Transcript Cognitive and affective disorders in the elderly

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-2009-0011
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-2009-0011
Márta Balaskó and Gyula Bakó
Molecular and Clinical Basics of Gerontology – Lecture
18
COGNITIVE AND
AFFECTIVE DISORDERS
IN THE ELDERLY
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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.
Aging-associated cognitive,
affective and psychiatric
disorders (outline)
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• Dementia
- Neurodegenerative disorders leading to
dementia (Alzheimer’s disease)
- Non-Alzheimer dementias (vascular dementia,
organic brain disorders)
- Delirium
- Amnestic syndromes
• Alcohol abuse and consequences
• Affective disorders: depression
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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
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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 syndromes
Senile dementia of the
Alzheimer type (SDAT,
Alzheimer’s disease) 1
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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 dropouts: 2× risk)
• positive family anamnesis:
4× risk
• head trauma: 2× risk
• smoking, metabolic syndrome X, atrial
fibrillation, stroke, alcohol consumption,
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Prevalence of Alzheimer’s
disease
60
50%
Prevalence (%)
50
40
30%
30
20
16%
10
0
1%
2%
4%
8%
60-64 65-69 70-74 75-79 80-84
Age (years)
85+
95+
Senile dementia of the
Alzheimer type (SDAT,
Alzheimer’s disease) 2
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Characteristics
Loss of neurons, synapses and atrophy in the
cerebral cortex and certain subcortical regions
(temporal and parietal lobes, parts of the
frontal cortex)
Pathogenesis
cholinergic theory: reduced synthesis of the
acetylcholine
beta-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
Senile dementia of the
Alzheimer type (SDAT,
Alzheimer’s disease) 3
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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 aging
2 Early stage
increasing forgetfulness, difficulties with
language, executive functions, agnosia,
apraxia, personality changes
3 Moderate stage
dependency increases
difficulty with speech, pathological behavior
(agression) and confusion, delusions
4 Advanced stage
Senile dementia of the
Alzheimer type (SDAT,
Alzheimer’s disease) 4
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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.
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Non-Alzheimer dementias
(organic brain disorders)
Characteristics
• Symptoms 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.
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Causes of non-Alzheimer
dementias
Intracranial:
Degenerative disorders
Parkinson’s, Pick, Lewy
Huntington
Vascular, post-stroke
states
Space occupying
lesions
Post-trauma states
polytrauma (boxing,
liver)
subdural hematoma,
hemodialysis
Infectious agents
AIDS, prion
Extracranial:
Poisons
alcohol, drugs,
medications
CO poisoning
Genetic, metabolic
causes
Wilson’s, hypoglycemias
Organ failures
Tumor, metastases
failure,
renal failure,
hydrocephalus
heart failure,
thyroid disorders
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Delirium: definition
Characteristics
• It is a clinical syndrome characterized by
inattention and acute severe (reversible)
cognitive dysfunctions
• In 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–
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Delirium in the elderly:
risk factors 1
Risk factors
• Dementia or cognitive impairment
• History 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
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Delirium in the elderly:
risk factors 2
Risk factors
• Intercurrent 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 deprivation
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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
Alcohol abuse and
consequences
in the elderly
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Prevalence
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.
Consequences of alcohol
abuse
in the elderly 1
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Consequences
Alcohol-induced alterations in drug metabolism:
• acute competitive 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.
coumarins
Falls 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!
Consequences of alcohol
abuse
in the elderly 2
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Consequences
Ischemic 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
withdrawal-induced delirium .
Chronic alcoholism lead to Wernicke encephalopathy
(an acute state of confusion, ataxia and abnormal
Depression in the elderly:
definition and
characteristics
Definition
Depression 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
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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 adaptability
• lack of perspectives in life, lack of
motivation,
• decreased ability to work,
Factors that make the
diagnosis of depression
especially difficult
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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.
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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
Differential diagnosis of
depression
(pseudodementia) and
dementia
PSEUDO-DEMENTIA
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• keeps complaining
• communicates in
detail
• “I don’t know”
• does not want to do
DEMENTIA
• does not complain
• poor communication
• replies with mistakes
• eager to cooperate