in the Teaching Material of Medical Biotechnology Masters Programmes at the University of Pécs and at the University of Debrecen Identification number TÁMOP412081A20090011 Cognitive ID: 398758
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Slide1
Manifestation of Novel Social Challenges of the European Union
in the Teaching Material of
Medical Biotechnology Master's
Programmes
at the University of
Pécs
and at the University of Debrecen
Identification number: TÁMOP-4.1.2-08/1/A-2009-0011Slide2
Cognitive
and affective disorders in the elderly
Márta Balaskó and Gyula BakóMolecular and Clinical Basics of Gerontology – Lecture 18
Manifestation of Novel Social Challenges of the European Union
in the Teaching Material of
Medical Biotechnology Master
'
s
Programmes
at the University of
Pécs
and at the University of Debrecen
Identification number: TÁMOP-4.1.2-08/1/A-2009-0011Slide3
Aging-associated cognitive, affective changes
In healthy aging overall intellectual performance does not necessarily deteriorate.
Various cognitive functions decline, while others improve: Activity requiring quick reactions and or high degree precision grow weaker.Decrease in speed of processing, working memory, inhibitory function and long-term memory are seen.
Wise consideration based on experience, the ability to understand and learn from new experience is maintained.Slide4
Aging-associated cognitive, affective and psychiatric disorders
(outline)
DementiaNeurodegenerative disorders leading to dementia (Alzheimer’s disease)
Non-Alzheimer dementias (vascular dementia, organic brain disorders)
Delirium
Amnestic
syndromes
Alcohol abuse and consequences
Affective disorders: depressionSlide5
Dementia: definition and prevalence
Definition
A serious loss of cognitive ability with maintained vigilance.Dementia is a clinical diagnosis.Impairments affect:
memory (disturbed recognition:
agnosia
),
speech (aphasia), language,
judgement
,
emotional control,
behavior,
attention ,
abstract thinking,
executive functions (
apraxia
),
that causes disruption in relationships and social functions.Slide6
Dementia: prevalence and most frequent forms
Prevalence
It affects 1% of population at the age of 60, prevalence doubles every year.It reaches 10 % at 65 years, and 35% above 90 years. Most prevalent dementias
Senile dementia of the Alzheimer type
(Alzheimer
’
s disease) 60%
Non-Alzheimer dementias (organic brain disorders)
Delirium
Amnestic
syndromesSlide7
Senile dementia of the Alzheimer type
(SDAT, Alzheimer’s disease) 1
Definition
A (premature) progressive age-associated loss of cognitive functions (in middle-aged and older) also involving affective and behavioral disturbances.
Risk factors
age
65 years
female gender
low education level (primary school drop-outs: 2
×
risk)
positive family anamnesis: 4
×
risk
head trauma: 2
×
risk
smoking, metabolic syndrome X,
atrial
fibrillation, stroke, alcohol consumption, genetic predispositionSlide8
Prevalence of
Alzheimer’s disease
0
10
20
30
40
50
60
60-64
65-69
70-74
75-79
80-84
85+
95+
Prevalence
(%)
Age
(years)
1%
2%
4%
8%
16%
30%
50%Slide9
Senile dementia of the Alzheimer type
(SDAT, Alzheimer’s disease)
2
Characteristics
L
oss
of neurons
,
synapses
and
atrophy in the cerebral cortex and certain
subcortical
regions
(
temporal and parietal lobe
s
, parts of the frontal cortex
)Pathogenesischolinergic theory: reduced synthesis of the acetylcholinebeta-amyloid
: dense and insoluble
deposits of amyloid beta precursor protein (APP) fragments form senile plaques around neurons initiating damage tau protein misfolding : intracellular neurofibrillary tangles cause microtubules to disintegrate,
damaging the neuron’s transport systemInflammation,
oxidative stress, accumulation
of aluminium in brain
, etc.Slide10
Senile dementia of the Alzheimer type
(SDAT, Alzheimer’s disease)
3
Phases
1
Mild
cognitive
impairment
,
preclinical
stage
a
gradual
,
hidden, progressive onset
may last for
7-8 years symptoms (memory loss) are mistaken for stress and aging2 Early stageincreasing forgetfulness, difficulties with language, executive functions, agnosia, apraxia, personality changes3 Moderate
stagedependency increasesdifficulty with speech, pathological behavior (
agression) and confusion, delusions 4 Advanced
stage complete dependency, verbal output decreases, pronounced memory decline, patients get bed-ridden
, deathSlide11
Senile dementia of the Alzheimer type
(SDAT, Alzheimer’s disease) 4
Prognosis
Average survival is 7 years. Most common causes of death: pressure ulcers, pneumonia
Treatment
No drug has been shown to cure the disease or delay progression.
Some drugs alleviate symptoms:
acetylcholinesterase
inhibitors
glutamate NMDA receptor antagonist
A safe, emotionally supportive environment, physical exercise, optimal diet may improve quality of life of the patient.Slide12
Non-Alzheimer dementias
(organic brain disorders)
CharacteristicsSymptoms may resemble those of Alzheimer’s disease
Onset is usually different, changes may occur suddenly or they may not be progressive over time
In case of metabolic or infectious causes progression may be stopped, even some alleviation of the symptoms is possible. Slide13
Causes of
non-Alzheimer dementias
Intracranial:Degenerative disordersParkinson’s, Pick, Lewy
Huntington
Vascular, post-stroke states
Space occupying lesions
Post-trauma states
polytrauma (boxing, liver)
subdural hematoma,
hemodialysis
Infectious agents
AIDS, prion (Creutzfeldt-Jakob),
neurosyphilis, Lyme disease
meningitis
Extracranial:
Poisons
alcohol, drugs, medications
CO poisoningGenetic, metabolic causesWilson’s, hypoglycemias
Organ failuresTumor, metastases failure,
renal failure, hydrocephalusheart failure, thyroid disordersDeficienciesvitamin B12-, folic acid-, niacin deficiencySlide14
Delirium: definition
Characteristics
It is a clinical syndrome characterized by inattention and acute severe (reversible) cognitive dysfunctionsIn the young, high fever, severe alcohol intoxication, severe metabolic disturbances, etc. may cause delirium
In the elderly, functional reserve capacity of the brain declines , therefore many
milder disorders
may lead to delirium
Delirium affects 14–56% of all hospitalized elderly patients.
Postoperative delirium occurs in 15–53% of surgical patients over 65 years, and 70–87% among elderly patients admitted to intensive care units.Slide15
Delirium in the elderly: risk factors
1
Risk factorsDementia or cognitive impairmentHistory of delirium, stroke, neurological disease, falls
Multiple
comorbidities
Male gender
Chronic renal or hepatic disease
Sensory impairment (hearing or vision)
Immobilization (restraint, catheters)
Medications (sedative hypnotics, narcotics,
anticholinergic
, drugs, corticosteroids,
polypharmacy
, alcohol or drug withdrawal)
Acute neurological diseases [acute stroke (usually right parietal), meningitis, encephalitis]Slide16
Delirium in the elderly: risk factors
2
Risk factorsIntercurrent illness
(minor infections, iatrogenic complications, anemia, ordinary volume loss, poor nutrition, fracture, trauma)
Metabolic derangement
severe hypoglycemia, hyper- or
hypotonicity
Surgery
Alarming environment
(e.g. admission to an intensive care unit)
Pain
Emotional distress
Sustained sleep deprivationSlide17
Amnestic syndromes
Definition
Memory functions are disproportionately impaired compared to other cognitive functions in an otherwise alert patient. The patient can not remember recent events or learn simple tasks, while performing complex tasks learned previously.
Most common forms
Wernicke-Korsakoff
Syndrome
chronic alcoholism, chronic thiamine deficiency
Transient
Amnestic
Syndromes
transient cerebral ischemia, migraine, alcohol intoxication (“blackouts”), drugs (e.g. benzodiazepines, barbiturates,
ketamine
), head injury (concussion)
Psychogenic amnesia
posttraumatic stress disorderSlide18
Alcohol abuse and consequences
in the elderlyPrevalence
Alcohol abuse and alcoholism are prevalent and under-recognized problems in the elderly. About 6 percent of older adults are considered heavy users of alcohol (13% of men, 2% of women).The majority of older alcoholic persons (around 66%) grow older with early-onset alcoholism, about 34% develop a problem with alcohol in later life.
Age-related alterations in pharmacokinetics of alcohol
Gastrointestinal absorption is comparable, distribution is diminished due to decrease in fat free mass.
Liver perfusion and metabolism in the liver declines slightly.
higher peak serum alcohol Slide19
Consequences of alcohol abuse
in the elderly 1
ConsequencesAlcohol-induced alterations in drug metabolism:
acute
competit
i
ve
inhibition of drug metabolism involving the
cytochrome
P450 system (
microsomal
ethanol oxidizing system=MEOS), e.g. narcotics, tranquillizers leading to suppression of respiratory center
chronic
upregulation
of the
cytochrome
P450 system enhancing clearance of drugs, e.g. coumarinsFalls may be precipitated by alcohol due to acute ataxia, acute hypotension (vasodilatory and diuretic effect), chronic myopathy, cerebellar atrophy and peripheral neuropathy. These falls may lead to hip fractures!Moderate drinking may exacerbate hypertension, and heavy drinking increases the risk of stroke. Arrhythmia may develop after an alcohol binge. Slide20
Consequences of alcohol abuse
in the elderly 2
ConsequencesIschemic heart disease is responsible for more cardiac deaths among older alcoholics than alcohol-induced cardiomyopathy.
Gastrointestinal bleeding
are common among older alcoholics.
The liver is more susceptible for
alcoholic
hepatitis, fatty liver or cirrhosis in old individuals. About 50% of elderly patients with
cirrhosis
die within one year of diagnosis.
Elderly patients are more prone to alcohol or its with
d
rawal
-induced
delirium
.Chronic alcoholism lead to Wernicke encephalopathy (an acute state of confusion, ataxia and abnormal eye movements) and Korsakoff’
s syndrome (an isolated memory deficit manifesting in confabulation). Global cognitive impairment and alcohol-related dementia based on profound
cerebral atrophy is more common in elderly alcoholics.Slide21
Depression in the elderly:
definition and characteristics
DefinitionDepression is a state of low mood and aversion to activity. It may can affect the thoughts, feelings, behavior, and physical well-being of the patient. It usually involves feelings of sadness, anxiety, emptiness, hopelessness, worthlessness, guilt, irritability or restlessness. The prevalence of depression among the elderly is increasing.
Their treatment presents a big strain on society.
Depression in the elderly is seldom properly diagnosed. It does not receive proper attention.Slide22
Depression in the elderly:
risk factors
It is strongly influenced by such risk
factors
that
become more common with
aging:
genetic factors determine susceptibility for depression
neurological
changes,
multimorbidity
, pain,
impaired
function of sensory
organs
loneliness, isolation
personal crises, bereavement, anxiety
reduced adaptabilitylack of perspectives in life, lack of motivation, decreased ability to work,
loss of family background, deficiencies of education, poor social network, negative effects of
retirement.Slide23
Factors that make the diagnosis of depression
especially difficult
Diagnostic factors: There is an overlap between the normal phenomena
of
aging and signs of depression.
Clinical characteristics may be misleading. Symptoms may be suppressed, non-characteristic or associated with
somatization
(complaining about unreal somatic symptoms) and agitation/anxiety.
It may occur (in a hardly discernible way) in association with
chronic diseases and organic cerebral disorders.
Characteristics
associated with the
patient:
Losses
, bereavement, isolation, shame, refusal of
treatment.
Neither
the patient nor the relatives hope for any improvement with the treatment. Characteristics of health professionals
:Misconceptions related to old age, lack of
empathy and attention.Slide24
Depression: prognosis
Poor prognosis, danger signs of
suicide:advanced age at the onset of depression,
presence
of anxiety in
past
medical history,
personality
disorders,
alcohol
abuse,
psychotic
signs,
cognitive
impairment,
organic
cerebral disorders, loneliness, poor social circumstances,
delayed treatment, inadequate management Slide25
Differential diagnosis of depression
(pseudodementia) and dementia
PSEUDO-DEMENTIAkeeps complainingcommunicates
in
detail
“I don
’
t know”
does
not want
to do
DEMENTIA
does not complain
poor communication
replies with mistakes
eager to cooperate