falls ◦ Autonomic dysfunction ◦ Complex delusions ◦ Tremor at rest ◦ Rigidity ◦ Bradykinesia ◦ Postural instability ◦ Usually asymmetric onset of symptoms ◦ Dementia in 20 – 60% MultipleSystem Atrophy Corticobasal Degeneration Progressive Supranuclear Palsy FTD with Parkinsonism A neurodegenerative disorder affecting the frontal and/or temporal lobes of the brain that presents predominantly with behavioral or language disturbance, with relative preservation of memory and spatial skills early in the illness -Earlier age of onset - 50% before age 65 -Survival 6.6 – 10 years after symptoms onset -Personality changes and decline in social skills -Impaired executive functions -Emotional blunting; apathy -Behavioral disinhibition; bizarre behavior -Language changes -Prominent temporal and/or frontal atrophy Behavioral variant – prominent changes in behavior and personality Progressive nonfluent aphasia –
expressive language changes
Semantic dementia – can’t
understand words or recognize
familiar people and objects Insidious onset and gradual progression Early decline in social interpersonal conduct Early impairment in regulation of personal
conduct Early emotional blunting Early loss of insight Decline in personal hygiene and grooming Mental rigidity and inflexibility Distractibility and impersistance Hyperorality and dietary changes Perseverative and stereotyped behavior Utilization Behavior Speech and language changes ◦ Rapidly progressive, fatal ◦ Cognitive and behavioral changes ◦ Loss of coordination ◦ Myoclonus ◦ Spongiform changes in frontal cortex ◦ A type of prion disease misfolded proteins ◦ Autosomal dominant pattern of inheritance ◦ Defect of chromosome 4 ◦ Basal ganglia affected ◦ Movement and coordination affected ◦ Loss of intellectual abilities and emotional and behavioral disturbances ◦ Subdural hematoma
It is important to know what PERSON the disease has, not what disease the person has. -Sir William Osler 1849-1919 Difficulty learning new things Misplaces items Forgets to tend to appliances Trouble following recipes/directions Can’t remember the date/time Trouble recalling recent events or conversations Forgets to pay bills or repays Trouble following plot in stories or on TV Use calendars, notes, reminders Write important information Repeat explanations or directions Try to limit distractions and simplify One specific location for keys,
glasses, important items
Supervise medications, finances, and
for safety needs
Provide reminder cues in conversations or in the environment Try to endure repetitiveness Help locate missing items Monitor appetite and weight Don’t force reality orientation Discuss positive memories from the past Judgment and decision making Abstract thinking Inhibition control Organizational skills Motivation and attention Loss of sense of risk and danger Financial vulnerability Difficulty problem-solving May appear more dependent and indecisive May trust strangers or be “inappropriately familiar” Unable to prioritize activities Identify surrogate decision maker/s Avoid extended logical explanations Set limits on unrealistic demands Anticipate safety needs and safety proof
surroundings Avoid situations where failure is likely Use distraction rather than confrontation Maintain the person’s integrity Takes more time to understand Difficulty with time relationships Trouble with calculations and money Unable to “figure out” complex problems Poor interpretation of social cues Change in sense of humor Allow time to process verbal communication Be alert for misunderstandings Interpret what is occurring in the
environment Help identify the function of objects Use discretion with humor More impulsive – desires immediate gratification Frustrated easily – quick to react May make hurtful/insensitive comments May have inappropriate social behavior Possibility for sexual disinhibition Anticipate needs and possible overreaction Maintain a calm environment Don’t take insensitive comments
personally Use a matter of fact approach for socially
inappropriate behavior Assist in covering social “mistakes” Unable to plan, organize, sequence activities Don’t remember “how” to get started
on tasks May appear apathetic or disinterested Trouble following directions Simplify the environment Continue with familiar routine Provide structured activities, but be flexible Break tasks into individual steps Give one-step directions Inconspicuously give cues Avoid sounding controlling or bossy If resistive, stop and try again later Problems with initiation Can’t switch mental gears easily Trouble completing tasks or “gets stuck” Loss of mental flexibility Difficulty maintaining effortful activities Distractibility Eliminate competing stimuli in the environment Provide cues and prompts Plan activities that do not require sustained
periods of concentration Attempt distraction if the person is “stuck” Plan frequent rest periods Problems with ◦ Stopping ◦ Starting ◦ Switching ◦ Socialization ◦ Planning ◦ Judgment Disinhibited/impulsive Blurtout socially inappropriate remarks Frontal release signs (grasp reflex,
palmomental reflex) Compulsive eating Unable to resist impulse to use or touch
objects Lack of motivation Unable to initiate Inability to maintain effortful behavior Apathy Perseveration Lack of mental flexibility Self management difficulty to make
any change Improper emotional responses Poor interpretation of social cues Difficulties secondary to lack of
motivation, personality changes,
and uninhibited behavior Insensitive to others Unable to “read” social signals
from others Inability of volition Cannot multitask Non compliance because can’t plan “Stubborn” – “Uncooperative” Unable to anticipate consequences Can’t prioritize Lack empathy Little or no insight Personality stability Emotions Language
Praxis Visual spatial skills Apathy vs irritability Paranoia Abnormal beliefs Delusions or hallucinations Fearfulness Clinging/shadowing Anger/frustration Tryto exhibit the desired demeanor Be aware of your limits and stress level Clearly identify the purpose of cares Avoid arguments about abnormal beliefs Depression Anxiety Denial – lack of insight Labile emotions Withdrawal Address depression if it is suspected Provide environmental and
interpersonal supports to minimize
fears and anxiety Distract rather than confront Maintain a calm, routine, predictable
environment Encourage social activities Word-finding problems Trouble with names – talks “around”
names Loses train of thought in mid-sentence Can’t filter out distractions during
conversations Less use of nouns May not recognize objects Approach slowly from the front or side and gain the person’s attention before talking Speak slowly and clearly Maintain relaxed body language Face the person, establish eye contact, and smile Introduce yourself and call the person by name Eliminate distracting background noises Speak in low pitched tones Begin with social conversation or “small
talk” Keep sentences short Keep to one clearly defined subject at a
time Use nouns or names rather than pronouns Use the same word every time to refer to
common tasks/objects Avoid open ended questions Limit the number of decisions the person
has to make Accompany verbal communication with
appropriate non-verbal cues
Exaggerate gestures or facial expressions if hearing or vision impaired Use gentle touch that is not task oriented Break down tasks into individual steps and
ask the person to do one at a time
Repeat explanations or directions as
needed Try to match requests to the person’s
current level of functioning
Allow sufficient time for the person to process information Focus on the feeling tone of the
conversation rather than content of words
State positive directions; limit the use of
“don’ts” Talk about pleasant memories from the past Try supplying a word if it is appreciated Repeat the last few words to help regain
train of thought if blocking is a problem
Allow word mistakes to go by “unnoticed” if
the general meaning is understood
Inconspicuously give prompts during
interactions Avoid “quizzing” or forcing a response Make “educated guesses” of what intent
could be if verbal statements are unclear
Give reassurance by making general
statements if that provides comfort
Use humor appropriately -Loss of “motor memory” -Need more time to complete tasks -Need assistance with daily tasks -Don’t rush well Allow more time to complete tasks Provide prompts and step-by-step
directions Demonstrate the desired action Do not rush the person Unaware of relationship to environment ◦ Might fall ◦ Unable to find way or gets lost ◦ May wander Geographic disorientation Evaluate fall risk Use way finding cues Use personal items to help recognize room Be aware of social distance in conversations Avoid abrupt movements toward the person Aggression/Agitation Delusions/hallucinations Depression Apathy Sleep disorders Wandering Sexually inappropriate behavior Others University of Nebraska Medical Center
-Prevention Trial -Mild AD study -Moderate AD study
-Asymptomatic AD -MMSE 20-26 -MMSE 12-22 -≥65 years -ages 55-90 -ages 55-85 -Monthly IV x 3yr -Monthly IV x 18m -oral med x 1yr -Solanezumab -Solanezumab -T-817MA -a4study.org -expedition3study.com -adcs.org (studies)
