DEMENTIA DELIRIUM AND AMNESTIC DISORDERS:Amnesia

<< DEMENTIA DELIRIUM AND AMNESTIC DISORDERS:DELIRIUM, Causes of Delirium

MENTAL RETARDATION AND DEVELOPMENTAL DISORDERS >>

Abnormal Psychology PSY404

Lecture 41

DEMENTIA DELIRIUM AND AMNESTIC DISORDERS

Recap lecture no 40

· Formerly called organic mental disorders now the new name according to DSM-IV-TR is cognitive

disorders or cognitive impairment disorders.

· It includes Delirium, Dementia and Amnesia.

Dementia

Dementia is a gradual worsening loss of memory and related cognitive functions, including the use of

language, as well as reasoning and decision making.

Delirium

Delirium is a state of confusion and disorientation that develops over a short period of time and is often

associated with agitation and hyperactivity.

Amnesia

People with Amnesia disorders experience memory impairments that are more limited than those seen in

dementia or delirium.

Research on brain and its role on psychopathology have increased in recent years. The term organic mental

disorder was dropped and the term cognitive mental disorder was adopted.

Cognitive disorders signify the impairment of cognitive abilities such as

· memory

· attention

· perception

· thinking

Cognitive disorders generally first appear during the patient's 50's or 60's and accelerate after the age of 70.

Cognitive impairment disorders include

· Dementia

· Delirium

· Amnesia

Some degenerative brain diseases include

1. Alzheimer's dementia

2. Parkinson's disease

3. Huntington's disease

4. Pick's disease

Causes of Cognitive Impairment Disorders

1. old age

2. improper use of medications

3. head injuries

4. Various types of brain traumas.

Treatment of Cognitive Impairment Disorders

1. Treatment of the Patient

a. Psychotropic Medications

b. Behavioral Programs

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c. Cognitive Rehabilitation

2. Treatment of Caregivers

· Because of the close link between cognitive disorders and brain disease, patients with these

problems are often diagnosed and treated by neurologists, physicians who deal primarily with

diseases of the brain and the nervous system.

· Multidisciplinary clinical teams study and provide care for people with dementia and amnestic

disorders.

· Direct care to patients and their families is usually provided by nurses and social workers.

· Neuropsychologists have particular expertise in the assessment of specific types of cognitive

impairment.

· Changes in emotional responsiveness and personality typically accompany the onset of memory

impairment in dementia.

· In some cases, personality changes may be evident before the development of full-blown cognitive

symptoms.

Assessment of Cognitive Impairment

There are many ways to measure a person's level of cognitive impairment.

a. One is the Mini-Mental State Examination.

· Some of the questions on this exam are directed at the person's orientation to time and place.

· Others are concerned with anterograde amnesia, such as the ability to remember the names of

objects for a short period of time.

b. Neuropsychological assessment can be used as a more precise index of cognitive

impairment.

· This process involves the evaluation of performance on psychological tests to indicate whether a

person has a brain disorder.

· The best-known neuropsychological assessment procedure is the Halstead-Reitan

Neuropsychological Test Battery, which includes an extensive series of tests that tap sensorimotor,

perceptual, and speech functions.

· Some neuropsychological tasks require the person to copy simple objects or drawings.

c. Personality and Emotion

· The emotional consequences of dementia are quite varied.

· Some demented patients appear to be apathetic or emotionally flat.

· At other times, emotional reactions may become exaggerated and less predictable.

· Depression is another problem that is frequently found in association with dementia.

d. Motor Behaviors

· Demented persons may become agitated, pacing restlessly or wandering away from familiar

surroundings.

· In the later stages of the disorder, patients may develop problems in the control of the muscles by

the central nervous system.

· Some specific types of dementia are associated with involuntary movements, or dyskinesia--tics,

tremors, and jerky movements of the face and limbs called chorea.

Amnesia

· Some cognitive disorders involve more circumscribed forms of memory impairment than those

seen in dementia.

· In amnestic disorders, a person exhibits a severe impairment of memory while other higher level

cognitive abilities are unaffected.

· The memory disturbance interferes with social and occupational functioning and represents a

significant decline from a previous level of adjustment.

· The most common type of amnestic disorder is alcohol-induced persisting amnestic disorder, also

known as Korsakoff's syndrome.

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In this disorder, which is caused by chronic alcoholism, memory is impaired but other cognitive

functions are not.

One widely accepted theory regarding this condition holds that lack of vitamin B1 (thiamine) leads

to atrophy of the medial thalamus.

Brief Historical Perspective

· Alois Alzheimer, a German psychiatrist, worked closely in Munich with Emil Kraepelin, who is

often considered responsible for modern psychiatric classification.

· Alzheimer's most famous case involved a 51-year-old woman who had become delusional and also

experienced a severe form of recent memory impairment, accompanied by apraxia and agnosia.

· This woman died 4 years after the onset of her dementia.

· Following her death, Alzheimer conducted a microscopic examination of her brain and made a

startling discovery: bundles of neurofibrillary tangles and amyloid plaques.

· Alzheimer presented the case at a meeting of psychiatrists in 1906 and published a three-page paper

in 1907.

· Emil Kraepelin began to refer to this condition as Alzheimer's disease in the eighth edition of his

famous textbook on psychiatry, published in 1910.

· Until recently, the diagnostic manual classified the various forms of dementia as Organic Mental

Disorders because of their association with known brain diseases.

· In order to be consistent with the rest of the diagnostic manual, and so as to avoid falling into the

trap of simplistic mindbody dualism, dementia and related clinical phenomena are now classified

as Cognitive Disorders in DSM-IV-TR.

· These disorders are divided into three major headings: deliria, dementias, and amnestic disorders.

Frequency of Delirium and Dementia

· The incidence of dementia will be much greater in the near future, because the average age of the

population is increasing steadily.

· By the year 2030, more than 9 million people in the United States will be affected by Alzheimer's

disease.

· Epidemiological studies must be interpreted with caution, of course, because of the problems

associated with establishing a diagnosis of dementia.

· Definitive diagnoses depend on information collected over an extended period of time so that the

progressive nature of the cognitive impairment, and deterioration from an earlier, higher level of

functioning, can be documented.

· Unfortunately, this kind of information is often not available in a large-scale epidemiological study.

· Also bear in mind the fact that the diagnosis of specific subtypes of dementia requires microscopic

examination of brain tissue after the person's death.

Prevalence of Cognitive Impairment Disorders

· Studies of community samples in North America and Europe indicate that the prevalence of

dementia in people between the ages of 65 and 69 is approximately 1 percent.

· For people between the ages of 75 and 79, the prevalence rate is approximately 6 percent, and it

increases dramatically in older age groups.

· Almost 40 percent of people over 90 years of age exhibit symptoms of moderate or severe

dementia.

· Survival rates are reduced among demented patients.

· There are no obvious differences between men and women with regard to the overall prevalence of

dementia, broadly defined.

· It seems, however, that dementia in men is more likely to be associated with vascular disease or to

be secondary to other medical conditions or to alcohol abuse.

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Alzheimer's disease appears to be the most common form of dementia, accounting for perhaps half

of all cases.

Dementia with Lewy bodies may be the second leading cause of dementia; studies report

prevalence rates between 12 and 27 percent for DLB among patients with primary dementia.

Prevalence rates for vascular dementia are similar to those for DLB.

Pick's disease is much less common than Alzheimer's disease, vascular dementia, or DLB.

Huntington's disease is rare by comparison.

It affects only 1 person in every 20,000.

Cross cultural Comparisons

· Alzheimer's disease may be more common in North America and Europe, whereas vascular

dementia may be more common in Japan and China.

· There are also some tentative indications that prevalence rates for dementia may be significantly

lower in developing countries than in developed countries.

Treatment and Management

· When a person clearly suffers from a primary type of dementia, such as dementia of the

Alzheimer's type, a return to previous levels of functioning is extremely unlikely.

· No form of treatment is presently capable of producing sustained and clinically significant

improvement in cognitive functioning for patients with Alzheimer's disease.

· Realistic goals include helping the person to maintain his or her level of functioning for as long as

possible in spite of cognitive impairment and minimizing the level of distress experienced by the

person and the person's family.

1. Medication

· Some drugs are designed to relieve cognitive symptoms of dementia by boosting the action of

acetylcholine (ACh), a neurotransmitter that is involved in memory and whose level is reduced in

patients with Alzheimer's disease.

· New drug treatments are being pursued that are aimed more directly at the processes by which

neurons are destroyed.

· Although the cognitive deficits associated with primary dementia cannot be completely reversed

with medication, neuroleptic medication can be used to treat some patients who develop psychotic

symptoms.

2. Environmental and Behavioral Management

· Patients with dementia experience fewer emotional problems and are less likely to become agitated

if they follow a structured and predictable daily schedule.

· Severely impaired patients often reside in nursing homes and hospitals.

· The most effective residential treatment programs combine the use of medication and behavioral

interventions with an environment that is specifically designed to maximize the level of functioning

and minimize the emotional distress of patients who are cognitively impaired.

· One important issue related to patient management involves the level of activity expected of the

patient.

· It is useful to help the person remain active and interested in everyday events.

· Patients who are physically active are less likely to have problems with agitation, and they may sleep

better.

· Social interactions are often troublesome for patients with dementia due to distorted views of

reality.

· Creative problem-solving strategies that accommodate the patient's distorted view of reality are

sometimes useful in this type of situation.

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3. Support for Caregivers

· In the United States, spouses and other family members provide primary care for more than 80

percent of people who have dementia of the Alzheimer's type.

· Their burdens are often overwhelming, both physically and emotionally.

· In addition to the profound loneliness and sadness that caregivers endure, they must also learn to

cope with more tangible stressors, such as the patient's incontinence, functional deficits, and

disruptive behavior.

· Some treatment programs provide support groups, as well as informal counseling and ad hoc

consultation services, for spouses caring for patients with Alzheimer's disease.

· Some treatment programs arrange for direct assistance in addition to social support.

· Respite programs provide caregivers with temporary periods of relief away from the patient.

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