Cognitive Disorders Chapter 14

Cognitive Disorders
Cognitive Disorders: Behavioral disturbances that result from transient or permanent damage to the brain. Affect thinking processes, memory, perception, consciousness, etc. caused by brain dysfunction DSM-IV-TR categories: Dementia Delirium Amnestic Disorders Cognitive Disorders Not Otherwise Specified

Cognitive Disorders
Diagnosis is often a process of elimination Possible causes: Aging, trauma, infection, loss of blood supply, substance abuse, and biochemical imbalance. Cognitive, emotional, and behavioral symptoms Prevalence: ~1% for severe disorders, 6% for mild disorders Severe impairment: At age 75, the rate is 22 times that of persons 18-34 Rate is higher for African Americans than for white or Hispanic Americans.

Prevalence of Cognitive Impairment by Demographic Characteristics

Cognitive Disorders The Assessment of Brain Damage Psychological tests and inventories assess behavioral responses and functions such as memory and manual dexterity. Neurological tests permit direct monitoring of brain functioning and structure. Electroencephalograph (EEG) Computerized axial tomography (CAT) scan Cerebral blood flow measurement Positron emission tomography (PET) scan

Cognitive Disorders The Assessment of Brain Damage Neurological tests: Magnetic resonance imaging (MRI): Produces snapshots of brain anatomy With patient in magnetic field, radio waves are used to produce pictures of the brain without bone obstruction. fMRI produces dynamic pictures

Cognitive Disorders The Assessment of Brain Damage Neurological tests: Each technique has strengths and weaknesses in costs, benefits, and possible side effects. CAT scan is less expensive and faster than MRI MRI does not use X-rays and is better at detecting neoplasms, brain abnormalities related to seizures, and certain lesions.

Cognitive Disorders The Assessment of Brain Damage Initial screening/assessment: Mental status examination Specific interview questions about general functioning, personality characteristics, and coping skills, changes in behavior.

Cognitive Disorders Localization of Brain Damage Overlap of functions complicates assessment. There is no 1:1 correspondence for specific physical areas related to specific psychological functions from brain to brain. Diaschisis: A lesion in a specific area of the brain disrupts other intact areas, sometimes in the other hemisphere.

Cognitive Disorders Localization of Brain Damage Recovery of function: Redundancy (unused portions of the brain take up functions of damaged areas). Plasticity: Undeveloped portions of the brain substitute for damaged portions. Plasticity and compensatory reorganization may improve functioning in one area at the expense of another function.

The Major Areas of the Brain

Brain Areas and the Functions They Control

Cognitive Disorders The Dimensions of Brain Damage Brain damage is evaluated on a continuum: Mild to moderate to severe Endogenous versus exogenous causes Diffuse versus specific damage Acute versus chronic conditions

Cognitive Disorders Diagnostic Problems

Overlap with symptoms of psychological disorders: Depression: Neuropsychological tests show similar characteristics. Tests may not show clear distinction between cognitive disorders and schizophrenia. If a general medical condition and mood disorder are related, diagnosis may be mood disorder due to general medical condition Impairment may show up where none exists if there is a monetary motive (e.g., lawsuit).

Cognitive Disorders Diagnostic Problems

Are symptoms due to CNS damage or some other causal agent (e.g., a toxin)? A person with brain damage may be diagnosed as having a psychological disorder. Age-related misdiagnosis may be due to reduced sensory acuity, performance anxiety, fatigue, failure to understand test instructions, or lack of agreement between different measures of cognitive functioning Elderly may score poorly on Halstead-Reitan Neuropsychological Test Battery but well on WAIS and daily functioning.

Types of Cognitive Disorders

Dementia: Syndrome characterized by memory impairment and cognitive disturbances, such as: Aphasia: (Language disturbance) Apraxia: Inability to carry out motor activities despite comprehension and motor function Agnosia: Failure to recognize/identify objects despites intact sensory function Thought disturbances: Planning and abstraction

Types of Cognitive Disorders

Dementia: Causes may include general medical conditions, substance use, multiple etiologies, and other causes not specified. Prevalence: 1.5 million Americans have severe dementia, 1-5 million have mild-moderate forms 5-7% over age 65; greater than 20% over age 85 2-4% have Alzheimers

Types of Cognitive Disorders

Dementia: Associated disorders: Alzheimers, vascular disease, normal pressure hydrocephalus, alcoholism, intracranial masses, and Huntingtons disease

Types of Cognitive Disorders

Delirium: Disturbance of consciousness and changes in cognition, (e.g., memory deficit, disorientation, language and perceptual disturbances). Rapid development over hours or days 10% of persons over age 65 hospitalized for general medical conditions exhibit delirium At-risk groups: The elderly and patients recovering from surgery, having preexisting brain dysfunction, in drug withdrawal, with AIDS, and high illness burden.

Types of Cognitive Disorders

Delirium Tremens: Occurs with alcohol withdrawal. Disorientation (self, place, time) Vivid hallucinations, intense fear Extreme suggestibility Tremor in hands, tongue, lips Rapid HR, fever, foul breath Death as high as 35%, but rare if treated with drugs like chlordiazapoxide

Types of Cognitive Disorders

Amnestic Disorders: Characterized by memory impairment as manifested by inability to learn new information and inability to recall previously learned knowledge or past events. Results from insult to central nervous system: Head trauma, stroke, Wernickes encephalopathy (alcohol-induced organic mental disorder involving thiamine deficiency).

Types of Cognitive Disorders

Cognitive Disorders Not-Otherwise-Specified: Cognitive disorders that do not meet the criteria for dementia, delirium, or amnestic disorder.

Etiology of Cognitive Disorders

Brain Trauma: Physical wound or injury to the brain. Concussion: Mild brain injury, typically caused by a blow to the head. Contusion: The brain is forced to shift slightly and press against the side of the skull. Laceration: Brain tissue is torn, pierced, or ruptured.

Etiology of Cognitive Disorders

ATLANTA PRO WRESTLER CHRIS BENOIT SUFFERED BRAIN DAMAGE FROM HIS YEARS IN THE RING THAT COULD HELP EXPLAIN WHY HE KILLED HIS WIFE, SON AND HIMSELF, A DOCTOR WHO STUDIED BENOIT'S BRAIN SAID WEDNESDAY. THE ANALYSIS BY DOCTORS AFFILIATED WITH THE SPORTS LEGACY INSTITUTE SUGGESTS REPEATED CONCUSSIONS COULD HAVE CONTRIBUTED TO THE KILLINGS AT BENOIT'S SUBURBAN ATLANTA HOME.

FoxNews.com 9-5-07

Thomas E. Witte/NewSport/CORBIS

Aging and Disorders Associated with Aging

Cerebrovascular Accident (stroke): Sudden stoppage of blood flow to a portion of the brain, leading to loss of brain function. Causes: burst blood vessels (25%), narrowing of blood vessels (atherosclerosis), or blocked blood vessels. Cerebral Infarction: death of brain tissue from decreased supply of blood to tissue. Vascular Dementia: Uneven deterioration of intellectual abilities resulting from several cerebral infarctions.

Aging and Disorders Associated with Aging

Memory loss in older people: Alzheimer's Brain cell deterioration, which may be mitigated in cognitively active persons
People that remain cognitively tend to remain relatively free of dementia and Alzheimers

Vascular dementia Occasional loss due to normal aging process (not indicative of dementia) Medications

Aging and Disorders Associated with Aging

Fluid abilities decline with age (novel problems, creativity); acquired knowledge remains stable 75% of elderly retain sharp mental functioning, 1015% have mild-moderate memory loss.

Aging and Disorders Associated with Aging

Aging and Disorders Associated with Aging

Cross-Sectional method suggests decline Longitudinal method suggests more stability

Aging and Disorders Associated with Aging Alzheimers Disease Alzheimers Disease: Dementia in which brain tissue atrophies, leading to marked deterioration of intellectual and emotional functioning. Accounts for 80% of dementia in the elderly Prevalence: 8-15% for people older than 65 Early symptoms: Memory dysfunction, irritability, cognitive impairment Later symptoms: Social withdrawal, depression, apathy, delusions, impulsive behaviors, neglect of personal hygiene

Aging and Disorders Associated with Aging Alzheimers Disease

Death usually occurs within 5 years of onset; 4th leading cause of death in the U.S. Atrophy of cortical tissue in the brain: Neurofibrillary Tangles: Abnormal fibers that appear to be tangles of brain tissue filaments. Senile Plaques: Patches of degenerated nerve endings.

Aging and Disorders Associated with Aging Alzheimers Disease

Etiology: Unknown (hereditary or environmental factors) Explanations: Reduced ACTH, repeated head injuries, infections and viruses, decreased cerebral blood flow, plaques and tangles (chromosome 21), aluminum, genetic anomalies Protective factors to delay onset: Genetic endowment with ApoE-e2 allele, higher education/occupation, NSAIDs, estrogen replacement therapy, vitamin E

Other Diseases and Conditions of the Brain

Parkinsons Disease: Progressively worsening disorder with muscle tremors, stiff, shuffling gait, lack of facial expression, social withdrawal, possibly dementia and depression Prevalence: 0.1%, 1-2% over the age of 65 Causes: brain infection, cerebrovascular disorders, brain trauma, carbon monoxide poisoning, genetic predisposition, other unknown causes Associated with lesions in the motor area of brainstem and lower dopamine levels

Other Diseases and Conditions of the Brain

AIDS (Acquired Immunodeficiency Syndrome) Dementia may be due to: AIDS virus reaching the brain, compromised immune functioning, effects of knowing one has AIDS, medications Neurosyphilis (general paresis): Spirochete Treponema pallidum Encephalitis (sleeping sickness): Brain inflammation caused by viral infection.

Other Diseases and Conditions of the Brain

Meningitis: Inflammation of meninges (membrane surrounding the brain and spinal cord) Bacterial, viral, and fungal Huntingtons Disease: Genetically transmitted degenerative disease; involuntary twitching movements and eventual dementia and death. 50% of offspring of affected person develop it Prevalence: 5-7 per 100,000 population

Other Diseases and Conditions of the Brain

Cerebral Tumors: Mass of abnormal tissue growing within the brain causing disturbances of consciousness, mild dementia, problems of thinking, mood changes. Epilepsy: Intermittent/brief periods of altered consciousness often accompanied by seizures or excessive electrical discharge from brain cells. 1-2% of U.S. population has seizures at some point in their lives Use of psychoactive substances

Cognitive Disorders Treatment Considerations Major interventions: Surgical, medical, psychological, and environmental. Comprehensive: Medication, rehabilitation, therapy, and environmental modifications. Surgical: Remove tumors, relieve pressure caused by tumors, restore ruptured blood vessels. Psychotherapy: Help patients deal with emotional aspects of the disorders.

Cognitive Disorders Treatment Considerations

Medication: Prevent, control, reduce symptoms; also control accompanying emotional problems. Side effects: Decrease in speed of motor responding; tremors; weight gain; swollen gums Alzheimers: Acetylcholinesterase inhibitors; antiinflammatory medications reduce risk. Current treatment goals: Delay onset of symptoms, slow progression, improve symptoms, reduce morbidity, modify risk factors, prevent disease.

Cognitive Disorders Treatment Considerations Environmental interventions: Modify patients environment to preserve sense of independence and control. Continued social contacts Diversions Tasks to provide sense of contributing Caregiver support: Education about disease and proper care Social support