Chapter 8 – Impaired cognitive and affective  function

Assessing mental status is complex

• Cognitive ability
• Level of consciousness
• Appearance, behavior
• Speech and language
• Mood
• Affect
• Perception
• Thought content
• Insight
• Judgment

Changes requiring evaluation

• Memory and intellectual difficulties
• Changes in sleep patterns
• Changes in sexual interest, capacity
• Fear of death
• Delusions
• Hallucinations
• Disordered thinking
• Changes in emotional expression

Principles for psychological assessment of the elderly

• Minimize the patient’s preoccupations:  pain, comfort, elimination, adequate hearing and seeing
• Explain what you’re doing…and why
• Minimize distractions:  quiet room, adequate lighting
• Speak slowly and clearly
• Takes breaks if necessary

Cognition vs affect

• Cognition
  • Conscious intellectual activity
  • Thinking
  • Reasoning
  • Remembering
• Affect
  • A mental state
  • Emotion
  • Mood
  • Feeling

Common disorders of the elderly

• Cognitive     
  • Dementia
• Cognitive
  •    Delirium
• Affective
  • Depression 

Delirium vs dementia

• Delirium
  • Temporary mental confusion, agitation
  • Disorientation
  • Fluctuating consciousness
  • Delusions
  • Sleep-wake disturbances
  • May be caused by fever, intoxication, shock
• Dementia
  • Deterioration of intellectual capacities
  • A syndrome, chronic and terminal
  • Caused by organic disease or brain disorder

The syndrome of dementia

• Compromised ability to function at work or home
• Decline in usual abilities
• Not explained by other causes
• Verified by history and cognitive assessment
• Includes at least 2 of the following:
  • Inability to acquire new information
  • Impaired ability to manage complex tasks
  • Inability to recognize
  • Impaired language function
  • Changes in personality

Types of dementia

• Alzheimer’s
• Vascular
• Lewy Body (Parkinson’s)
• Fronto-temporal

Comparison of types of dementia

• Alzheimer’s
  • Most common form of dementia
  • Causes include genetics, environment, lifestyle
• Vascular
  • Second most common form
  • Caused by cardiovascular factors
• Lewy body
  • Protein bodies present in the brain
  • Can occur late in Parkinson’s disease
• Frontotemporal
  • Personality change
  • Frontal brain atrophy occurring in mid-50s
• Older adults can have more than one type:  mixed dementia

Mild cognitive impairment vs dementia

• Transition between normal aging and dementia
• Memory problems without deficits in ADLs
• Associated with increased risk of death
• If found in conjunction with depression, risk of converting to AD is greater

Alzheimer’s disease

• Before the 1950s, misidentified as alcoholism or some other presentation
• From ages 65 to 74, risk is about 2%
• Risk increases with age (42% at age 85)
• Risk increases with family history of AD
• Medical risks:
  • Head trauma
  • Diabetes
  • Frailty
  • High cholesterol
  • Obesity
  • Low physical activity
  • Low vitamin D
  • Clinical depression

Incidence of Alzheimer’s disease

• Twice as common in women
• Common in people whose mothers had the disease (the “maternal effect”)
• Age is greatest risk factor
• Associated with low education level

Cultural considerations

• Symptoms begin on average 7 years earlier in US Latinos than in non-Latino whites.
• Affects African Americans 3 times more than European Americans.
• Japanese American men have higher prevalence that Japanese men living in Japan.

Diagnosis of Alzheimer’s disease

• No definitive diagnostic test
• Physical examination
• Formal mental status exam
• Onset after age 40, most after age 65
• Postmortem examination of brain tissue is only way to confirm diagnosis

Prognosis of Alzheimer’s disease

• Cognitive decline is inevitable
• Average survival time from time of diagnosis is 7-8 years
• May last more than 20 years

Signs and symptoms of Alzheimer’s

• Brain changes may begin up to 20 years before symptoms are obvious
• Loss of short term memory is often the first sign
• Disease progresses gradually but may plateau for long periods of time
• Distinct symptoms for early, intermediate and late stages.

Mild Alzheimer’s disease (early-stage)

• Memory difficulties
• Spatial disorientation
• Learning and retaining new information becomes difficult
• Language difficulties (word finding)
• Mood swings—hostility, irritability, agitation
• Personality changes
• Progressive difficulty with activities of normal living
• Abstract thinking, insight, judgment impaired

Tasks at time of diagnosis

• Preparation for progressive decline
• Establishing DPAHC
• Establish interventions to address functional impairment
• Tasks apply to both family and patient!

Possible behaviors—mild Alzheimer’s

• Agitation
• Restlessness
• Irritability
• Confusion, disorientation
• Suspiciousness
• Yelling
• Pacing
• Violence
• Hallucinations

Sundowner syndrome

• Many patients with mild cognitive impairment or early Alzheimer’s develop this syndrome
• Behavioral changes that occur in later afternoon or evening
• Triggered by diminishing sunlight
• Less light, more shadows may cause fear, confusion
• Dreams and reality become blended

Caring for a patient with Sundowner’s

• Establish a routine
• Keep calm
• Discuss the source of agitation
• Provide for basic needs

Moderate Alzheimer’s disease (middle-stage)

• Aphasia
• Apraxia
• Confusion, inability to initiate meaningful activities
• Agitation
• Insomnia
• Remote memory reduced, but not lost
• May require help with basic ADLs
• Personality changes may progress
• Behavior problems may progress
• Sense of time and place is lost; wandering
• Risk of falls, accidents
• Disorganized sleep patterns

Severe Alzheimer’s disease (late-stage)

• Resistiveness to care
• Incontinence
• Eating difficulties
• Motor impairment
• Cannot walk, feed self, other ADLs
• Unable to swallow
• Recent and remote memory lost
• Problems include…
• Immobility
• Pressure ulcers
• Nutrition

Mental changes to anticipate

• Changes create increasingly difficult behavior….
• Depression
• Anxiety
• Hallucinations
• Paranoia due to:
  • Confusion
  • Inherent personality
  • Unique coexisting mental disorder
  • Brain physiological changes

Goals of treatment of dementia

• Treatment is focused on 4 areas:
  • Safety and environmental measures
  • Maintain physical/functional abilities
  • Drugs
  • Caregiver assistance

Patient safety

• Evaluate home for safety
• Signal monitoring systems for wandering
• Unplug the stove, remove the car, confiscate the keys
• Install alarms?
• Ultimately requires assistance or change in environment
• Patient care goals:
  • Prevent accidents
  • Manage behavior disorders
  • Plan for change as disease progresses
  • Transfer of responsibility…
    • From patient to family…
    • From family to others?

Maintaining functional abilities requires addressing specific behaviors

• Resistiveness
• Repetitiveness
• Sexual inappropriateness
• Aggression
• Food refusal

Non-medication management of resistiveness

• Task may be too difficult—break into small steps
• Caregiver impatience—allow ample time
• Can’t follow directions—simplify request
• Modesty causes embarrassment—respect privacy
• Fear of task—reassure, comfort, distract with music or conversation

Non-medication management of food refusal

• Make meal times a measure of the day’s progression
• Create an inviolable routine
• Incorporate patient preferences
• Eliminate any source of discomfort
• Maximize dense calories
• Use finger foods
• Avoid dry foods
• Keep patient upright

Non-medication management of inappropriate sexual behavior

• Misinterpreting caregiver interaction—no mixed sexual messages
• Decreased judgment, lack of social awareness—do not overreact, confront
• Uncomfortable—check for irritants
• Need for attention—increase basic need for touch and warmth, offer soothing objects
• Self-stimulating—offer privacy, remove from inappropriate place

Drugs for Alzheimer’s disease

• Minimize the use of drugs with CNS activity
• Sedation worsens dementia!
• Antipsychotics may be used to control behavior disorders (not Alzheimer’s disease itself)
• Signs of depression treated with anti-depressants (preferably SSRIs—Paxil, Zoloft, Lexapro)
• Mild to moderate disease—cholinesterase inhibitors (Donepezil [Aricept], Rivastigmine [Exelon])
• Moderate to severe disease—Memantine (Namenda)

Factors in caregiver burden

• Screaming   
• Repetitive questions
• Verbal and physical aggression       
• Reckless or careless behavior
• Personality clashes 
• Not sleeping at night
• Wandering 
• Suspiciousness
• Accusations           
• Sexual actions
• Depression 
• Resistance

Caregiver burden interventions

• Design strategies for sharing responsibility
• Emphasize importance of caring for oneself
• Allow for opportunities to discuss feeling of possible guilt
• Establish priorities
• Education regarding disease
• Support groups
• Caregiver respite

Terminal stage of Alzheimer’s disease

• Bedridden
• Dysphagia
• Eventually mute
• Completely dependent
• Risk of undernutrition, pneumonia, pressure ulcers
• Eventual death usually from infection

Issues associated with terminal stage

• Finding appropriate environment or facility
• Address guilt associated with transfer
• Important to discuss placement early on in process
• Address four important concepts:
  • CPR (should not be offered)
  • Transfer to acute care facility (not in patient’s best interest)
  • Insertion of feeding tube (does not enhance quality of life)
  • Treatment of infections (does not promote comfort)

Depression in the elderly

• Symptoms may be emotional and/or physical
• Apathy is common
• Multiple somatic complaints
• Chronic pain
• Older women 2x as susceptible
• Older men less likely to admit to depression
• Can be associated with medications
• Depression is common with dementia

Consider major depression with 4 or more
persisting for at least 2 weeks….

• Significant weight loss or gain, change in appetite
• Sleep disturbances
• Agitation, slowness
• Fatigue
• Feelings of worthlessness, guilt
• Inability to concentrate, make decisions
• Recurrent thoughts of suicide, death
• Hypochondriasis

Geriatric depression scale

• Long version—30 items
• Short version—15 items
• Can be used on healthy, ill, or those with cognitive impairment
• Patients who score >10 should be referred

Geriatric depression scale

• > 5 suggestive of depression
• > 10 depression very likely

Antidepressants commonly used in the care of the elderly depressed patient

• Selective serotonin reuptake inhibitors (SSRIs) have replaced tricyclic antidepressants (TCAs)
  • Citalopram (Celexa)
  • Escitalopram (Lexapro)
  • Fluoxetine (Prozac)
  • Sertaline (Zoloft)
  • Paroxetine (Paxil)
• Side effects include—
  • CNS effects:  agitation, anxiety, insomnia, sedation, headache; GI effects:  N/V/D, anorexia; GU effects: sexual dysfunction, urgency;  Respiratory effects: cough, dyspnea

Suicide

• 65 years+ have highest suicide rate of all ages
• Major risk is depression
• Older Caucasian males have highest death rates from suicide
• 70% of successful suicide attempts in older adults had seen primary physician within the previous month
• Consider any threat of suicide to be a valid threat

Risk factors for suicide

• Previous suicide attempt
• Alcohol or substance abuse
• Psychiatric illness
• Auditory hallucinations
• Living alone
• Guns at home
• Exposure to suicide

A note on schizophrenia

• The incidence of schizophrenia in the elderly is quite low
• The prevalence of schizophrenia in the elderly  (> 65 years) estimated between 0.1% to 1%
• Approximately 35% of elderly patients treated in public psychiatric facilities have schizophrenia
• 12% of patients in nursing homes have schizophrenia
• A frequent feature of schizophrenia is auditory hallucinations
• Auditory hallucinations can trigger a suicide attempt