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Abnormal
Psychology PSY404
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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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