aging mild cognitive impairment and dementia When I was younger I could remember anything whether it happened or not but my faculties are decaying now and soon I shall be so I cannot remember anything but the things that never happened ID: 744063
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Loss of everyday competency: aging, mild cognitive impairment and dementia
“
When I was younger, I could remember anything whether
it happened or not; but my faculties are decaying now and soon I shall be so I cannot remember anything but the things that never happened.” Mark Twain, 1877
Robert D. Harbaugh, MD
Neurology Associates of Santa Barbara
May, 2015Slide2
Overview: - basic concepts: definitions
continuum = aging - mild cognitive impairment – dementia
Survey the “landscape” of the dementias ...Review essentials of the behavioral & psychological symptoms of dementia (BPSD) ...
Caveats for the MDL “affiliate” …
Loss of everyday competency:
aging, mild cognitive impairment and dementia
Presentation OutlineSlide3
Dementia (latin = “
without mind”)
is an umbrella term (medical syndrome) for groups of symptoms related to an acquired decline in thinking (cognition) and/or behavior
What Is Dementia?
Common expressions include: gradual loss of memory, problems with reasoning or judgment, disorientation, difficulty in learning, loss of language skills, and decline in the ability to perform routine tasks.
People with dementia frequently demonstrate changes in their personalities and/or behavior, such as agitation, anxiety, delusions (believing in a reality that does not exist), and hallucinations (seeing things that do not exist).Slide4
“Dementia
is diagnosed when there are cognitive or behavioral (neuropsychiatric) symptoms that:
Interfere with the ability to function at work or at usual activities; andRepresent a decline from previous levels of functioning and performing; AndAre not explained by delirium or major psychiatric disorder;Cognitive impairment is detected and diagnosed through a combination of (1) history-taking from the patient and a knowledgeable informant and
(2) an objective cognitive assessment, either a “bedside” mental status examination or neuropsychological testing. Neuropsychological testing should be performed when the routine history and bedside mental status examination cannot provide a confident diagnosis.
The cognitive or behavioral impairment involves a minimum of two of the following
domains ...Slide5
“Impaired
ability to acquire and remember new information—symptoms include: repetitive questions or conversations, misplacing personal belongings, forgetting events or appointments, getting lost on a familiar route.
Impaired reasoning and handling of complex tasks, poor judgment—symptoms include: poor understanding of safety risks, inability to manage finances, poor decision-making ability, inability to plan complex or sequential activities.Impaired visuospatial abilities—symptoms include: inability to recognize faces or common objects or to find objects in direct view despite good acuity, inability to operate simple implements, or orient clothing to the body.Impaired language functions (speaking, reading, writing)—symptoms include: difficulty thinking of common words while speaking, hesitations; speech, spelling, and writing errors.Changes in personality, behavior, or comportment—symptoms include: uncharacteristic mood fluctuations such as agitation, impaired motivation, initiative, apathy, loss of drive, social withdrawal, decreased interest in previous activities, loss of empathy, compulsive or obsessive behaviors, socially unacceptable behaviors.
The differentiation of dementia from Minimal Cognitive Impairment (MCI) rests on the determination of whether or not there is significant interference in the ability to function at work or in usual daily activities.
This is inherently a clinical judgment made by a skilled clinician on the basis of the individual circumstances of the patient and the description of daily affairs of the patient obtained from the patient and from a knowledgeable informant
.”Slide6
Dementia Epidemic:The Grey Tsunami …Slide7Slide8
What Causes Dementia?
Over one-hundred (100) causes of dementia have been described … in everyday practice, ~ 10 categories account for the majority:
DEMENTIA = state of diminished functionSlide9
Another way of perceiving the concept ...Slide10Slide11
What is normal aging & what is dementia?Precise delineation of normal and abnormal memory, and of normal and abnormal “
aging” do not currently existDiseases of aging confound our definition of
“normal” agingSurprisingly, intellectual abilities decline minimally in
“normal” aging (up to 75 years, and possibly 90 years)Speed of thinking slows modestly“rules of thumb”“Forgetting to forget” is abnormal“Remembering to forget” is probably normal (memory of a real event returns with cues)Slide12
Loss of everyday competency: aging, mild cognitive impairment and dementia Slide13
Cognitive Continuum
Normal
Minimal Cognitive
Impairment (MCI)
Dementia
Absence of sharp delineation
Absence of biomarkerSlide14
Mild cognitive impairment (MCI) converts to “dementia” ~ 15 % per year ... NOT all persons become demented over timeSlide15
Slide16Slide17Slide18
When does “dementia start?
degenerative dementias evolve over many years – the “tail” of early, discernible pathological changes may antedate the “clinical diagnosis” by 10 – 15 years or more!
thus, subtle, but SIGNIFICANT impairment in areas more susceptible to high level cognition and memory may be observed well before persons are diagnosed with a dementia (e.g. poor financial judgment!)Slide19
Loss of everyday competency: aging, mild cognitive impairment and dementia Slide20Slide21
Dementia –Neurobehavioral Disturbances
The Behavioral and Psychological Symptoms of Dementia (BPSD)
:
constitute all relevant behaviors or emotions that are are “maladaptive” and/or abnormal for that affected individual’s (
and/or caregiver
’
s!) well-being. are a result of a specific brain disease superimposed upon a lifetime of co-existent behavioral and/or possible psychiatric disorders.Slide22Slide23
Peak Frequency of Behavioral Symptoms as Alzheimer’
s Disease Progresses
Agitation
Diurnal rhythmIrritability
Wandering
Aggression
Hallucinations
Mood
change
Socially
unacc.
Delusions
Sexually inappr.
Accusatory
Suicidal
ideation
Paranoia
Depression
100
80
60
40
20
0
-40
-30
-20
-10
0
10
20
30
Months Before/After Diagnosis
Frequency
(% of patients)
Anxiety
Social
withdrawal
Jost BC, Grossberg GT.
J Am Geriatr Soc.
1996;44:1078-1081.
DiagnosisSlide24Slide25
Dementia – Behavioral and psychologic symptoms of dementia (BPSD) Slide26Slide27
Common Psychological Features: Dementia Slide28
Common Psychological Features: Dementia Slide29
Repetition (not normal in 7-10 min conversation)Tangential, circumstantial responsesSimplification, imprecise languageLosing track of the “conversation”
Frequently deferring to familyOverreliance on old information/memories
Inattentive to appearanceUnexplained weight loss or “failure to thrive”Lack of awareness of cognitive impairment
Red flags in casual conversations (early dementia):Slide30
Caveats for the worker in the field …
“trust but verify” … independent party (parties)dementia increases with aging – remember Bayes theorem (in essence, common things are common!)dementia has a long “tail” (many years) … NO SHARP DEMARCATION“treatable” disorders may present as elder abuse cases …Slide31
Caveats for the worker in the field …
suspicions for diminished capacity
a change in behavior, personality or “common sense” approach NOT observed in the past ...vague, “talking around,” imprecise, “fluctuating,” petulant, inconsistent ...early dementia: very susceptible to “undue influence” …“emotional thinking” pre-empts “rational thinking”Recall high intrinsic levels of anxiety in early dementia
ANY delusion/hallucination (late life onset)
ANY major “change of heart” or alteration of core values
ANY sudden commitment to a new entity, person or “cause” not clearly identified in the pastANY major psychological disorder presenting in later life
Be aware of frontotemporal dementia – the “behavioral dementia” which NOT demonstrate early cognitive impairment ...