Abnormal brain changes.ppt
Download as PPT, PDF0 likes21 views
The document discusses several topics related to abnormalities in brain function associated with aging: - Delirium, depression, and dementia are identified as key manifestations. Delirium is often unrecognized but can indicate a serious medical condition. - Depression is the most common psychiatric condition in older adults and can lead to disability, suffering, and increased health risks if left untreated. - Dementia, specifically Alzheimer's disease, is a chronic, progressive neurological disorder causing impairment in memory, cognition, and daily functioning. It is the most common cause of dementia.
Abnormal brain changes.ppt
- 1. What happens when something goes wrong…..
- 2. Identify manifestations of abnormalities in brain function associated with aging. Explore interventions and treatments to maximize functioning when pathology is present.
- 3. Delirium Depression Dementia
- 4. Delirium is often unrecognized Delirium might be the only indication of a life threatening condition Extremely important to identify
- 5. 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)
- 7. 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. 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. 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. 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. Hyperactive ◦ Agitated ◦ Restless ◦ Yelling Hypoactive ◦ Inactivity ◦ Withdrawal Mixed
- 12. 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
- 14. 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. 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. 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. Increased risk of suicide Increased economic burden Could lead to substance abuse or misuse Treatment is often very effective
- 18. 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. 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. 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. 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. 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. 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. 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. Insomnia or hypersomnia Early morning awakening Middle insomnia Waking too early
- 26. Agitation – restlessness, irritable, appear anxious and distressed, hand wringing Slowness in movement, slowed speech, latency of response
- 27. Tired and worn out Everything is just too much effort Poor time management Apathetic “It’s too much work.”
- 28. 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. Slowed thinking Inability to focus or concentrate Indecisive Feels confused and bewildered Ruminations about insignificant problems Negativity
- 30. 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. 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. 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. 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. 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. 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. 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. 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. Medical illnesses ◦ hypoglycemia, hyperthyroidism Medications ◦ caffeine, stimulants, sympathomimetics Withdrawal states ◦ alcohol, benzodiazepines Situational anxiety ◦ going to a dentist, flying
- 39. Panic disorder Agoraphobia Phobias Obsessive-Compulsive disorder Posttraumatic stress disorder Acute stress disorder Generalized anxiety disorder
- 40. Minimize caffeine Social interaction Relaxation techniques Diversion and recreational activities Physical exercise Counseling or psychotherapy Medication, if use is justified
- 41. Minor Neurocognitive Disorder Major Neurocognitive Disorder
- 42. 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. 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. 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. A chronic, progressive, irreversible, neurological disorder affecting memory, cognition, ability to function, personality, language, and behavior
- 46. 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. 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 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
- 50. 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
- 51. Memory Judgment and decision making Abstract thinking Inhibition control Organizational skills Motivation and attention
- 52. Personality stability Emotions Language Praxis Visual spatial skills
- 53. ◦ 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
- 54. 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
- 55. Progression less predictable Focus on stroke prevention ◦ Manage hypertension ◦ Treat diabetes ◦ Lipid lowering agents Alzheimer’s drugs generally not beneficial
- 56. Memory impairment evident with progression, but not always early Abnormal proteinaceous (alpha-synuclein) cytoplasmic inclusions called Lewy bodies develop in cells throughout the brain
- 57. 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
- 58. Supportive Features ◦ REM sleep behavior disorder ◦ Antipsychotic medication sensitivity ◦ Syncope ◦ Repeated falls ◦ Autonomic dysfunction ◦ Complex delusions
- 59. ◦Tremor at rest ◦Rigidity ◦Bradykinesia ◦Postural instability ◦Usually asymmetric onset of symptoms ◦Dementia in 20 – 60%
- 60. Multiple System Atrophy Corticobasal Degeneration Progressive Supranuclear Palsy FTD with Parkinsonism
- 61. 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
- 62. -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
- 63. 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
- 64. 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
- 65. 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
- 66. ◦ Rapidly progressive, fatal ◦ Cognitive and behavioral changes ◦ Loss of coordination ◦ Myoclonus ◦ Spongiform changes in frontal cortex ◦ A type of prion disease misfolded proteins
- 67. ◦ 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
- 68. ◦ Subdural hematoma ◦ Traumatic brain injury ◦ Hypoxemic anoxia
- 69. ◦Alcohol/substance abuse ◦Heavy metals ◦Carbon monoxide poisoning ◦Drugs
- 70. ◦AIDS dementia ◦Viral encephalitis ◦Bacterial meningitis ◦Neurosyphilis
- 71. ◦ Dementia ◦ Ataxia ◦ Urinary Incontinence ◦ “Wild, wet, and wacky”
- 72. It is important to know what PERSON the disease has, not what disease the person has. -Sir William Osler 1849-1919
- 73. 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
- 74. 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
- 75. 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
- 76. Judgment and decision making Abstract thinking Inhibition control Organizational skills Motivation and attention
- 77. 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
- 78. 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
- 79. 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
- 80. 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
- 81. More impulsive – desires immediate gratification Frustrated easily – quick to react May make hurtful/insensitive comments May have inappropriate social behavior Possibility for sexual disinhibition
- 82. 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”
- 83. Unable to plan, organize, sequence activities Don’t remember “how” to get started on tasks May appear apathetic or disinterested Trouble following directions
- 84. 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
- 85. Problems with initiation Can’t switch mental gears easily Trouble completing tasks or “gets stuck” Loss of mental flexibility Difficulty maintaining effortful activities Distractibility
- 86. 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
- 87. Problems with ◦ Stopping ◦ Starting ◦ Switching ◦ Socialization ◦ Planning ◦ Judgment
- 88. Disinhibited/impulsive Blurt out socially inappropriate remarks Frontal release signs (grasp reflex, palmomental reflex) Compulsive eating Unable to resist impulse to use or touch objects
- 89. Lack of motivation Unable to initiate Inability to maintain effortful behavior Apathy
- 90. Perseveration Lack of mental flexibility Self management difficulty to make any change Improper emotional responses
- 91. 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
- 92. Inability of volition Cannot multitask Non compliance because can’t plan “Stubborn” – “Uncooperative”
- 93. Unable to anticipate consequences Can’t prioritize Lack empathy Little or no insight
- 94. Personality stability Emotions Language Praxis Visual spatial skills
- 95. Apathy vs irritability Paranoia Abnormal beliefs Delusions or hallucinations Fearfulness Clinging/shadowing Anger/frustration
- 96. Try to exhibit the desired demeanor Be aware of your limits and stress level Clearly identify the purpose of cares Avoid arguments about abnormal beliefs
- 97. Depression Anxiety Denial – lack of insight Labile emotions Withdrawal
- 98. 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
- 99. 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
- 100. 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
- 101. 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
- 102. 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
- 103. 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
- 104. 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
- 105. 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
- 106. 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
- 107. -Loss of “motor memory” -Need more time to complete tasks -Need assistance with daily tasks -Don’t rush well
- 108. Allow more time to complete tasks Provide prompts and step-by-step directions Demonstrate the desired action Do not rush the person
- 109. Unaware of relationship to environment ◦ Might fall ◦ Unable to find way or gets lost ◦ May wander Geographic disorientation
- 110. 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
- 111. Aggression/Agitation Delusions/hallucinations Depression Apathy Sleep disorders Wandering Sexually inappropriate behavior Others
- 112. Current Alzheimer’s Trials at UNMC -Prevention Trial -Asymptomatic AD -≥65 years -Monthly IV x 3yr -Solanezumab -a4study.org Interested? Call 402-552-6241 -Mild AD study -MMSE 20-26 -ages 55-90 -Monthly IV x 18m -Solanezumab -expedition3study.com -Moderate AD study -MMSE 12-22 -ages 55-85 -oral med x 1yr -T-817MA -adcs.org (studies) University of Nebraska Medical Center