Neurocognitive Disorders

Aging: Issues and Methods

 In U.S., many people dread aging
• Elderly not revered as in other cultures
 When are we old?
• Society arbitrarily sets old as over 65
• Young-old: 65-74 years, old-old: 75-84, oldest-old: 85+
 2001 census
• 12.4% or 35 million individuals were 65 or older
Number of Old and Oldest-Old
 Myths About Late Life
 Aging involves inexorable cognitive decline
• Severe cognitive problems do not occur for most
 Mild declines are common
 Late life is a sad time and most elderly are depressed
• Older individuals report less negative emotion than younger people
 More brain activation in key areas when viewing positive images
 Late life is a lonely time
• Some less likely to develop new friendships
• Social selectivity
 As we age, we focus on the interpersonal relationships that matter most to us
 Older people lose interest in sex
• Sexual activity does not decrease from mid-to late life for most people
 Late Life Problems
 Problems multiply with age
• physical decline and disabilities
• sensory and neurological deficits
• loss of loved ones
• social stresses such as stigmatizing attitudes towards elderly
• Eighty percent of elderly people have at least one major medical condition
 Sleep disturbances increase with age
• Insomnia
• Sleep apnea
 Medical treatment
• Chronic problems instead of curable disorders
• Polypharmacy
• Psychoactive drugs usually tested on younger participants
 Research Designs
 Cross-sectional studies
• Researcher tests different age groups at one point in time
• Fails to provide information about how people change over
time
 Longitudinal studies
• Researcher retests the same group of people with the same
measures at different points in time
 May extend over several years or decades
• Attrition a potential problem
 Selective mortality can lead to biased sample
One-year Prevalence Estimates for Psychological
Disorders by Age Group
 Neurocognitive Disorders in Late Life
 Most elderly do not have cognitive disorders
• Prevalence has decreased over last 15 years
 Dementia
• A deterioration of cognitive function
 Delirium
• A state of mental confusion
 Dementia
 Deterioration of cognitive function
• Impaired social and occupational functioning
• Progresses over time
 Begins with difficulty remembering recent events
 Deficits can be detected before impairment becomes
obvious
 Mild cognitive impairment develop slowly
 DSM-5 proposes two categories, differentiated by ability
to live independently:
• Mild neurocognitive disorder (mild cognitive impairment)
• Major neurocognitive disorder (dementia)
DSM-5 Neurocognitive Disorders
 DSM-5 Criteria for
Minor Neurocognitive Disorder
 Minor cognitive decline from previous levels in one or more domains based on both of the following:

o Concerns of the patient, a close other, or a clinician

o Neurocognitive performance below appropriate norms (i.e., between the 3rd and 16th percentile) on
formal testing, or equivalent clinical evaluation.

 The cognitive deficits do not interfere with independence (i.e., tasks such as paying bills or managing
medications), even though greater effort, compensatory strategies, or accommodation may be required to
maintain independence.

 The cognitive deficits do not occur exclusively in the context of a delirium and are not due to another
psychological disorder
 DSM-5 Criteria for
Major Neurocognitive Disorder
 Evidence of significant cognitive decline from previous levels in one or more domains based on both of the

following:

o Concerns of the patient, a close other, or a clinician

o Neurocognitive performance below the 3rd percentile on formal testing, or equivalent clinical evaluation.

 The cognitive deficits interfere with independence

 The cognitive deficits do not occur exclusively in the context of a delirium and are not due to another psychological

disorder
 Symptoms of Major NCD
 Memory lapses
 Aphasia
• Deterioration of language
 Apraxia
• Impairment of ability to execute common actions
 Agnosia

 Loss of executive functions

 Changes in emotional functioning & personality
 NCD assoc. with
Alzheimer’s Disease
 Described by Alois Alzheimer in 1906
 Irreversible brain tissue deterioration
• Death usually occurs within 12 years
 Usually begins with
• Difficulty remembering recent events
• Learning new material
• Irritability
 As disease progresses
• Language problems intensify, including word-finding
• Disorientation
 Time, place, and identity confusion
• Agitation
• Depression
 Brain Changes in Alzheimer’s Disease
 Plaques
• β-amyloid protein deposits
• Primarily found in frontal cortex
 Neurofibrillary tangles
• Protein filaments composed of tau in axons of neurons
• Primarily found in hippocampus
 Measured using PET scans
 Plaques most dense in frontal cortex; tangles most dense in hippocampus
 Loss of synapses for acetylcholinergic (Ach) and glutaminergic neurons
• As neurons die, atrophy of cerebral and entorhinal cortices and hippocampus
• Enlargement of ventricles
ApoE-4 Gene Increases Production of Amyloid
Precursors
 Alzheimer’s Disease
 Genetic factors
• Heritability 79%
• ApoE4 allele: Gene on chromosome 19
 Having one E4 allele increases risk by 20%
 Having two E4 alleles increases risk substantially more
 Related to over-production of beta-amyloid plaques, loss of neurons in the hippocampus, and
low glucose metabolism in cerebral cortex
 Environmental factors
• Smoking, being single, low social support, and depression related to greater
risk of developing Alzheimer’s
• Mediterranean diet, exercise, education, and cognitive engagement predict a
lower risk
 e.g. solving crossword puzzles, reading the newspaper daily
• Cognitive reserve
 Use alternative brain networks to compensate for disease
 Frontotemporal Dementia
 Loss of neurons in frontal and temporal lobes
• Memory not severely disrupted
 Impairment of executive functions
• Planning
• Problem solving
• Goal-directed behavior
 Difficulty recognizing and regulating emotion
• Much more profound impact than Alzheimer’s
 Caused by multiple genetic pathways
• High levels of tau proteins
 Vascular Dementia
 Typically results from stroke (cardiovascular)
• Clot forms and impairs circulation
• Cells die
 Risk factors
• Smoking, high LDL cholesterol, high BP
 Symptoms can vary greatly, depending upon location of
strokes
 NCD due to HIV
 Cause mild & major NCD
• Impairment in memory & concentration
• Weakness in extremities making them clumsy & lacking
coordination
• Speech becomes impaired

 HIV-associated major NCD is diagnosed when…

• Deficits & symptoms become severe & global
 Dementia d/t Huntington’s Disease
 Huntington’s disease
• Rare, genetic disorder afflicting people early in life
• develop NCD & chorea
• Transmitted by a single dominant gene on chromosome 4
(Gusella et al., 1993)

 Affects many neurotransmitters in the brain

 Dementia d/t Prion’s Disease
 Prion’s disease
• disease associated with infectious protein

 Prion - an infectious particle of protein that, unlike a virus, contains no

nucleic acid, does not trigger an immune response, and is not destroyed by
extreme heat or cold.
 Dementia with Lewy Bodies (DLB)

 Two subtypes
• With Parkinson’s
• No Parkinson’s
 Symptoms similar to Parkinson’s and Alzheimer’s
diseases
• Shuffling gait
• Loss of memory
 Symptoms differ in that DLB patients have:
• Fluctuating cognitive symptoms
• Prominent visual hallucinations
• Intense dreams involving movement and vocalizing
 Dementias Caused by Disease and Injury
 Other medical issues
• Encephalitis (inflammation of brain tissue by viruses)
• Meningitis (inflammation of covering membranes by
bacteria)
• Head traumas
• Brain tumors
• Nutritional deficits (B-complex vitamins)
 Prevention and Treatment of Dementia
 Medications
• No drug reverses Alzheimer’s disease
• Some drugs produce slightly less decline
 Cholinesterase inhibitors (drugs that prevent breakdown of acetylcholine)
 Donepezil (Aricept)
 Galantamine (Reminyl)
 Vitamin E, statins, and nonsteroidal anti-inflammatory drugs
have failed to find support
 Preventive work focuses on processes involved in the creation
of amyloid from its precursor protein
 Antidepressants for depression
 Antipsychotic medication for agitation
 Treatment of Dementia
 Psychological treatments
• Supportive psychotherapy for family and patient
• Education about disease and care
• Cognitive interventions when disease is in early stages
 Labeling drawers, appliances
 Calendars, clocks, and strategically placed notes
• Exercise has been associated with cognitive benefits
• Music appears to reduce agitation and disruptive behavior
 Delirium
 Clouded state of consciousness
• Extreme trouble focusing attention
• Disturbances in the sleep/wake cycle
• Fragmented thinking
• Speech is rambling and incoherent
• Disorientation
• Perceptual disturbances
• Memory impairments
• Mood swings
 Secondary to underlying medical condition
 Detection of delirium important but often missed
• Untreated, further cognitive decline and mortality may occur
 Beyond treating the underlying medical conditions, the most common treatment is
atypical antipsychotic medication
Comparative Features of Dementia and
Delirium
Case 1: Ellen
 Case 2
A 76-year-old white woman is brought to her general
practitioner by her children because she is becoming
more forgetful. She used to pay her bills
independently and enjoyed cooking but has recently
received overdue notices from utility companies and
found it difficult to prepare a balanced meal. She has
lost 3.5 kg in the past 3 months, and left the water
running in her bathtub and flooded the bathroom.
When her children express their concerns, she
becomes irritable and resists their help. Her house
has become more cluttered and unkempt. On a past
visit to her physician, she had normal laboratory tests
for metabolic, haematological, and thyroid function.
The current evaluation reveals no depressive
symptoms and 2/15 on the Geriatric Depression Scale
short-form. Her Mini-Mental State Examination
(MMSE) score is 20/30.
 Case 3
Mrs Everly is an 84 year old woman who was found by a
neighbour "collapsed" outside her home.  She is admitted
to your unit with increased confusion over the past 1 to 2
days. She appears agitated and to be having hallucinations.
Mrs Everly lives with her daughter who is present during
admission and assists in providing information regarding her
mother's history.
Medical history revealed mild dementia, osteoarthritis,
osteoporosis, diabetes
She had taken several medications such as paracetamol
500mg ii qid prn, tramadole SR100 mg bd, imipramine 25
mg nocte, glibenclamide 10mg bd, alendronate 70 mg
weekly.
Examination revealed bruising to face, arm, and hips. She is
underweight and walks on an unsteady gait. She showed
decreased ankle reflexes. Her body temperature is 37.5 ‘C.
There are no other abnormalities found.